Humana Medicare Supplement plan by lzy18804

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									                    Outline of Medicare
                    Supplement Coverage
                    for SOUTH CAROLINA residents Medicare supplement
                    benefit plans: A, B, C, F, High Deductible F, K, and L




Humana Medicare Supplement plan

SC81077RR 506
                                                                             Humana Insurance Company
                                              Outline of Medicare Supplement Coverage - Cover Page: 1 of 2
                                                  Benefit Plans A, B, C, F, and High Deductible F, K, and L
                These charts show the benefits included in each of the standard Medicare supplement plans. Every company must make available Plan A.
                Some plans may not be available in your state.




SC81077RR 506
                   Basic Benefits for Plans A-J:
                   Hospitalization: Part A coinsurance plus coverage for 365 additional days after Medicare benefits end.
                   Medical Expenses: Part B coinsurance (generally 20% of Medicare-approved expenses) or copayments for hospital outpatient services.
                   Blood: First three pints of blood each year.


                      A               B               C               D               E           F       F*          G               H                I            J       J*
                    Basic           Basic              Basic           Basic           Basic           Basic           Basic           Basic           Basic             Basic
                   benefits        benefits         benefits        benefits        benefits        benefits        benefits        benefits        benefits          benefits
                                                Skilled Nursing Skilled Nursing Skilled Nursing Skilled Nursing Skilled Nursing Skilled Nursing Skilled Nursing   Skilled Nursing
                                                     Facility        Facility        Facility        Facility        Facility        Facility        Facility          Facility
                                                 coinsurance     coinsurance     coinsurance     coinsurance     coinsurance     coinsurance     coinsurance       coinsurance
                                    Part A            Part A          Part A          Part A          Part A          Part A          Part A          Part A            Part A
                                  deductible      deductible      deductible      deductible      deductible      deductible      deductible      deductible        deductible
                                                      Part B                                          Part B                                                            Part B
                                                  deductible                                      deductible                                                        deductible
                                                                                                 Part B excess Part B excess                     Part B excess     Part B excess
                                                                                                    (100%)            (80%)                         (100%)            (100%)
                                                     Foreign         Foreign         Foreign         Foreign         Foreign         Foreign         Foreign           Foreign
                                                      travel          travel          travel          travel           travel         travel          travel            travel
                                                  emergency       emergency       emergency       emergency       emergency       emergency       emergency         emergency
                                                                   At-home                                         At-home                         At-home           At-home
                                                                    recovery                                        recovery                        recovery          recovery
                                                                                Preventive care                                                                   Preventive care
                                                                                 NOT covered                                                                       NOT covered
                                                                                 by Medicare                                                                      by Medicare


                *Plans F and J also have an option called a High Deductible Plan F and a High Deductible Plan J. These high deductible plans pay the same benefits as Plans
                F and J after one has paid a calendar year $2,000 deductible. Benefits from High Deductible Plans F and J will not begin until out-of-pocket expenses exceed
                $2,000. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. These expenses include the Medicare deductibles
                for Part A and Part B, but do not include, the plan's separate foreign travel emergency deductible.




1
2
                                                                             Humana Insurance Company
                                             Outline of Medicare Supplement Coverage - Cover Page 2
                Basic Benefits for Plans K and L include similar services as plans A-J, but cost sharing for the basic benefits is at different levels.

                  K**                                                                       L**
                  100% of Part A Hospitalization coinsurance plus coverage for              100% of Part A Hospitalization coinsurance plus
                  365 days after Medicare benefits end                                      coverage for 365 days after Medicare benefits end
                  50% Hospice cost-sharing                                                  75% Hospice cost-sharing
                  50% of Medicare-eligible expenses for the first three pints of            75% of Medicare-eligible expenses for the first three
                  blood                                                                     pints of blood
                  50% Part B coinsurance, except 100% coinsurance for Part B                75% Part B coinsurance, except 100% coinsurance for
                  Preventive Services                                                       Part B Preventive Services
                  50% Skilled Nursing Facility coinsurance                                  75% Skilled Nursing Facility coinsurance

                  50% Part A deductible                                                     75% Part A deductible




                  $4,620 out-of-pocket annual limit***                                      $2,310 out-of-pocket annual limit***

                ** Plans K and L provide for different cost-sharing for items and services than Plans A-J.
                Once you reach the annual limit, the plan pays 100% of the Medicare copayments, coinsurance, and deductibles for the rest of the calendar year. The
                out-of-pocket annual limit does NOT include charges from your provider that exceed Medicare-approved amounts, called "Excess Charges". You will be
                responsible for paying excess charges.
                *** The out-of-pocket annual limit will increase each year for inflation.




SC81077RR 506
                See Outlines of Coverage for details and exceptions.
      Humana Medicare Supplement Monthly Premiums for Area 1
                               Area 1 includes the following counties:
            Aiken, Berkeley, Charleston, Chester, Colleton, Darlington, Dillon, Dorchester,
                Florence, Georgetown, Hampton, Horry, Kershaw, Lancaster, Marion



Plan A                                                Plan B
Area 1 Rates                                          Area 1 Rates
Effective Date 05-01-2009                             Effective Date 05-01-2009
 Attained    Gender      Preferred    Standard         Attained      Gender      Preferred    Standard
   Age                                                   Age
    65        Male          $125        $185              65          Male          $131        $195
    65       Female         $117        $174              65         Female         $124        $184
  66-67       Male          $127        $189            66-67         Male          $134        $199
  66-67      Female         $120        $178            66-67        Female         $126        $187
  68-69       Male          $142        $212            68-69         Male          $150        $223
  68-69      Female         $135        $200            68-69        Female         $142        $211
  70-74      Unisex         $150        $223            70-74        Unisex         $158        $235
  75-79      Unisex         $172        $257            75-79        Unisex         $182        $271
  80-84      Unisex         $191        $284            80-84        Unisex         $201        $299
   85+       Unisex         $204        $304             85+         Unisex         $215        $321



Plan C                                                Plan F
Area 1 Rates                                          Area 1 Rates
Effective Date 05-01-2009                             Effective Date 05-01-2009
 Attained   Gender       Preferred    Standard        Attained       Gender      Preferred    Standard
   Age                                                  Age
    65        Male          $152        $226             65           Male          $153       $228
    65       Female         $143        $213             65          Female         $144       $214
  66-67       Male          $155        $231           66-67          Male          $156       $232
  66-67      Female         $146        $217           66-67         Female         $147       $219
  68-69       Male          $174        $258           68-69          Male          $175       $260
  68-69      Female         $164        $245           68-69         Female         $165       $246
  70-74      Unisex         $183        $272           70-74         Unisex         $184       $274
  75-79      Unisex         $210        $314           75-79         Unisex         $212       $316
  80-84      Unisex         $233        $347           80-84         Unisex         $234       $349
   85+       Unisex         $249        $371            85+          Unisex         $251       $374




SC81077RR 506                                                                                          3
         Humana Medicare Supplement Monthly Premiums for Area 1

                                         (Continued)




HIGH DEDUCTIBLE Plan F                          Plan K
Area 1 Rates                                    Area 1 Rates
Effective Date 05-01-2009                       Effective Date 05-01-2009
    Attained   Gender   Preferred   Standard        Attained     Gender    Preferred   Standard
      Age                                             Age
       65       Male        $62       $91              65          Male      $74        $110
       65      Female       $58       $86              65         Female     $70        $103
     66-67      Male        $63       $93            66-67         Male      $76        $112
     66-67     Female       $59       $88            66-67        Female     $71        $105
     68-69      Male        $70      $104            68-69         Male      $85        $125
     68-69     Female       $67       $99            68-69        Female     $80        $119
     70-74     Unisex       $74      $110            70-74        Unisex     $89        $132
     75-79     Unisex       $85      $126            75-79        Unisex     $102       $152
     80-84     Unisex       $94      $139            80-84        Unisex     $113       $168
      85+      Unisex       $100     $149             85+         Unisex     $121       $180




                        Plan L
                        Area 1 Rates
                        Effective Date 05-01-2009
                        Attained     Gender    Preferred       Standard
                          Age
                           65         Male          $107        $159
                           65        Female         $100        $149
                         66-67        Male          $109        $162
                         66-67       Female         $102        $152
                         68-69        Male          $122        $181
                         68-69       Female         $115        $171
                         70-74       Unisex         $128        $191
                         75-79       Unisex         $148        $219
                         80-84       Unisex         $163        $243
                          85+        Unisex         $175        $260




4                                                                                SC81077RR 506
      Humana Medicare Supplement Monthly Premiums for Area 2
                               Area 2 includes the following counties:
        Bamberg, Barnwell, Beaufort, Calhoun, Cherokee, Chesterfield, Clarendon, Greenville,
             Jasper, Lee, Lexington, Marlboro, Orangeburg, Union, Williamsburg, York



Plan A                                              Plan B
Area 2 Rates                                        Area 2 Rates
Effective Date 05-01-2009                           Effective Date 05-01-2009
 Attained    Gender      Preferred   Standard        Attained      Gender      Preferred   Standard
   Age                                                 Age
    65        Male          $119       $177             65          Male         $126          $187
    65       Female         $112       $166             65         Female        $118          $175
  66-67       Male          $121       $181           66-67         Male         $128          $190
  66-67      Female         $114       $170           66-67        Female        $120          $179
  68-69       Male          $136       $202           68-69         Male         $143          $213
  68-69      Female         $129       $191           68-69        Female        $136          $202
  70-74      Unisex         $143       $213           70-74        Unisex        $151          $224
  75-79      Unisex         $165       $245           75-79        Unisex        $174          $258
  80-84      Unisex         $182       $271           80-84        Unisex        $192          $286
   85+       Unisex         $195       $290            85+         Unisex        $205          $306



Plan C                                              Plan F
Area 2 Rates                                        Area 2 Rates
Effective Date 05-01-2009                           Effective Date 05-01-2009
 Attained    Gender      Preferred   Standard        Attained      Gender      Preferred   Standard
   Age                                                 Age
    65        Male          $145       $216             65          Male         $146          $218
    65       Female         $137       $203             65         Female        $138          $205
  66-67       Male          $148       $220           66-67         Male         $149          $222
  66-67      Female         $139       $207           66-67        Female        $140          $209
  68-69       Male          $166       $247           68-69         Male         $167          $248
  68-69      Female         $157       $234           68-69        Female        $158          $235
  70-74      Unisex         $175       $260           70-74        Unisex        $176          $262
  75-79      Unisex         $201       $299           75-79        Unisex        $202          $301
  80-84      Unisex         $222       $331           80-84        Unisex        $224          $333
   85+       Unisex         $238       $355            85+         Unisex        $240          $357




SC81077RR 506                                                                                         5
         Humana Medicare Supplement Monthly Premiums for Area 2

                                         (Continued)




HIGH DEDUCTIBLE Plan F                          Plan K
Area 2 Rates                                    Area 2 Rates
Effective Date 05-01-2009                       Effective Date 05-01-2009
    Attained   Gender   Preferred   Standard        Attained     Gender    Preferred   Standard
      Age                                             Age
       65       Male        $59       $87              65          Male      $71        $105
       65      Female       $56       $82              65         Female     $67         $99
     66-67      Male        $60       $89            66-67         Male      $72        $107
     66-67     Female       $57       $84            66-67        Female     $68        $101
     68-69      Male        $67      $99             68-69         Male      $81        $120
     68-69     Female       $64      $94             68-69        Female     $77        $113
     70-74     Unisex       $71      $105            70-74        Unisex     $85        $126
     75-79     Unisex       $81      $120            75-79        Unisex     $98        $145
     80-84     Unisex       $90      $133            80-84        Unisex     $108       $160
      85+      Unisex       $96      $142             85+         Unisex     $115       $172




                        Plan L
                        Area 2 Rates
                        Effective Date 05-01-2009
                        Attained     Gender    Preferred       Standard
                          Age
                           65         Male          $102        $151
                           65        Female          $96        $142
                         66-67        Male          $104        $154
                         66-67       Female          $98        $145
                         68-69        Male          $116        $173
                         68-69       Female         $110        $164
                         70-74       Unisex         $122        $182
                         75-79       Unisex         $141        $210
                         80-84       Unisex         $156        $232
                          85+        Unisex         $167        $248




6                                                                                SC81077RR 506
      Humana Medicare Supplement Monthly Premiums for Area 3
                               Area 3 includes the following counties:
        Abbeville, Allendale, Anderson, Edgefield, Fairfield, Greenwood, Laurens, McCormick,
                 Newberry, Oconee, Pickens, Richland, Saluda, Spartanburg, Sumter




Plan A                                              Plan B
Area 3 Rates                                        Area 3 Rates
Effective Date 05-01-2009                           Effective Date 05-01-2009
 Attained    Gender      Preferred   Standard        Attained      Gender      Preferred   Standard
   Age                                                 Age
    65        Male          $111       $164             65          Male         $117          $173
    65       Female         $104       $155             65         Female        $110          $163
  66-67       Male          $113       $168           66-67         Male         $119          $177
  66-67      Female         $106       $158           66-67        Female        $112          $166
  68-69       Male          $126       $188           68-69         Male         $133          $198
  68-69      Female         $120       $178           68-69        Female        $126          $187
  70-74      Unisex         $133       $198           70-74        Unisex        $140          $208
  75-79      Unisex         $153       $228           75-79        Unisex        $161          $240
  80-84      Unisex         $169       $252           80-84        Unisex        $178          $265
   85+       Unisex         $181       $270            85+         Unisex        $191          $284



Plan C                                              Plan F
Area 3 Rates                                        Area 3 Rates
Effective Date 05-01-2009                           Effective Date 05-01-2009
 Attained    Gender      Preferred   Standard        Attained     Gender      Preferred    Standard
   Age                                                 Age
    65        Male          $135       $201             65          Male         $136          $202
    65       Female         $127       $189             65         Female        $128          $190
  66-67       Male          $138       $205           66-67         Male         $139          $206
  66-67      Female         $129       $192           66-67        Female        $130          $194
  68-69       Male          $154       $229           68-69         Male         $155          $231
  68-69      Female         $146       $217           68-69        Female        $147          $218
  70-74      Unisex         $162       $241           70-74        Unisex        $163          $243
  75-79      Unisex         $187       $278           75-79        Unisex        $188          $280
  80-84      Unisex         $206       $307           80-84        Unisex        $208          $309
   85+       Unisex         $221       $329            85+         Unisex        $222          $332



SC81077RR 506                                                                                         7
         Humana Medicare Supplement Monthly Premiums for Area 3

                                         (Continued)




HIGH DEDUCTIBLE Plan F                          Plan K
Area 3 Rates                                    Area 3 Rates
Effective Date 05-01-2009                       Effective Date 05-01-2009
    Attained   Gender   Preferred   Standard        Attained     Gender    Preferred   Standard
      Age                                             Age
       65       Male        $55       $81              65          Male      $66         $98
       65      Female       $52       $76              65         Female     $62         $92
     66-67      Male        $56      $83             66-67         Male      $67         $99
     66-67     Female       $53      $78             66-67        Female     $63         $94
     68-69      Male        $62      $92             68-69         Male      $75        $111
     68-69     Female       $59      $87             68-69        Female     $71        $105
     70-74     Unisex       $66      $97             70-74        Unisex     $79        $117
     75-79     Unisex       $75      $112            75-79        Unisex     $91        $135
     80-84     Unisex       $83      $123            80-84        Unisex     $100       $149
      85+      Unisex       $89      $132             85+         Unisex     $107       $159




                        Plan L
                        Area 3 Rates
                        Effective Date 05-01-2009
                        Attained     Gender    Preferred       Standard
                          Age
                           65         Male          $95         $141
                           65        Female         $89         $132
                         66-67        Male          $97         $143
                         66-67       Female          $91        $135
                         68-69        Male          $108        $161
                         68-69       Female         $102        $152
                         70-74       Unisex         $114        $169
                         75-79       Unisex         $131        $195
                         80-84       Unisex         $145        $215
                          85+        Unisex         $155        $230




8                                                                                SC81077RR 506
Medicare Supplement Outline of Coverage
Premium Information
We can only change the renewal
premium for your policy if we also
change the renewal premium for all
policies that we issue like yours on a
Class basis. No change in premium
will be made because of the number
of claims you file, nor because of a
change in your health or your type
of work.
Your premiums will also be adjusted
following your 66th, 68th, 70th,
75th, 80th and 85th birthdays.


Disclosure
Use this outline to compare benefits
and premiums among policies.
                                         within 30 days of its delivery. If you   Complete answers are
Read your policy very                    do so, the policy will be void from      very important
carefully                                the effective date. We will refund
                                         your premium to you less any             When you fill out the application for
This is only an outline describing       claims paid.                             the new policy, be sure to truthfully
your policy’s most important                                                      and completely answer all questions
features. The policy is your insurance                                            about your medical and health
contract. You must read the policy       Policy replacement                       history. The company may cancel
itself to understand all of the rights                                            your policy and refuse to pay any
and duties of both you and your          If you are replacing another health      claims if you leave out or falsify
insurance company.                       insurance policy, do NOT cancel it       important medical information.
                                         until you have actually received your
                                         new policy and are sure you want to      Review the application carefully
Right to return policy                   keep it.                                 before you sign it. Be certain that
                                                                                  all information has been properly
We want you to fully understand
                                                                                  recorded.
and be satisfied with your policy. If    Notice
for any reason you are not satisfied,
return it to your agent or mail          This policy may not fully cover all of
it to:                                   your medical costs.
                                         Neither Humana Insurance Company
  Humana Insurance Company               nor its agents are connected with
  Attn: Medicare Enrollments             Medicare.
  P.O. Box 70329
  Louisville, KY 40202                   This Outline of Coverage does not
                                         give all the details of Medicare
                                         coverage. Contact your local Social
                                         Security Office or consult the
                                         “Medicare & You” handbook for
                                         more details.


SC81077RR 506                                                                                                           9
Exclusions and Limitations
Unless specifically stated otherwise, this Policy does not   10. Dental care or treatment, except as related to
cover any service or portion of a service that is not a          surgery of the jaw or related structures or setting
Medicare Eligible Expense, including but not limited to:         fractures of the jaw or facial bones.
                                                             11. Charges for which benefits are payable for those
1. Services that are provided before Your coverage               expenses under the mandatory part of any auto
   begins or after it ends.                                      insurance policy written to comply with
2. Services or supplies for any Injury or Sickness               a. a “no fault” insurance law” or
   that is covered by Worker’s Compensation or a                 b. an uninsured motorist insurance law.
   similar law.                                              12. Foot care in connection with corns, calluses, flat
3. Custodial care, transportation, or routine physical           feet, fallen arches, weak feet, chronic foot strain
   exams and routine immunizations not covered                   or symptomatic complaints of the feet not covered
   by Medicare.                                                  by Medicare.
4. Treatment of alcoholism and drug dependence,              13. Chiropractic care in connection with detection
   except to the extent covered by Medicare.                     and correction of structural imbalance, distortion,
5. Services or supplies for cosmetic surgery, unless             misalignment or subluxation of the vertebrae to
   a. You receive an Injury which results in bodily              remove nerve interference and its effects unless
       damage requiring the surgery; or                          covered by Medicare.
   b. It qualifies as reconstructive surgery performed       14. Home health care, or private duty nursing, including
       following surgery, and both the surgery and the           full-time nursing at home.
       reconstructive surgery are Medically Necessary        15. Prescription drugs.
       and covered by Medicare.                              16. Treatment of any Injury or Sickness caused by war or
6. Charges made by a Hospital owned or run by                    any act of war, whether declared or undeclared.
   the United States Government or a state                   17. Charges paid for by Medicare or charges that would
   government unless You are legally required to                 have been paid for by Medicare if You were enrolled
   pay for such charges.                                         in Parts A and B of Medicare.
7. Charges in connection with education or training or       18. The Medicare Part A and Part B Deductibles.
   medical services provided by a member of                  19. Physician charges in excess of Medicare Eligible
   your family.                                                  Expenses, except for Plan F or High Deductible
8. Charges for which You are paid or entitled to                 plan F.
   payment by or through a public program, other             20. Care received outside the United States.
   than Medicaid.                                            21. Charges which You are not legally required to pay
9. Charges for eyeglasses, hearing aids, contact lenses          or which would not have been made in the absence
   or the examination or fitting of such aids, not               of insurance.
   covered by Medicare.




10                                                                                                SC81077RR 506
PLAN A
MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD
*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have
been out of the hospital and have not received skilled care in any other facility for 60 days in a row.


                     Services                     Medicare Pays               Plan Pays              You Pay
 HOSPITALIZATION*
 Semiprivate room and board, general nursing
 and miscellaneous services and supplies

 First 60 days                                    All but $1,068        $0                      $1,068
                                                                                                (Part A deductible)

 61st through 90th day                            All but $267 a day    $267 a day              $0

 91st day and after
 • while using 60 lifetime reserve days           All but $534 a day    $534 a day              $0
 • once lifetime reserve days are used:
   - additional 365 days                          $0                    100% of Medicare        $0**
                                                                        eligible expenses

  - beyond the additional 365 days                $0                    $0                      All costs

 SKILLED NURSING FACILITY CARE*
 You must meet Medicare’s requirements,
 including having been in a hospital
 for at least three days and entered a
 Medicare-approved facility within
 30 days after leaving the hospital

 First 20 days                                    All approved amounts $0                       $0

 21st through 100th day                           All but $133.50 a day $0                      Up to $133.50 a day

 101st day and after                              $0                    $0                      All costs

 BLOOD
 First three pints                                $0                    Three pints             $0

 Additional amounts                               100%                  $0                      $0

 HOSPICE CARE
 Available as long as your doctor                 All but limited        $0                     Balance
 certifies you are terminally ill and you elect   coinsurance for
 to receive these services                        outpatient drugs and
                                                  inpatient respite care

**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and
will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core
Benefits.” During this time the hospital is prohibited from billing you for the balance based on any difference between
its billed charges and the amount Medicare would have paid.



SC81077RR 506                                                                                                         11
PLAN A
MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR
*Once you have been billed $135 of Medicare-approved amounts for covered services (which are noted with an
asterisk), your Part B deductible will have been met for the calendar year.


                     Services                    Medicare Pays          Plan Pays             You Pay
 MEDICAL EXPENSES – IN OR
 OUT OF THE HOSPITAL AND OUTPATIENT
 HOSPITAL TREATMENT, such as physician’s
 services, inpatient and outpatient medical
 and surgical services and supplies, physical
 and speech therapy, diagnostic tests, durable
 medical equipment

 First $135 of Medicare-approved amounts*        $0                $0                    $135
                                                                                         (Part B deductible)

 Remainder of Medicare-approved amounts          Generally 80%     Generally 20%         $0

 PART B EXCESS CHARGES
 (above Medicare-approved amounts)               $0                $0                    All costs

 BLOOD
 First three pints                               $0                All costs             $0

 Next $135 of Medicare-approved amounts*         $0                $0                    $135
                                                                                         (Part B deductible)

 Remainder of Medicare-approved amounts          80%               20%                   $0

 CLINICAL LABORATORY SERVICES –
 TESTS FOR DIAGNOSTIC SERVICES                   100%              $0                    $0


                                           Medicare Parts A & B
                     Services                    Medicare Pays          Plan Pays             You Pay
 HOME HEALTH CARE
 MEDICARE-APPROVED SERVICES

 Medically necessary skilled care services and   100%              $0                    $0
 medical supplies

 Durable medical equipment
  First $135 of Medicare-approved amounts*       $0                $0                    $135
                                                                                         (Part B deductible)

  Remainder of Medicare-approved amounts         80%               20%                   $0




12                                                                                            SC81077RR 506
PLAN B
MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD
*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have
been out of the hospital and have not received skilled care in any other facility for 60 days in a row.


                     Services                     Medicare Pays               Plan Pays              You Pay
 HOSPITALIZATION*
 Semiprivate room and board, general nursing
 and miscellaneous services and supplies

 First 60 days                                    All but $1,068        $1,068                  $0
                                                                        (Part A deductible)

 61st through 90th day                            All but $267 a day    $267 a day              $0

 91st day and after
 • while using 60 lifetime reserve days           All but $534 a day    $534 a day              $0
 • once lifetime reserve days are used:
   - additional 365 days                          $0                    100% of Medicare        $0**
                                                                        eligible expenses

  - beyond the additional 365 days                $0                    $0                      All costs

 SKILLED NURSING FACILITY CARE*
 You must meet Medicare’s requirements,
 including having been in a hospital
 for at least three days and entered a
 Medicare-approved facility within
 30 days after leaving the hospital

 First 20 days                                    All approved amounts $0                       $0

 21st through 100th day                           All but $133.50 a day $0                      Up to $133.50 a day

 101st day and after                              $0                    $0                      All costs

 BLOOD
 First three pints                                $0                    Three pints             $0

 Additional amounts                               100%                  $0                      $0

 HOSPICE CARE
 Available as long as your doctor                 All but limited        $0                     Balance
 certifies you are terminally ill and you elect   coinsurance for
 to receive these services                        outpatient drugs and
                                                  inpatient respite care

**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and
will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core
Benefits.” During this time the hospital is prohibited from billing you for the balance based on any difference between
its billed charges and the amount Medicare would have paid.



SC81077RR 506                                                                                                         13
PLAN B
MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR
*Once you have been billed $135 of Medicare-approved amounts for covered services (which are noted with an
asterisk), your Part B deductible will have been met for the calendar year.

                     Services                    Medicare Pays          Plan Pays             You Pay
 MEDICAL EXPENSES – IN OR
 OUT OF THE HOSPITAL AND OUTPATIENT
 HOSPITAL TREATMENT, such as physician’s
 services, inpatient and outpatient medical
 and surgical services and supplies, physical
 and speech therapy, diagnostic tests, durable
 medical equipment

 First $135 of Medicare-approved amounts*        $0                $0                    $135
                                                                                         (Part B deductible)

 Remainder of Medicare-approved amounts          Generally 80%     Generally 20%         $0

 PART B EXCESS CHARGES
 (above Medicare-approved amounts)               $0                $0                    All costs

 BLOOD
 First three pints                               $0                All costs             $0

 Next $135 of Medicare-approved amounts*         $0                $0                    $135
                                                                                         (Part B deductible)

 Remainder of Medicare-approved amounts          80%               20%                   $0

 CLINICAL LABORATORY SERVICES –
 TESTS FOR DIAGNOSTIC SERVICES                   100%              $0                    $0


                                           Medicare Parts A & B
                     Services                    Medicare Pays          Plan Pays             You Pay
 HOME HEALTH CARE
 MEDICARE-APPROVED SERVICES

 Medically necessary skilled care services and   100%              $0                    $0
 medical supplies

 Durable medical equipment
  First $135 of Medicare-approved amounts*       $0                $0                    $135
                                                                                         (Part B deductible)

  Remainder of Medicare-approved amounts         80%               20%                   $0




14                                                                                            SC81077RR 506
PLAN C
MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD
*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have
been out of the hospital and have not received skilled care in any other facility for 60 days in a row.


                     Services                     Medicare Pays               Plan Pays               You Pay
 HOSPITALIZATION*
 Semiprivate room and board, general nursing
 and miscellaneous services and supplies

 First 60 days                                    All but $1,068        $1,068                   $0
                                                                        (Part A deductible)

 61st through 90th day                            All but $267 a day    $267 a day               $0

 91st day and after
 • while using 60 lifetime reserve days           All but $534 a day    $534 a day               $0
 • once lifetime reserve days are used:
   - additional 365 days                          $0                    100% of Medicare         $0**
                                                                        eligible expenses

  - beyond the additional 365 days                $0                    $0                       All costs

 SKILLED NURSING FACILITY CARE*
 You must meet Medicare’s requirements,
 including having been in a hospital
 for at least three days and entered a
 Medicare-approved facility within
 30 days after leaving the hospital

 First 20 days                                    All approved amounts $0                        $0

 21st through 100th day                           All but $133.50 a day Up to $133.50 a day      $0

 101st day and after                              $0                    $0                       All costs

 BLOOD
 First three pints                                $0                    Three pints              $0

 Additional amounts                               100%                  $0                       $0

 HOSPICE CARE
 Available as long as your doctor                 All but limited        $0                      Balance
 certifies you are terminally ill and you elect   coinsurance for
 to receive these services                        outpatient drugs and
                                                  inpatient respite care

**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and
will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core
Benefits.” During this time the hospital is prohibited from billing you for the balance based on any difference between
its billed charges and the amount Medicare would have paid.



SC81077RR 506                                                                                                         15
PLAN C
MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR
*Once you have been billed $135 of Medicare-approved amounts for covered services (which are noted with an
asterisk), your Part B deductible will have been met for the calendar year.


                     Services                    Medicare Pays          Plan Pays             You Pay
 MEDICAL EXPENSES – IN OR
 OUT OF THE HOSPITAL AND OUTPATIENT
 HOSPITAL TREATMENT, such as physician’s
 services, inpatient and outpatient medical
 and surgical services and supplies, physical
 and speech therapy, diagnostic tests, durable
 medical equipment

 First $135 of Medicare-approved amounts*        $0                $135                  $0
                                                                   (Part B deductible)

 Remainder of Medicare-approved amounts          Generally 80%     Generally 20%         $0

 PART B EXCESS CHARGES
 (above Medicare-approved amounts)               $0                $0                    All costs

 BLOOD
 First three pints                               $0                All costs             $0

 Next $135 of Medicare-approved amounts*         $0                $135                  $0
                                                                   (Part B deductible)

 Remainder of Medicare-approved amounts          80%               20%                   $0

 CLINICAL LABORATORY SERVICES –
 TESTS FOR DIAGNOSTIC SERVICES                   100%              $0                    $0


                                           Medicare Parts A & B
                     Services                    Medicare Pays          Plan Pays             You Pay
 HOME HEALTH CARE
 MEDICARE-APPROVED SERVICES

 Medically necessary skilled care services and   100%              $0                    $0
 medical supplies

 Durable medical equipment
  First $135 of Medicare-approved amounts*       $0                $135                  $0
                                                                   (Part B deductible)

  Remainder of Medicare-approved amounts         80%               20%                   $0




16                                                                                            SC81077RR 506
PLAN C

                        Other Benefits - Not Covered By Medicare
                 Services                     Medicare Pays        Plan Pays           You Pay
FOREIGN TRAVEL –
NOT COVERED BY MEDICARE

Medically necessary emergency care services
beginning during the first 60 days of each
trip outside of the USA

 First $250 each calendar year                $0              $0                   $250

 Remainder of charges                         $0              80% to a lifetime    20% and amounts
                                                              maximum benefit of   over the $50,000
                                                              $50,000              lifetime maximum




SC81077RR 506                                                                                         17
PLAN F
MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD
*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have
been out of the hospital and have not received skilled care in any other facility for 60 days in a row.


                     Services                     Medicare Pays               Plan Pays               You Pay
 HOSPITALIZATION*
 Semiprivate room and board, general nursing
 and miscellaneous services and supplies

 First 60 days                                    All but $1,068        $1,068                   $0
                                                                        (Part A deductible)

 61st through 90th day                            All but $267 a day    $267 a day               $0

 91st day and after
 • while using 60 lifetime reserve days           All but $534 a day    $534 a day               $0
 • once lifetime reserve days are used:
   - additional 365 days                          $0                    100% of Medicare         $0**
                                                                        eligible expenses

  - beyond the additional 365 days                $0                    $0                       All costs

 SKILLED NURSING FACILITY CARE*
 You must meet Medicare’s requirements,
 including having been in a hospital
 for at least three days and entered a
 Medicare-approved facility within
 30 days after leaving the hospital

 First 20 days                                    All approved amounts $0                        $0

 21st through 100th day                           All but $133.50 a day Up to $133.50 a day      $0

 101st day and after                              $0                    $0                       All costs

 BLOOD
 First three pints                                $0                    Three pints              $0

 Additional amounts                               100%                  $0                       $0

 HOSPICE CARE
 Available as long as your doctor                 All but limited        $0                      Balance
 certifies you are terminally ill and you elect   coinsurance for
 to receive these services                        outpatient drugs and
                                                  inpatient respite care

**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and
will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core
Benefits.” During this time the hospital is prohibited from billing you for the balance based on any difference between
its billed charges and the amount Medicare would have paid.



18                                                                                                    SC81077RR 506
PLAN F
MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR
*Once you have been billed $135 of Medicare-approved amounts for covered services (which are noted with an
asterisk), your Part B deductible will have been met for the calendar year.


                     Services                    Medicare Pays          Plan Pays             You Pay
 MEDICAL EXPENSES – IN OR
 OUT OF THE HOSPITAL AND OUTPATIENT
 HOSPITAL TREATMENT, such as physician’s
 services, inpatient and outpatient medical
 and surgical services and supplies, physical
 and speech therapy, diagnostic tests, durable
 medical equipment

 First $135 of Medicare-approved amounts*        $0                $135                  $0
                                                                   (Part B deductible)

 Remainder of Medicare-approved amounts          Generally 80%     Generally 20%         $0

 PART B EXCESS CHARGES
 (above Medicare-approved amounts)               $0                100%                  $0

 BLOOD
 First three pints                               $0                All costs             $0

 Next $135 of Medicare-approved amounts*         $0                $135                  $0
                                                                   (Part B deductible)

 Remainder of Medicare-approved amounts          80%               20%                   $0

 CLINICAL LABORATORY SERVICES –
 TESTS FOR DIAGNOSTIC SERVICES                   100%              $0                    $0


                                           Medicare Parts A & B
                     Services                    Medicare Pays          Plan Pays             You Pay
 HOME HEALTH CARE
 MEDICARE-APPROVED SERVICES

 Medically necessary skilled care services and   100%              $0                    $0
 medical supplies

 Durable medical equipment
  First $135 of Medicare-approved amounts*       $0                $135                  $0
                                                                   (Part B deductible)

  Remainder of Medicare-approved amounts         80%               20%                   $0




SC81077RR 506                                                                                                19
PLAN F

                        Other Benefits - Not Covered By Medicare
                 Services                         Medicare Pays        Plan Pays           You Pay
FOREIGN TRAVEL –
NOT COVERED BY MEDICARE

Medically necessary emergency care services
beginning during the first 60 days of each trip
outside of the USA

 First $250 each calendar year                    $0              $0                   $250

 Remainder of charges                             $0              80% to a lifetime    20% and amounts
                                                                  maximum benefit of   over the $50,000
                                                                  $50,000              lifetime maximum




20                                                                                        SC81077RR 506
HIGH DEDUCTIBLE PLAN F
MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD
*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been
out of the hospital and have not received skilled care in any other facility for 60 days in a row.

**This high deductible plan pays the same or offers the same benefits as Plan F after one has paid a calendar year
$2,000 deductible. Benefits from the high deductible plan F will not begin until out-of-pocket expenses are $2,000.
Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes
the Medicare deductibles for Part A and Part B, but does not include the plan’s separate foreign travel emergency
deductible.


                                                                            After You               In Addition
                                                                            Pay $2,000               To $2,000
                                                                           Deductible,**           Deductible,**
                  Services                        Medicare Pays              Plan Pays                You Pay
 HOSPITALIZATION*
 Semiprivate room and board, general nursing
 and miscellaneous services and supplies

 First 60 days                                   All but $1,068           $1,068                  $0
                                                                          (Part A deductible)

 61st through 90th day                           All but $267 a day       $267 a day              $0

 91st day and after
 • while using 60 lifetime reserve days          All but $534 a day       $534 a day              $0
 • once lifetime reserve days are used:
   - additional 365 days                         $0                       100% of Medicare        $0***
                                                                          eligible expenses

  - beyond the additional 365 days               $0                       $0                      All costs

 SKILLED NURSING FACILITY CARE*
 You must meet Medicare’s requirements,
 including having been in a hospital
 for at least three days and entered a
 Medicare-approved facility within
 30 days after leaving the hospital

 First 20 days                                   All approved amounts $0                          $0

 21st through 100th day                          All but $133.50 a day Up to $133.50 a day        $0

 101st day and after                             $0                       $0                      All costs

***NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place
of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in
the policy’s “Core Benefits.” During this time the hospital is prohibited from billing you for the balance based on any
difference between its billed charges and the amount Medicare would have paid.



SC81077RR 506                                                                                                         21
HIGH DEDUCTIBLE PLAN F
MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD (CONTINUED)
**This high deductible plan pays the same or offers the same benefits as Plan F after one has paid a calendar year
$2,000 deductible. Benefits from the high deductible plan F will not begin until out-of-pocket expenses are $2,000.
Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes
the Medicare deductibles for Part A and Part B, but does not include the plan’s separate foreign travel emergency
deductible.


                                                                           After You               In Addition
                                                                           Pay $2,000               To $2,000
                                                                          Deductible,**           Deductible,**
                     Services                     Medicare Pays             Plan Pays                You Pay
 BLOOD
 First three pints                                $0                    Three pints              $0

 Additional amounts                               100%                  $0                       $0

 HOSPICE CARE
 Available as long as your doctor                 All but limited        $0                      Balance
 certifies you are terminally ill and you elect   coinsurance for
 to receive these services                        outpatient drugs and
                                                  inpatient respite care




22                                                                                                    SC81077RR 506
HIGH DEDUCTIBLE PLAN F
MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR
*Once you have been billed $135 of Medicare-approved amounts for covered services (which are noted with an
asterisk), your Part B deductible will have been met for the calendar year.

**This high deductible plan pays the same or offers the same benefits as Plan F after one has paid a calendar year
$2,000 deductible. Benefits from the high deductible plan F will not begin until out-of-pocket expenses are $2,000.
Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes
the Medicare deductibles for Part A and Part B, but does not include the plan’s separate foreign travel emergency
deductible.


                                                                           After You               In Addition
                                                                           Pay $2,000               To $2,000
                                                                          Deductible,**           Deductible,**
                     Services                    Medicare Pays              Plan Pays                You Pay
 MEDICAL EXPENSES – IN OR
 OUT OF THE HOSPITAL AND OUTPATIENT
 HOSPITAL TREATMENT, such as physician’s
 services, inpatient and outpatient medical
 and surgical services and supplies, physical
 and speech therapy, diagnostic tests, durable
 medical equipment

 First $135 of Medicare-approved amounts*        $0                      $135                    $0
                                                                         (Part B deductible)

 Remainder of Medicare-approved amounts          Generally 80%           Generally 20%           $0

 PART B EXCESS CHARGES
 (above Medicare-approved amounts)               $0                      100%                    $0

 BLOOD
 First three pints                               $0                      All costs               $0

 Next $135 of Medicare-approved amounts*         $0                      $135                    $0
                                                                         (Part B deductible)

 Remainder of Medicare-approved amounts          80%                     20%                     $0

 CLINICAL LABORATORY SERVICES –
 TESTS FOR DIAGNOSTIC SERVICES                   100%                    $0                      $0




SC81077RR 506                                                                                                         23
HIGH DEDUCTIBLE PLAN F
MEDICARE (PARTS A             AND    B)
*Once you have been billed $135 of Medicare-approved amounts for covered services (which are noted with an
asterisk), your Part B deductible will have been met for the calendar year.

**This high deductible plan pays the same or offers the same benefits as Plan F after one has paid a calendar year
$2,000 deductible. Benefits from the high deductible plan F will not begin until out-of-pocket expenses are $2,000.
Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes
the Medicare deductibles for Part A and Part B, but does not include the plan’s separate foreign travel emergency
deductible.


                                                                           After You               In Addition
                                                                           Pay $2,000               To $2,000
                                                                          Deductible,**           Deductible,**
                  Services                         Medicare Pays            Plan Pays                You Pay
 HOME HEALTH CARE
 MEDICARE-APPROVED SERVICES

 Medically necessary skilled care services and     100%                 $0                       $0
 medical supplies

 Durable medical equipment
  First $135 of Medicare-approved amounts* $0                           $135                     $0
                                                                        (Part B deductible)

  Remainder of Medicare-approved amounts           80%                  20%                      $0

                         Other Benefits - Not Covered By Medicare

                                                                           After You               In Addition
                                                                           Pay $2,000               To $2,000
                                                                          Deductible,**           Deductible,**
                  Services                         Medicare Pays            Plan Pays                You Pay
 FOREIGN TRAVEL –
 NOT COVERED BY MEDICARE

 Medically necessary emergency care services
 beginning during the first 60 days of each trip
 outside of the USA

 First $250 each calendar year                     $0                   $0                       $250

 Remainder of charges                              $0                   80% to a lifetime        20% and amounts
                                                                        maximum benefit of       over the $50,000
                                                                        $50,000                  lifetime maximum


24                                                                                                    SC81077RR 506
PLAN K
*You will pay half of the cost-sharing of some covered services until you reach the annual out-of-pocket limit of
$4,620 each calendar year. The amounts that count toward your annual limit are noted with diamonds (u) in the
chart below. Once you reach the annual limit, the plan pays 100% of your Medicare copayment and coinsurance
for the rest of the calendar year. However, this limit does NOT include charges from your provider that
exceed Medicare-approved amounts (these are called "Excess Charges") and you will be responsible for
paying this difference in the amount charged by your provider and the amount paid by Medicare for the
item or service.

MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD
**A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have
been out of the hospital and have not received skilled care in any other facility for 60 days in a row.


                 Services                       Medicare Pays               Plan Pays               You Pay*
 HOSPITALIZATION**
 Semiprivate room and board, general nursing
 and miscellaneous services and supplies

 First 60 days                                  All but $1,068         $534                    $534
                                                                       (50% of Part A          (50% of Part A
                                                                       deductible)             deductible)u

 61st through 90th day                          All but $267 a day     $267 a day              $0

 91st day and after
 • while using 60 lifetime reserve days         All but $534 a day     $534 a day              $0
 • once lifetime reserve days are used:
   - additional 365 days                        $0                     100% of Medicare        $0***
                                                                       eligible expenses

  - beyond the additional 365 days              $0                     $0                      All costs

 SKILLED NURSING FACILITY CARE**
 You must meet Medicare’s requirements,
 including having been in a hospital
 for at least three days and entered a
 Medicare-approved facility within
 30 days after leaving the hospital

 First 20 days                                  All approved amounts $0                        $0

 21st through 100th day                         All but $133.50 a day Up to $66.75 a day       Up to $66.75 a dayu

 101st day and after                            $0                     $0                      All costs




SC81077RR 506                                                                                                     25
PLAN K
MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD (CONTINUED)
                    Services                     Medicare Pays               Plan Pays                You Pay*
BLOOD
First three pints                                $0                     50%                      50%u

Additional amounts                               100%                   $0                       $0

HOSPICE CARE
Available as long as your doctor                 Generally, most        50% of coinsurance       50% of coinsurance
certifies you are terminally ill and you elect   Medicare eligible      or copayments            or copaymentsu
to receive these services                        expenses for
                                                 outpatient drugs and
                                                 inpatient respite care

***NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare
and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s
“Core Benefits.” During this time the hospital is prohibited from billing you for the balance based on any difference
between its billed charges and the amount Medicare would have paid.




26                                                                                                    SC81077RR 506
PLAN K
MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR
****Once you have been billed $135 of Medicare-approved amounts for covered services (which are noted with an
asterisk), your Part B deductible will have been met for the calendar year.


                     Services                    Medicare Pays           Plan Pays              You Pay*
 MEDICAL EXPENSES – IN OR
 OUT OF THE HOSPITAL AND OUTPATIENT
 HOSPITAL TREATMENT, such as physician’s
 services, inpatient and outpatient medical
 and surgical services and supplies, physical
 and speech therapy, diagnostic tests, durable
 medical equipment

 First $135 of Medicare-approved                 $0                 $0                     $135 (Part B
 amounts****                                                                               deductible)****u

 Preventive Benefits for Medicare                Generally 75% or   Remainder of           All costs above
 covered services                                more of Medicare   Medicare approved      Medicare approved
                                                 approved amounts   amounts                amounts
 Remainder of Medicare-approved amounts          Generally 80%      Generally 10%          Generally 10%u
 PART B EXCESS CHARGES
 (above Medicare-approved amounts)               $0                 $0                     All costs (and they
                                                                                           do not count toward
                                                                                           annual out-of-pocket
                                                                                           limit of $4,620)*

 BLOOD
 First three pints                               $0                 50%                    50%u

 Next $135 of Medicare-approved                  $0                 $0                     $135 (Part B
 amounts****                                                                               deductible)****u

 Remainder of Medicare-approved amounts          Generally 80%      Generally 10%          Generally 10%u

 CLINICAL LABORATORY SERVICES –
 TESTS FOR DIAGNOSTIC SERVICES                   100%               $0                     $0

*This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $4,620 per year.
However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these
are called "Excess Charges") and you will be responsible for paying this difference in the amount charged by your
provider and the amount paid by Medicare for the item or service.




SC81077RR 506                                                                                                  27
PLAN K

                                           Medicare Parts A & B
                  Services                       Medicare Pays             Plan Pays              You Pay*
 HOME HEALTH CARE
 MEDICARE-APPROVED SERVICES

 Medically necessary skilled care services and   100%                 $0                     $0
 medical supplies

 Durable medical equipment
  First $135 of Medicare-approved                $0                   $0                     $135
  amounts*****                                                                               (Part B deductible)u

  Remainder of Medicare-approved amounts         80%                  10%                    10%u

*****Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People
with Medicare.




28                                                                                                SC81077RR 506
PLAN L
*You will pay one-fourth of the cost-sharing of some covered services until you reach the annual out-of-pocket limit
of $2,310 each calendar year. The amounts that count toward your annual limit are noted with diamonds (u) in the
chart below. Once you reach the annual limit, the plan pays 100% of your Medicare copayment and coinsurance
for the rest of the calendar year. However, this limit does NOT include charges from your provider that
exceed Medicare-approved amounts (these are called "Excess Charges") and you will be responsible for
paying this difference in the amount charged by your provider and the amount paid by Medicare for the
item or service.

MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD
**A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have
been out of the hospital and have not received skilled care in any other facility for 60 days in a row.


                  Services                      Medicare Pays               Plan Pays               You Pay*
 HOSPITALIZATION**
 Semiprivate room and board, general nursing
 and miscellaneous services and supplies

 First 60 days                                  All but $1,068         $801                    $267
                                                                       (75% of Part A          (25% of Part A
                                                                       deductible)             deductible)u

 61st through 90th day                          All but $267 a day     $267 a day              $0

 91st day and after
 • while using 60 lifetime reserve days         All but $534 a day     $534 a day              $0
 • once lifetime reserve days are used:
   - additional 365 days                        $0                     100% of Medicare        $0***
                                                                       eligible expenses

   - beyond the additional 365 days             $0                     $0                      All costs

 SKILLED NURSING FACILITY CARE**
 You must meet Medicare’s requirements,
 including having been in a hospital
 for at least three days and entered a
 Medicare-approved facility within
 30 days after leaving the hospital

 First 20 days                                  All approved amounts $0                        $0

 21st through 100th day                         All but $133.50 a day Up to $100.13 a day      Up to $33.37 a dayu

 101st day and after                            $0                     $0                      All costs




SC81077RR 506                                                                                                     29
PLAN L
MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD (CONTINUED)

                    Services                     Medicare Pays                Plan Pays               You Pay*
BLOOD
First three pints                                $0                      75%                     25%u

Additional amounts                               100%                    $0                      $0

HOSPICE CARE
Available as long as your doctor                 Generally, most        75% of coinsurance       25% of coinsurance
certifies you are terminally ill and you elect   Medicare eligible      or copayments            or copaymentsu
to receive these services                        expenses for
                                                 outpatient drugs and
                                                 inpatient respite care

***NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare
and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s
“Core Benefits.” During this time the hospital is prohibited from billing you for the balance based on any difference
between its billed charges and the amount Medicare would have paid.




30                                                                                                    SC81077RR 506
PLAN L
MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR
****Once you have been billed $135 of Medicare-approved amounts for covered services (which are noted with an
asterisk), your Part B deductible will have been met for the calendar year.


                     Services                    Medicare Pays           Plan Pays              You Pay*
 MEDICAL EXPENSES – IN OR
 OUT OF THE HOSPITAL AND OUTPATIENT
 HOSPITAL TREATMENT, such as physician’s
 services, inpatient and outpatient medical
 and surgical services and supplies, physical
 and speech therapy, diagnostic tests, durable
 medical equipment

 First $135 of Medicare-approved                 $0                 $0                     $135 (Part B
 amounts****                                                                               deductible)****u

 Preventive Benefits for Medicare                Generally 75% or   Remainder of           All costs above
 covered services                                more of Medicare   Medicare approved      Medicare approved
                                                 approved amounts   amounts                amounts
 Remainder of Medicare-approved amounts          Generally 80%      Generally 15%          Generally 5%u
 PART B EXCESS CHARGES
 (above Medicare-approved amounts)               $0                 $0                     All costs (and they
                                                                                           do not count toward
                                                                                           annual out-of-pocket
                                                                                           limit of $2,310)*

 BLOOD
 First three pints                               $0                 75%                    25%u

 Next $135 of Medicare-approved                  $0                 $0                     $135 (Part B
 amounts****                                                                               deductible)****u

 Remainder of Medicare-approved amounts          Generally 80%      Generally 15%          Generally 5%u

 CLINICAL LABORATORY SERVICES –
 TESTS FOR DIAGNOSTIC SERVICES                   100%               $0                     $0

*This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $2,310 per year.
However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these
are called "Excess Charges") and you will be responsible for paying this difference in the amount charged by your
provider and the amount paid by Medicare for the item or service.




SC81077RR 506                                                                                                  31
PLAN L

                                           Medicare Parts A & B
                  Services                       Medicare Pays             Plan Pays              You Pay*
 HOME HEALTH CARE
 MEDICARE-APPROVED SERVICES

 Medically necessary skilled care services and   100%                 $0                     $0
 medical supplies

 Durable medical equipment
  First $135 of Medicare-approved                $0                   $0                     $135
  amounts*****                                                                               (Part B deductible)u

  Remainder of Medicare-approved amounts         80%                  15%                    5%u

*****Medicare benefits are subject to change. Please consult the latest Guide to Health Insurance for People
with Medicare.




32                                                                                                SC81077RR 506
SC81077RR 506   Insured by Humana Insurance Company   509

								
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