Medicare Supplement and Medicare SELECT Plans A, B, C, Innovative F, G, K and N are available.

Transcription

1 Medicare Supplemen and Medicare SELECT Plans A, B, C, Innovaive F, G, K and N are available. These chars show he benefis included in each of he sandard Medicare supplemen plans. Every company mus make available Sandard Plan A, B, C or F. Some plans may no be available in Your sae. BASIC BENEFITS for Plans A-N: Hospializaion Par A coinsurance plus coverage for 365 addiional days in Your lifeime afer Medicare benefis end. Medical Expenses Par B coinsurance (generally 20% of Medicare-approved expenses), or copaymens for hospial oupaien services. Plans K, L and N require insureds o pay a porion of Par B coinsurance or copaymens. Blood Firs hree pins of blood each year. Hospice Par A coinsurance. s A s B s C D F s F *F* s Innovaive F s G s K** L** M s N Basic, including 100% Par B coinsurance Basic, including 100% Par B coinsurance Par A Deducible Basic, including 100% Par B coinsurance Skilled Nursing Faciliy Coinsurance Par A Deducible Par B Deducible Foreign Travel Emergency Basic, including 100% Par B coinsurance Skilled Nursing Faciliy Coinsurance Par A Deducible Foreign Travel Emergency Basic, including 100% Par B coinsurance* Skilled Nursing Faciliy Coinsurance Par A Deducible Par B Deducible Par B Excess (100%) Foreign Travel Emergency +Basic Benefis Skilled Nursing Faciliy Coinsurance Par A Deducible Par B Deducible Par B Excess (100%) Foreign Travel Emergency +Innovaive Benefis+ Basic, including 100% Par B coinsurance Skilled Nursing Faciliy Coinsurance Par A Deducible Par B Excess (100%) Foreign Travel Emergency Hospializaion and prevenaive care paid a 100%; oher basic benefis paid a 50% 50% Skilled Nursing Faciliy Coinsurance 50% Par A Deducible Ou-of-pocke limi $4,800; benefis paid a 100% afer limi reached Hospializaion and prevenaive care paid a 100%; oher basic benefis paid a 75% 75% Skilled Nursing Faciliy Coinsurance 75% Par A Deducible Ou-of -pocke limi $2,400; benefis paid a 100% afer limi reached Basic, including 100% Par B coinsurance Skilled Nursing Faciliy Coinsurance 50% Par A Deducible Foreign Travel Emergency Basic, including 100% Par B coinsurance, excep up o $20 copaymen for office visi, and up o $50 copaymen for ER Skilled Nursing Faciliy Coinsurance Par A Deducible Foreign Travel Emergency *Plan F also has an opion called a high deducible Plan F. This high deducible plan pays he same benefis as Plans F afer one has paid a calendar year $2,110 deducible. Benefis from high deducible Plan F will no begin unil ou-of-pocke expenses exceed $2,110. Ou-of-pocke expenses for his deducible are expenses ha would ordinarily be paid by he policy. These expenses include he Medicare deducibles for Par A and Par B, bu do no include he plan s separae foreign ravel emergency deducible. +Innovaive F includes innovaive benefis no conained in oher sandardized Medicare Supplemen Plans. They include, subjec o plan limiaions: (a) access o nurse advice elephone service, (b) annual physical examinaion, (c) prevenive denal care, (d) rouine vision care, and (e) rouine hearing exam. These innovaive benefis are no subjec o nework resricions s Plans (A, B, C, Innovaive F, G, K, N) are he Medicare Supplemen and Medicare SELECT Plans available. Medicare SELECT plans conain resricions on your use of hospials. **Once you reach he annual limi, he plan pays 100% of he Medicare copaymens, coinsurance, and deducibles for he res of he calendar year. The ou-of-pocke annual limi does NOT include charges from your provider ha exceed Medicare-approved amouns, called Excess Charges. You will be responsible for paying excess charges. The ou-of-pocke annual limi will increase each year for inflaion. Medicare SELECT plans conain resricions on Your use of hospials. See Oulines of Coverage for deails and excepions. PA OC (01/13) 2

2 PREMIUM INFORMATION Premiums will change wih each change in aained age. Addiionally, we reserve he righ o revise he able of premium raes. We can only raise your premiums under hese circumsances if we raise he premiums for all policies like Yours in Pennsylvania. Premiums are aained age raed and based on he mode of he premium paymen seleced. We will noify You hiry (30) days prior o any premium change. Premium in he char below is subjec o change. Your rae changes auomaically in he monh of your policy anniversary each year afer you ener a new age incremen.) (INSERT PREMIUM INFORMATION PAGES) PA OC (01/13) 3

3 OUTLINE OF MEDICARE SUPPLEMENT COVERAGE DISCLOSURES PREMIUM INFORMATON DISCLOSURES Use his ouline o compare benefis and premiums among policies. Premiums will change wih each change in aained age. Addiionally, we reserve he righ o revise he able of premium raes. We can only raise your premiums under hese circumsances if we raise he premiums for all policies like Yours in Pennsylvania. Premiums are aained age raed and based on he mode of he premium paymen seleced. We will noify You hiry (30) days prior o any premium change. (Your rae changes auomaically in he monh of your policy anniversary each year afer you ener a new age incremen.) READ YOUR POLICY VERY CAREFULLY This is only an ouline describing Your policy s mos imporan feaures. The policy is Your insurance conrac. You mus read he policy iself o undersand all of he righs and duies of boh You and Your insurance company. RIGHT TO RETURN POLICY If You are no saisfied wih Your policy, You may reurn i o us a P.O. Box 5348, Bellingham, WA If you send he policy back o us wihin hiry (30) days afer You receive i, we will rea he policy as if i had never been issued and reurn all of your paymens. POLICY REPLACEMENT If You are replacing anoher healh insurance policy, do NOT cancel i unil You have acually received Your new policy and are sure You wan o keep i. NOTICE This policy may no fully cover all of Your medical coss. Neiher Serling Life Insurance Company nor is agens are conneced wih Medicare. This ouline of coverage does no give all he deails of Medicare coverage. Conac your local Social Securiy Office or consul Medicare and You for more deails. COMPLETE ANSWERS ARE VERY IMPORTANT When you fill ou he applicaion for he new policy, be sure o answer ruhfully and compleely all quesions abou your medical and healh hisory. The company may cancel your policy and refuse o pay any claims if you leave ou or falsify imporan medical informaion. Review he applicaion carefully before You sign i. Be cerain ha all informaion has been properly recorded. PA OC (01/13) 4

4 NETWORK HOSPITAL RESTRICTIONS MEDICARE SELECT PRODUCTS ONLY Excep as specified below, Par A and Par B (hospial or faciliy) benefis will no be paid for services provided a a Hospial which is no a Nework Hospial and Par B (hospial or faciliy) benefis for oupaien surgery will only be provided if performed a a docor s office, Nework Hospial, or oupaien surgery clinic which is owned, operaed by or has a wrien agreemen wih a Nework Hospial o provide services. Full benefis of Your coverage will be paid when: 1. Services are provided in he following places: a Physician s office; in anoher office seing (oher han an oupaien surgery clinic); in a Skilled Nursing Faciliy; 2. The services are for sickness requiring emergency care or are immediaely required for an unforeseen Illness, Injury or a condiion, and i is no reasonable o obain such services hrough he Nework Hospial; 3. While Traveling ouside he Service Area, services will be covered. Travel mus be for purposes oher han he receip of medical care; or 4. Required services are no available a a Nework Hospial in Your Service Area. Nework Hospials A Nework Hospial is one ha has a wrien agreemen wih Serling and has been designaed by Serling o provide hospial services insured under his policy. You may use any Nework Hospial which is lised on Your curren Serling Medicare SELECT Supplemen Insurance Nework Hospial Direcory. This direcory is updaed periodically. To verify he saus of a hospial please call beween he hours of 5AM and 5PM Pacific Time, Monday hrough Friday. Non-Nework Hospial Admission Procedures Prior o admission o a non-nework Hospial, You, eiher direcly or hrough Your physician, should conac Serling s Cusomer Service Cener. The Cusomer Service Cener will confirm wheher he required services are available from a Nework Hospial, and if no available, will assis You in locaing a hospial ha provides he necessary service. Uilizing Serling s Cusomer Service Cener prior o use of a non-nework Hospial eliminaes he need for rerospecive inquiry as o he legiimacy of he filed claim. These non-nework Hospial Admission Procedures do no apply in emergency siuaions or while You are raveling ouside of he service area. Travel mus be for purposes oher han he receip of medical care. COMPLAINT PROCEDURE MEDICARE SELECT PRODUCTS ONLY Complains While Saying A A Nework Hospial. If, while confined a a Nework Hospial, You have a complain regarding he hospial s services being provided, You may conac Serling s Cusomer Service Cener by phone AM o 5PM Pacific Time, Monday hrough Friday, o express he complain. The complain will be ransmied o appropriae decision-makers who have he auhoriy o fully invesigae he issue and ake correcive acion. Serling s Cusomer Service represenaives will relay he complain wihin weny-four (24) hours, o he hospial s Adminisraor for response wihin weny (20) days. Calls received beween 5PM and 5AM, weekends and holidays, will be ransferred o auomaed voic , where You may leave Your name, policyholder idenificaion number, elephone number and commen, reques or complain. Reurn phone calls will be placed he following business day. If a complain is found o be valid, correcive acion will be aken wihin fory-five (45) days. PA OC (01/13) 5

5 Oher Complains. If You have quesions or are dissaisfied wih he qualiy of care received from a Nework Hospial, have a complain or wan o cones he disposiion of a claim, You may direc such inquiries o he Cusomer Service Cener, P.O. Box 5348, Bellingham, WA , wihou iniiaing a formal grievance. Quesions or complains regarding any of hese areas which are presened shall receive acknowledgmen wihin hree (3) business days of receip. A response will be sen o You wihin hiry (30) business days of he complain. If afer hiry (30) business days a response is unavailable, we will provide a saus updae o You every en (10) business days. GRIEVANCE PROCEDURE MEDICARE SELECT PRODUCTS ONLY In he even You are dissaisfied wih he response received o a complain or wih he disposiion of a claim, You may submi a formal grievance by wriing o he Claims Adminisraor a P.O. Box 5348, Bellingham, WA Formal grievances in all oher areas should be submied o Us in wriing a he same address. A grievance mus clearly sae This is a grievance, or oher words ha clearly sae ha he inenion of he wrien communicaion is o serve as a wrien grievance o be handled according o his procedure. Acknowledgmen of receip of he grievance will be mailed wihin hree (3) business days and he grievance will be invesigaed. The grievance will be ransmied o appropriae decision-makers who have he auhoriy o fully invesigae he issue and ake correcive acion. A response will be sen wihin hiry (30) days following he dae he grievance is received and shall explain in deail he reasons for he deerminaion. If Serling upholds he grievance, correcive acion will be aken promply o remedy he siuaion. Grievance Appeal Commiee. In he even You are no saisfied wih he resuls of Our deerminaion, You have he righ o file an appeal by wrien reques wih Serling. The appeal should be submied o he Grievance Appeal Commiee of Serling wihin fory-five (45) days from he dae You are noified of he complain procedure resuls. The Grievance Appeal Commiee shall be made up of individuals no involved in he decision making process of he original grievance or reques for deerminaion. The Grievance Appeal Commiee shall schedule a hearing on he grievance wihin fory-five (45) days of is receip. Boh You and he person or organizaion agains whom he complain has been made shall be noified of he ime and place of he Grievance Appeal Commiee hearing a which ime such individuals shall have he righ o appear in person or by elephone and presen any informaion which suppors heir posiion. A he close of he hearing, he Grievance Appeal Commiee shall make findings and issue a wrien decision wihin fifeen (15) business days afer he hearing is held unless addiional informaion is needed. If You are dissaisfied wih he decision, You should submi a wrien complain o he Commonwealh of Pennsylvania Insurance Deparmen, 1209 Srawberry Square, Harrisburg, PA 17120, or call (717) CONTINUATION OF COVERAGE If he auhoriy o issue Medicare SELECT policies is disconinued for whaever reason or he Service Area no longer exiss, Your coverage can coninue. Coverage will be coninued under any oher Medicare Supplemen policy We have available conaining comparable or lesser benefis and which does no conain Resriced Nework Provisions. You will no need o provide evidence of insurabiliy. CONVERSION PRIVILEGE MEDICARE SELECT PRODUCTS ONLY You may reques o conver his policy o a policy ha does no conain Resriced Nework Provisions wihou submission of evidence of insurance a anyime. Your reques mus be received by Serling on or before he 20h day of he monh, and will be effecive he 1s day of he following monh. The conversion will be o a Medicare Supplemen policy wih comparable or lesser benefis which is offered by Serling. Conversion is subjec o he availabiliy of a Serling Medicare Supplemen policy for sale in Your Sae. PA OC (01/13) 6

6 Plan A - Benefis Char for Medicare Supplemen and Medicare SELECT MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD HOSPITALIZATION* SERVICES MEDICARE PAYS PLAN PAYS 1 YOU PAY Semiprivae room and board, general nursing and miscellaneous services and supplies Firs 60 days All bu $1,184 $0 $1,184 (Par A Deducible) 61s hru 90h day All bu $296 a day $296 a day $0 91s day and afer: -While using 60 lifeime reserve days All bu $592 a day $592 a day $0 -Once lifeime reserve days are used: -Addiional 365 days $0 100% of Medicare Eligible Expenses $0** -Beyond he Addiional 365 days $0 $0 All Coss SKILLED NURSING FACILITY CARE* You mus mee Medicare s requiremens, including having been in a hospial for a leas 3 days and enered a Medicare-approved faciliy wihin 30 days afer leaving he hospial Firs 20 days All approved amouns $0 $0 21s hru 100h day All bu $148 a day $0 Up o $148 a day 101s day and afer $0 $0 All Coss BLOOD Firs 3 pins $0 3 pins $0 Addiional amouns 100% $0 $0 HOSPICE CARE You mus mee Medicare s requiremens, including a docor s cerificaion of erminal illness All bu very limied copaymen/ coinsurance for oupaien drugs and inpaien respie care Medicare copaymen/coinsurance $0 * A benefi period begins on he firs day you receive service as an inpaien in a hospial and ends afer you have been ou of he hospial and have no received skilled care in any oher faciliy for 60 days in a row. ** NOTICE: When your Medicare Par A hospial benefis are exhaused, he insurer sands in he place of Medicare and will pay whaever amoun Medicare would have paid for up o an addiional 365 days as provided in he policy s Basic Benefis. During his ime, he hospial is prohibied from billing you for he balance based on any difference beween is billed charges and he amoun Medicare would have paid. 1 Medicare SELECT Plans: Medicare Par A and Par B (hospial or faciliy) benefis will no be paid for services provided a a Hospial which is no a Nework Hospial. Addiionally, Par B (hospial or faciliy) benefis will no be provided unless services are performed a a docor s office, Nework Hospial, or oupaien surgery clinic which is owned, operaed by or has an agreemen wih a Nework Hospial o provide services. For complee deails, please refer o he nework hospial resricions on he disclosure Page # 4. PA OC (01/13) 7

7 Plan A - Benefis Char for Medicare Supplemen and Medicare SELECT MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDER YEAR MEDICAL EXPENSES SERVICES MEDICARE PAYS PLAN PAYS 1 YOU PAY IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as Physician s services, inpaien and oupaien medical and surgical services and supplies, physical and speech herapy, diagnosic ess, durable medical equipmen Firs $147 of Medicare-Approved $0 $0 $147 (Par B Deducible) Amouns* Remainder of Medicare-Approved Amouns Generally 80% Generally 20% $0 PART B EXCESS CHARGES Above Medicare-Approved Amouns $0 $0 All Coss BLOOD Firs 3 pins $0 All Coss $0 Nex $147 of Medicare-Approved Amouns* Remainder of Medicare-Approved Amouns CLINICAL LABORATORY SERVICES $0 $0 $147 (Par B Deducible) 80% 20% $0 Tess For Diagnosic Services 100% $0 $0 HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable Medical Equipmen Firs $147 of Medicare-Approved Amouns* Remainder of Medicare-Approved Amouns PARTS A & B 100% $0 $0 $0 $0 $147 (Par B Deducible) 80% 20% $0 * Once you have been billed $147 of Medicare-Approved amouns for covered services (which are noed wih an aserisk), your Par B Deducible will have been me for he calendar year. 1 Medicare SELECT Plans: Medicare Par A and Par B (hospial or faciliy) benefis will no be paid for services provided a a Hospial which is no a Nework Hospial. Addiionally, Par B (hospial or faciliy) benefis will no be provided unless services are performed a a docor s office, Nework Hospial, or oupaien surgery clinic which is owned, operaed by or has an agreemen wih a Nework Hospial o provide services. For complee deails, please refer o he nework hospial resricions on he disclosure Page # 4. PA OC (01/13) 8

8 Plan B - Benefis Char for Medicare Supplemen and Medicare SELECT MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD HOSPITALIZATION* SERVICES MEDICARE PAYS PLAN PAYS 1 YOU PAY Semiprivae room and board, general nursing and miscellaneous services and supplies Firs 60 days All bu $1,184 $1,184 (Par A Deducible) $0 61s hru 90h day All bu $296 a day $296 a day $0 91s day and afer: -While using 60 lifeime reserve days All bu $592 a day $592 a day $0 -Once lifeime reserve days are used: -Addiional 365 days $0 100% of Medicare Eligible Expenses $0** -Beyond he Addiional 365 days $0 $0 All Coss SKILLED NURSING FACILITY CARE* You mus mee Medicare s requiremens, including having been in a hospial for a leas 3 days and enered a Medicare-approved faciliy wihin 30 days afer leaving he hospial Firs 20 days All approved amouns $0 $0 21s hru 100h day All bu $148 a day $0 Up o $148 a day 101s day and afer $0 $0 All Coss BLOOD Firs 3 pins $0 3 pins $0 Addiional amouns 100% $0 $0 HOSPICE CARE You mus mee Medicare s requiremens, including a docor s cerificaion of erminal illness All bu very limied copaymen/ coinsurance for oupaien drugs and inpaien respie care Medicare copaymen/coinsurance $0 * A benefi period begins on he firs day you receive service as an inpaien in a hospial and ends afer you have been ou of he hospial and have no received skilled care in any oher faciliy for 60 days in a row. ** NOTICE: When your Medicare Par A hospial benefis are exhaused, he insurer sands in he place of Medicare and will pay whaever amoun Medicare would have paid for up o an addiional 365 days as provided in he policy s Basic Benefis. During his ime, he hospial is prohibied from billing you for he balance based on any difference beween is billed charges and he amoun Medicare would have paid. 1 Medicare SELECT Plans: Medicare Par A and Par B (hospial or faciliy) benefis will no be paid for services provided a a Hospial which is no a Nework Hospial. Addiionally, Par B (hospial or faciliy) benefis will no be provided unless services are performed a a docor s office, Nework Hospial, or oupaien surgery clinic which is owned, operaed by or has an agreemen wih a Nework Hospial o provide services. For complee deails, please refer o he nework hospial resricions on he disclosure Page # 4. PA OC (01/13) 9

9 Plan B - Benefis Char for Medicare Supplemen and Medicare SELECT MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDER YEAR MEDICAL EXPENSES SERVICES MEDICARE PAYS PLAN PAYS 1 YOU PAY IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as Physician s services, inpaien and oupaien medical and surgical services and supplies, physical and speech herapy, diagnosic ess, durable medical equipmen Firs $147 of Medicare-Approved $0 $0 $147 (Par B Deducible) Amouns* Remainder of Medicare-Approved Amouns Generally 80% Generally 20% $0 PART B EXCESS CHARGES Above Medicare-Approved Amouns $0 $0 All Coss BLOOD Firs 3 pins $0 All Coss $0 Nex $147 of Medicare-Approved Amouns* Remainder of Medicare-Approved Amouns CLINICAL LABORATORY SERVICES $0 $0 $147 (Par B Deducible) 80% 20% $0 Tess For Diagnosic Services 100% $0 $0 HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable Medical Equipmen Firs $147 of Medicare-Approved Amouns* Remainder of Medicare-Approved Amouns PARTS A & B 100% $0 $0 $0 $0 $147 (Par B Deducible) 80% 20% $0 * Once you have been billed $147 of Medicare-Approved amouns for covered services (which are noed wih an aserisk), your Par B Deducible will have been me for he calendar year. 1 Medicare SELECT Plans: Medicare Par A and Par B (hospial or faciliy) benefis will no be paid for services provided a a Hospial which is no a Nework Hospial. Addiionally, Par B (hospial or faciliy) benefis will no be provided unless services are performed a a docor s office, Nework Hospial, or oupaien surgery clinic which is owned, operaed by or has an agreemen wih a Nework Hospial o provide services. For complee deails, please refer o he nework hospial resricions on he disclosure Page # 4. PA OC (01/13) 10

10 Plan C - Benefis Char for Medicare Supplemen and Medicare SELECT MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD HOSPITALIZATION* SERVICES MEDICARE PAYS PLAN PAYS 1 YOU PAY Semiprivae room and board, general nursing and miscellaneous services and supplies Firs 60 days All bu $1,184 $1,184 (Par A Deducible) $0 61s hru 90h day All bu $296 a day $296 a day $0 91s day and afer: -While using 60 lifeime reserve days All bu $592 a day $592 a day $0 -Once lifeime reserve days are used: -Addiional 365 days $0 100% of Medicare Eligible Expenses $0** -Beyond he Addiional 365 days $0 $0 All Coss SKILLED NURSING FACILITY CARE* You mus mee Medicare s requiremens, including having been in a hospial for a leas 3 days and enered a Medicare-approved faciliy wihin 30 days afer leaving he hospial Firs 20 days All approved amouns $0 $0 21s hru 100h day All bu $148 a day Up o $148 a day $0 101s day and afer $0 $0 All Coss BLOOD Firs 3 pins $0 3 pins $0 Addiional amouns 100% $0 $0 HOSPICE CARE Available as long as your docor cerifies you are erminally ill and you elec o receive hese services All bu very limied copaymen/ coinsurance for oupaien drugs and inpaien respie care Medicare copaymen/coinsurance $0 * A benefi period begins on he firs day you receive service as an inpaien in a hospial and ends afer you have been ou of he hospial and have no received skilled care in any oher faciliy for 60 days in a row. ** NOTICE: When your Medicare Par A hospial benefis are exhaused, he insurer sands in he place of Medicare and will pay whaever amoun Medicare would have paid for up o an addiional 365 days as provided in he policy s Basic Benefis. During his ime, he hospial is prohibied from billing you for he balance based on any difference beween is billed charges and he amoun Medicare would have paid. 1 Medicare SELECT Plans: Medicare Par A and Par B (hospial or faciliy) benefis will no be paid for services provided a a Hospial which is no a Nework Hospial. Addiionally, Par B (hospial or faciliy) benefis will no be provided unless services are performed a a docor s office, Nework Hospial, or oupaien surgery clinic which is owned, operaed by or has an agreemen wih a Nework Hospial o provide services. For complee deails, please refer o he nework hospial resricions on he disclosure Page # 4. PA OC (01/13) 11

11 Plan C - Benefis Char for Medicare Supplemen and Medicare SELECT MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDER YEAR SERVICES MEDICARE PAYS PLAN PAYS 1 YOU PAY MEDICAL EXPENSES IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as Physician s services, inpaien and oupaien medical and surgical services and supplies, physical and speech herapy, diagnosic ess, durable medical equipmen Firs $147 of Medicare-Approved Amouns* $0 $147 (Par B Deducible) $0 Remainder of Medicare-Approved Amouns Generally 80% Generally 20% $0 PART B EXCESS CHARGES Above Medicare-Approved Amouns $0 $0 All Coss BLOOD Firs 3 pins $0 All Coss $0 Nex $147 of Medicare-Approved Amouns* $0 $147 (Par B Deducible) $0 Remainder of Medicare-Approved Amouns 80% 20% $0 CLINICAL LABORATORY SERVICES Tess For Diagnosic Services 100% $0 $0 PARTS A & B HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services 100% $0 $0 and medical supplies Durable Medical Equipmen Firs $147 of Medicare-Approved Amouns* $0 $147 (Par B Deducible) $0 Remainder of Medicare-Approved Amouns 80% 20% $0 FOREIGN TRAVEL - NOT COVERED BY MEDICARE Medically Necessary Emergency care services beginning during he firs 60 days of each rip ouside he USA Firs $250 each Calendar Year $0 $0 $250 Remainder of Charges $0 80% o a Lifeime Maximum Benefi of $50,000 20% and amouns over he $50,000 Lifeime Maximum Benefi * Once you have been billed $147 of Medicare-Approved amouns for covered services (which are noed wih an aserisk), your Par B Deducible will have been me for he calendar year. 1 Medicare SELECT Plans: Medicare Par A and Par B (hospial or faciliy) benefis will no be paid for services provided a a Hospial which is no a Nework Hospial. Addiionally, Par B (hospial or faciliy) benefis will no be provided unless services are performed a a docor s office, Nework Hospial, or oupaien surgery clinic which is owned, operaed by or has an agreemen wih a Nework Hospial o provide services. For complee deails, please refer o he nework hospial resricions on he disclosure Page # 4. PA OC (01/13) 12

12 Plan F wih Innovaive Benefis - Benefi Char for Medicare Supplemen and Medicare SELECT MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD HOSPITALIZATION* SERVICES MEDICARE PAYS PLAN PAYS 1 YOU PAY Semiprivae room and board, general nursing and miscellaneous services and supplies Firs 60 days All bu $1,184 $1,184 (Par A Deducible) $0 61s hru 90h day All bu $296 a day $296 a day $0 91s day and afer: -While using 60 lifeime reserve days All bu $592 a day $592 a day $0 -Once lifeime reserve days are used: -Addiional 365 days $0 100% of Medicare Eligible Expenses $0 See NOTICE below (See your policy, page 5 or 6 for deails of coverage.) -Beyond he Addiional 365 days $0 $0 All Coss SKILLED NURSING FACILITY CARE* You mus mee Medicare s requiremens, including having been in a hospial for a leas 3 days and enered a Medicare-approved faciliy wihin 30 days afer leaving he hospial Firs 20 days All approved amouns $0 $0 21s hru 100h day All bu $148 a day Up o $148 a day $0 101s day and afer $0 $0 All Coss BLOOD Firs 3 pins $0 3 pins $0 Addiional amouns 100% $0 $0 HOSPICE CARE You mus mee Medicare s requiremens, including a docor s cerificaion of erminal illness. All bu very limied copaymen/coinsurance for oupaien drugs and inpaien respie care Medicare cos sharing $0 * A benefi period begins on he firs day you receive service as an inpaien in a hospial and ends afer you have been ou of he hospial and have no received skilled care in any oher faciliy or 60 days in a row. NOTICE: When your Medicare Par A hospial benefis are exhaused, he insurer sands in he place of Medicare and will pay whaever amoun Medicare would have paid for up o an addiional 365 days as provided in he policy s Basic Benefis. During his ime, he hospial is prohibied from billing you for he balance based on any difference beween is billed charges and he amoun Medicare would have paid. 1 Medicare SELECT Plans: Medicare Par A and Par B (hospial or faciliy) benefis will no be paid for services provided a a Hospial which is no a Nework Hospial. Addiionally, Par B (hospial or faciliy) benefis will no be provided unless services are performed a a docor s office, Nework Hospial, or oupaien surgery clinic which is owned, operaed by or has an agreemen wih a Nework Hospial o provide services. For complee deails, please refer o he nework hospial resricions on he disclosure Page # 4. PA OC (01/13) 13

13 Plan F wih Innovaive Benefis - Benefi Char for Medicare Supplemen and Medicare SELECT MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR SERVICES MEDICARE PAYS PLAN PAYS 1 YOU PAY MEDICAL EXPENSES IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as Physician s services,inpaien and oupaien medical and surgical services and supplies, physical and speech herapy, diagnosic ess, durable medical equipmen Firs $147 of Medicare-Approved Amouns* $0 $147 (Par B Deducible) $0 Remainder of Medicare-Approved Amouns Generally 80% Generally 20% $0 PART B EXCESS CHARGES Above Medicare-Approved Amouns $0 100% $0 BLOOD Firs 3 pins $0 All Coss $0 Nex $147 of Medicare-Approved Amouns* $0 $147 (Par B Deducible) $0 Remainder of Medicare-Approved Amouns 80% 20% $0 CLINICAL LABORATORY SERVICES Tess For Diagnosic Services 100% $0 $0 HOME HEALTH CARE MEDICARE-APPROVED SERVICES PARTS A & B Medically necessary skilled care services and medical supplies 100% $0 $0 Durable Medical Equipmen Firs $147 of Medicare-Approved Amouns* $0 $147 (Par B Deducible) $0 Remainder of Medicare-Approved Amouns 80% 20% $0 FOREIGN TRAVEL - NOT COVERED BY MEDICARE Medically Necessary Emergency care services beginning during he firs 60 days of each rip ouside he USA Firs $250 each Calendar Year $0 $0 $250 Remainder of Charges $0 80% o a Lifeime Maximum Benefi of $50,000 20% and amouns over he $50,000 Lifeime Maximum Benefi * Once you have been billed $147 of Medicare-Approved amouns for covered services (which are noed wih an aserisk), your Par B Deducible will have been me for he calendar year. 1 Medicare SELECT Plans: Medicare Par A and Par B (hospial or faciliy) benefis will no be paid for services provided a a Hospial which is no a Nework Hospial. Addiionally, Par B (hospial or faciliy) benefis will no be provided unless services are performed a a docor s office, Nework Hospial, or oupaien surgery clinic which is owned, operaed by or has an agreemen wih a Nework Hospial o provide services. For complee deails, please refer o he nework hospial resricions on he disclosure Page # 4. PA OC (01/13) 14

14 Plan F wih Innovaive Benefis - Benefi Char for Medicare Supplemen and Medicare SELECT INNOVATIVE BENEFITS - NOT COVERED BY MEDICARE OR STANDARDIZED MEDICARE SUPPLEMENT PLANS SERVICES MEDICARE PAYS PLAN PAYS 1 YOU PAY NURSE ADVICE TELEPHONE LINE** Coverage for access o our elephone Nurse Advice Line for answers o healh-relaed quesions. $0 All Coss $0 ANNUAL PHYSICAL EXAMINATION** Coverage for up o $100 for one (1) rouine physical examinaion every year, including rouine lab ess billed as par of he rouine physical exam. You are responsible for any charges above he $100 rouine physical exam allowance, including lab ess. This benefi is separae from he one-ime physical examinaion covered by Medicare wihin he firs 12 monhs of Par B enrollmen. $0 All Coss $0 PREVENTIVE DENTAL BENEFIT** Coverage for up o $500 per calendar year for prevenive denal care, limied o American Denal Associaion codes , as well as Coverage is limied o: A. Oral Examinaions - Limied o one ime every six monhs $0 All Coss $0 B. Bie Wing Radiographs - Limied o 1 series of films per calendar year $0 All Coss $0 C. Complee Series of Panorex Radiographs - Limied o one ime per $0 All Coss $0 36 monhs D. Denal Prophylaxis - Limied o one ime per every six monhs $0 All Coss $0 E. Diagnosic Cass - Limied o one ime per 24 monhs $0 All Coss $0 F. Exraoral Radiographs - Limied o 2 films per calendar year $0 All Coss $0 ROUTINE VISION CARE** Coverage for up o $100 for one (1) rouine eye examinaion every year. This is separae from diagnosic eye examinaions and relaed charges as covered by Medicare. $0 All Coss $0 ROUTINE HEARING EXAMINATIONS** Coverage for up o $100 for one (1) rouine hearing es every year. This is separae from diagnosic hearing examinaions and relaed charges as covered by Medicare. $0 All Coss $0 * Once you have been billed $147 of Medicare-Approved amouns for covered services (which are noed wih an aserisk), your Par B Deducible will have been me for he calendar year. ** Innovaive benefis are no subjec o nework resricions. PA OC (01/13) 15

15 Plan G - Benefis Char for Medicare Supplemen and Medicare SELECT MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD HOSPITALIZATION* SERVICES MEDICARE PAYS PLAN PAYS 1 YOU PAY Semiprivae room and board, general nursing and miscellaneous services and supplies Firs 60 days All bu $1,184 $1,184 (Par A Deducible) $0 61s hru 90h day All bu $296 a day $296 a day $0 91s day and afer: -While using 60 lifeime reserve days All bu $592 a day $592 a day $0 -Once lifeime reserve days are used: -Addiional 365 days $0 100% of Medicare Eligible Expenses $0** -Beyond he Addiional 365 days $0 $0 All Coss SKILLED NURSING FACILITY CARE* You mus mee Medicare s requiremens, including having been in a hospial for a leas 3 days and enered a Medicare-approved faciliy wihin 30 days afer leaving he hospial Firs 20 days All approved amouns $0 $0 21s hru 100h day All bu $148 a day Up o $148 a day $0 101s day and afer $0 $0 All Coss BLOOD Firs 3 pins $0 3 pins $0 Addiional amouns 100% $0 $0 HOSPICE CARE You mus mee Medicare s requiremens, including a docor s cerificaion of erminal illness All bu very limied copaymen/ coinsurance for oupaien drugs and inpaien respie care Medicare copaymen/coinsurance $0 * A benefi period begins on he firs day you receive service as an inpaien in a hospial and ends afer you have been ou of he hospial and have no received skilled care in any oher faciliy for 60 days in a row. ** NOTICE: When your Medicare Par A hospial benefis are exhaused, he insurer sands in he place of Medicare and will pay whaever amoun Medicare would have paid for up o an addiional 365 days as provided in he policy s Basic Benefis. During his ime, he hospial is prohibied from billing you for he balance based on any difference beween is billed charges and he amoun Medicare would have paid. 1 Medicare SELECT Plans: Medicare Par A and Par B (hospial or faciliy) benefis will no be paid for services provided a a Hospial which is no a Nework Hospial. Addiionally, Par B (hospial or faciliy) benefis will no be provided unless services are performed a a docor s office, Nework Hospial, or oupaien surgery clinic which is owned, operaed by or has an agreemen wih a Nework Hospial o provide services. For complee deails, please refer o he nework hospial resricions on he disclosure Page # 4. PA OC (01/13) 16

16 Plan G - Benefis Char for Medicare Supplemen and Medicare SELECT MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDER YEAR SERVICES MEDICARE PAYS PLAN PAYS 1 YOU PAY MEDICAL EXPENSES IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as Physician s services, inpaien and oupaien medical and surgical services and supplies, physical and speech herapy, diagnosic ess, durable medical equipmen Firs $147 of Medicare-Approved Amouns* $0 $0 $147 (Par B Deducible) Remainder of Medicare-Approved Amouns Generally 80% Generally 20% $0 PART B EXCESS CHARGES Above Medicare-Approved Amouns $0 100% $0 BLOOD Firs 3 pins $0 All Coss $0 Nex $147 of Medicare-Approved Amouns* $0 $0 $147 (Par B Deducible) Remainder of Medicare-Approved Amouns 80% 20% $0 CLINICAL LABORATORY SERVICES Tess For Diagnosic Services 100% $0 $0 HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable Medical Equipmen PARTS A & B 100% $0 $0 Firs $147 of Medicare-Approved Amouns* $0 $0 $147 (Par B Deducible) Remainder of Medicare-Approved Amouns 80% 20% $0 FOREIGN TRAVEL - NOT COVERED BY MEDICARE Medically Necessary Emergency care services beginning during he firs 60 days of each rip ouside he USA Firs $250 each Calendar Year $0 $0 $250 Remainder of Charges $0 80% o a Lifeime Maximum Benefi of $50,000 20% and amouns over he $50,000 Lifeime Maximum Benefi * Once you have been billed $147 of Medicare-Approved amouns for covered services (which are noed wih an aserisk), your Par B Deducible will have been me for he calendar year. 1 Medicare SELECT Plans: Medicare Par A and Par B (hospial or faciliy) benefis will no be paid for services provided a a Hospial which is no a Nework Hospial. Addiionally, Par B (hospial or faciliy) benefis will no be provided unless services are performed a a docor s office, Nework Hospial, or oupaien surgery clinic which is owned, operaed by or has an agreemen wih a Nework Hospial o provide services. For complee deails, please refer o he nework hospial resricions on he disclosure Page # 4. PA OC (01/13) 17

17 Plan K - Benefis Char for Medicare Supplemen and Medicare SELECT MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD SERVICES MEDICARE PAYS PLAN PAYS 1 YOU PAY HOSPITALIZATION* Semiprivae room and board, general nursing and miscellaneous services and supplies Firs 60 days All bu $1,184 $592 (50% of Par A Deducible) $592 (50% of Par A Deducible) F 61s hru 90h day All bu $296 a day $296 a day $0 91s day and afer: -While using 60 lifeime reserve days All bu $592 a day $592 a day $0 -Once lifeime reserve days are used: -Addiional 365 days $0 100% of Medicare Eligible Expenses $0** -Beyond he Addiional 365 days $0 $0 All Coss SKILLED NURSING FACILITY CARE* You mus mee Medicare s requiremens, including having been in a hospial for a leas 3 days and enered a Medicare-approved faciliy wihin 30 days afer leaving he hospial Firs 20 days All approved amouns $0 $0 21s hru 100h day All bu $148 a day Up o $74 a day Up o $74 a day F 101s day and afer $0 $0 All Coss BLOOD Firs 3 pins $0 50% 50% F Addiional amouns 100% $0 $0 HOSPICE CARE You mus mee Medicare s requiremens, including a docor s cerificaion of erminal illness All bu very limied copaymen/ coinsurance for oupaien drugs and inpaien respie care 50% of copaymen/coinsurance 50% of copaymen/coinsurance F You will pay half he cos sharing of some covered services unil you reach he annual ou-of-pocke limi of $4,800 each calendar year. The amouns ha coun oward your annual limi are noed wih he diamonds (F) in he char above. Once you reach he annual limi, he plan pays 100% of your Medicare copaymen and coinsurance for he res of he calendar year. However, his limi does NOT include charges from your provider ha exceed Medicare-approved amouns (hese are called Excess Charges ) and you will be responsible for paying his difference in he amoun charged by your provider and he amoun paid by Medicare for he iem or service. * A benefi period begins on he firs day you receive service as an inpaien in a hospial and ends afer you have been ou of he hospial and have no received skilled care in any oher faciliy for 60 days in a row. ** NOTICE: When your Medicare Par A hospial benefis are exhaused, he insurer sands in he place of Medicare and will pay whaever amoun Medicare would have paid for up o an addiional 365 days as provided in he policy s Basic Benefis. During his ime, he hospial is prohibied from billing you for he balance based on any difference beween is billed charges and he amoun Medicare would have paid. 1 Medicare SELECT Plans: Medicare Par A and Par B (hospial or faciliy) benefis will no be paid for services provided a a Hospial which is no a Nework Hospial. Addiionally, Par B (hospial or faciliy) benefis will no be provided unless services are performed a a docor s office, Nework Hospial, or oupaien surgery clinic which is owned, operaed by or has an agreemen wih a Nework Hospial o provide services. For complee deails, please refer o he nework hospial resricions on he disclosure Page # 4. PA OC (01/13) 18

18 Plan K - Benefis Char for Medicare Supplemen and Medicare SELECT MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDER YEAR SERVICES MEDICARE PAYS PLAN PAYS 1 YOU PAY MEDICAL EXPENSES IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as Physician s services, inpaien and oupaien medical and surgical services and supplies, physical and speech herapy, diagnosic ess, durable medical equipmen Firs $147 of Medicare-Approved Amouns* $0 $0 $147 (Par B Deducible)*F Prevenive Benefis for Medicare covered services Remainder of Medicare-Approved Amouns PART B EXCESS CHARGES Generally 75% or more of Medicare- Approved amouns Remainder of Medicare-Approved amouns Generally 80% Generally 10% Generally 10% F All coss above Medicare-Approved amouns Above Medicare-Approved Amouns $0 $0 All coss (and hey do no coun oward annual ou-of-pocke limi of $4,800)*** BLOOD Firs 3 pins $0 50% 50% F Nex $147 of Medicare-Approved Amouns* $0 $0 $147 (Par B Deducible)*F Remainder of Medicare-Approved Amouns Generally 80% Generally 10% Generally 10% F CLINICAL LABORATORY SERVICES Tess For Diagnosic Services 100% $0 $0 PARTS A & B HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies 100% $0 $0 Durable Medical Equipmen Firs $147 of Medicare-Approved Amouns*** $0 $0 $147 (Par B Deducible)*F Remainder of Medicare-Approved Amouns 80% 10% 10% F * Once you have been billed $147 of Medicare-Approved amouns for covered services (which are noed wih an aserisk), your Par B Deducible will have been me for he calendar year. ***This plan limis your annual ou-of-pocke paymens for Medicare-approved amouns o $4,800 per year. However, his limi does NOT include charges from your provider ha exceed Medicare-approved amouns (hese are called Excess Charges ) and you will be responsible for paying his difference in he amoun charged by your provider and he amoun paid by Medicare for he iem or service. Medicare benefis are subjec o change. Please consul he laes Guide o Healh Insurance for People Wih Medicare. 1 Medicare SELECT Plans: Medicare Par A and Par B (hospial or faciliy) benefis will no be paid for services provided a a Hospial which is no a Nework Hospial. Addiionally, Par B (hospial or faciliy) benefis will no be provided unless services are performed a a docor s office, Nework Hospial, or oupaien surgery clinic which is owned, operaed by or has an agreemen wih a Nework Hospial o provide services. For complee deails, please refer o he nework hospial resricions on he disclosure Page # 4. PA OC (01/13) 19

19 Plan N - Benefis Char for Medicare Supplemen and Medicare SELECT MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD HOSPITALIZATION* SERVICES MEDICARE PAYS PLAN PAYS 1 YOU PAY Semiprivae room and board, general nursing and miscellaneous services and supplies Firs 60 days All bu $1,184 $1,184 (Par A Deducible) $0 61s hru 90h day All bu $296 a day $296 a day $0 91s day and afer: -While using 60 lifeime reserve days All bu $592 a day $592 a day $0 -Once lifeime reserve days are used: -Addiional 365 days $0 100% of Medicare Eligible Expenses $0** (See your policy, page 5 or 6 for deails of coverage.) -Beyond he Addiional 365 days $0 $0 All Coss SKILLED NURSING FACILITY CARE* You mus mee Medicare s requiremens, including having been in a hospial for a leas 3 days and enered a Medicare-approved faciliy wihin 30 days afer leaving he hospial Firs 20 days All approved amouns $0 $0 21s hru 100h day All bu $148 a day Up o $148 a day $0 101s day and afer $0 $0 All Coss BLOOD Firs 3 pins $0 3 pins $0 Addiional amouns 100% $0 $0 HOSPICE CARE You mus mee Medicare s requiremens, including a docor s cerificaion of erminal illness All bu very limied copaymen/ coinsurance for oupaien drugs and inpaien respie care Medicare copaymen/coinsurance $0 * A benefi period begins on he firs day you receive service as an inpaien in a hospial and ends afer you have been ou of he hospial and have no received skilled care in any oher faciliy for 60 days in a row. ** NOTICE: When your Medicare Par A hospial benefis are exhaused, he insurer sands in he place of Medicare and will pay whaever amoun Medicare would have paid for up o an addiional 365 days as provided in he policy s Basic Benefis. During his ime, he hospial is prohibied from billing you for he balance based on any difference beween is billed charges and he amoun Medicare would have paid. 1 Medicare SELECT Plans: Medicare Par A and Par B (hospial or faciliy) benefis will no be paid for services provided a a Hospial which is no a Nework Hospial. Addiionally, Par B (hospial or faciliy) benefis will no be provided unless services are performed a a docor s office, Nework Hospial, or oupaien surgery clinic which is owned, operaed by or has an agreemen wih a Nework Hospial o provide services. For complee deails, please refer o he nework hospial resricions on he disclosure Page # 4. PA OC (01/13) 20

20 SERVICES MEDICARE PAYS PLAN PAYS 1 YOU PAY MEDICAL EXPENSES IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as Physician s services, inpaien and oupaien medical and surgical services and supplies, physical and speech herapy, diagnosic ess, durable medical equipmen Firs $147 of Medicare-Approved Amouns* $0 $0 $147 (Par B Deducible) Remainder of Medicare-Approved Amouns Generally 80% Balance, oher han up o $20 per office visi and up o $50 per emergency room visi. The copaymen of up o $50 is waived if he insured is admied o any hospial and he emergency visi is covered as a Medicare Par A expense. PART B EXCESS CHARGES Above Medicare-Approved Amouns $0 $0 All Coss Up o $20 per office visi and up o $50 per emergency visi. The copaymen of up o $50 is waived if he insured is admied o any hospial and he emergency room visi is covered as a Medicare Par A expense. BLOOD Firs 3 pins $0 All Coss $0 Nex $147 of Medicare-Approved Amouns* $0 $0 $147 (Par B Deducible) Remainder of Medicare-Approved Amouns 80% 20% $0 CLINICAL LABORATORY SERVICES Tess For Diagnosic Services 100% $0 $0 PARTS A & B HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies 100% $0 $0 Durable Medical Equipmen Firs $147 of Medicare-Approved Amouns* $0 $0 $147 (Par B Deducible) Remainder of Medicare-Approved Amouns 80% 20% $0 FOREIGN TRAVEL - NOT COVERED BY MEDICARE Medically Necessary Emergency care services beginning during he firs 60 days of each rip ouside he USA Firs $250 each Calendar Year $0 $0 $250 Remainder of Charges $0 Plan N - Benefis Char for Medicare Supplemen and Medicare SELECT MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDER YEAR 80% o a Lifeime Maximum Benefi of $50,000 20% and amouns over he $50,000 Lifeime Maximum Benefi * Once you have been billed $147 of Medicare-Approved amouns for covered services (which are noed wih an aserisk), your Par B Deducible will have been me for he calendar year. 1 Medicare SELECT Plans: Medicare Par A and Par B (hospial or faciliy) benefis will no be paid for services provided a a Hospial which is no a Nework Hospial. Addiionally, Par B (hospial or faciliy) benefis will no be provided unless services are performed a a docor s office, Nework Hospial, or oupaien surgery clinic which is owned, operaed by or has an agreemen wih a Nework Hospial o provide services. For complee deails, please refer o he nework hospial resricions on he disclosure Page # 4. PA OC (01/13) 21

21 PREMIUM INFORMATION Serling Life Insurance Company 2013(1) Raing Area I: Supplemen Counies: Allegheny, Beaver, Bucks, Buler, Cheser, Delaware, Fayee, Mongomery, Philadelphia, Washingon and Wesmoreland Counies. SELECT Counies: Bucks and Mongomery Counies. Raing Area II: Supplemen Counies: Adams, Armsrong, Bedford, Berks, Blair, Bradford, Cambria, Cameron, Carbon, Cenre, Clarion, Clearfield, Clinon, Columbia, Crawford, Cumberland, Dauphin, Elk, Erie, Fores, Franklin, Fulon, Greene, Huningdon, Indiana, Jefferson, Juniaa, Lackawanna, Lancaser, Lawrence, Lebanon, Lehigh, Luzerne, Lycoming, McKean, Mercer, Mifflin, Monroe, Monour, Norhampon, Norhumberland, Perry, Pike, Poer, Schuylkill, Snyder, Somerse, Sullivan, Susquehanna, Tioga, Union, Venango, Warren, Wayne, Wyoming and York Counies. SELECT Counies: Berks, Carbon, Lehigh, Monroe and Norhampon Counies. PA OC (01/13) 3

22 PREMIUM INFORMATION Serling Life Insurance Company Raing Area I 2013(1) Plan A PAC Monhly Premium STD SELECT Aained Age STD SELECT 1, , open enrollmen , , Under , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , and above Plan B PAC Monhly Premium STD SELECT Aained Age STD SELECT 2, , open enrollmen , , Under , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , and above Annual premium conversion formulas: Semi Annual X.5203, Quarerly X.2646, Monhly X.0900 All premiums are rounded o he neares penny. *If you are applying during an open enrollmen or guaranee issue period you qualify for he non obacco rae. PA OC (01/13) 3A