Monthly Rates. Plans A, F, High Deductible Plan F, G & N Effective January 1, 2012

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1 Administrative Office: PO Box 906, Oxnard, CA Toll Free Telephone Number: Effective January, 0 Premium Information We, Anthem, can only raise your premium if we raise the premium for all plans like yours in this State. Your premium rate increases based upon your attained age. We will recalculate your age each year. Your premium rate will increase annually based upon your new attained age. Premium changes due to your attained age occur at the beginning of your policy term. To determine your premium, select your age as of your requested policy effective date, then refer to the zip code listing on pages 6 and 7 to determine which area you live in. Some zip codes may fall in two or more rating areas. Plan A Plan F Male Female Male Female Male Female Male Female Male Female Male Female < 65 $ 59.5 $ 7.4 $ 44.8 $ 4.4 $ 9.9 $.5 $ 7.49 $ $ 06. $ 77.6 $ $ (continued on next page.) 0 Outline of Medicare Supplement Coverage

2 Administrative Office: PO Box 906, Oxnard, CA Toll Free Telephone Number: Effective January, 0 Premium Information (Continued) High Deductible Plan F Plan G Male Female Male Female Male Female Male Female Male Female Male Female < 65 $ 76.6 $ 65.8 $ $ 59.4 $ 6.88 $ 5.04 $.7 $ 8. $ 9.7 $ $ 7.8 $ (continued on next page.) 0 Outline of Medicare Supplement Coverage 4

3 Administrative Office: PO Box 906, Oxnard, CA Toll Free Telephone Number: Effective January, 0 Premium Information (Continued) Plan N Male Female Male Female Male Female < 65 $ $ 5.9 $ 4. $.57 $ 7.54 $ Save $ on your monthly premium! Enroll in our Automatic Bank Draft or Electronic Fund Transfer (EFT) program and you will save $ on your monthly premium. (To enroll, simply complete the Premium Payment Form.) OR Save $48 by paying your premium for the entire year! (Note: Based on the policy effective date, the discount may be pro-rated the first year.) Save 5% when more than one member in the household enrolls in a Medicare Supplement plan with us. The discount is for policies with effective dates of June, 00 or after and available to those members who occupy the same housing unit. 0 Outline of Medicare Supplement Coverage 5

4 Administrative Office: PO Box 906, Oxnard, CA Toll Free Telephone Number: Effective January, 0 5-Digit Zip Code Guide To determine your premium, refer to the zip code listing to determine which area you live in, then select your age as of your requested policy effective date from the prior pages.. Go to Column and locate the (first digits of your Zip Code) (P.O. Box addresses are not acceptable.) , 0-9,,, 4, 0,,, 4-8, 40-4, ,,, * 80 0, 04, 08, 09, 0-, 6, 8, 0-, 5-7, 50, 5, 55, 60-6, 65, , 07, 7,, 80 0, 05, 06, 4, 8, * 80 0-, 4-9, 4, 4, 44, 46-5, 56, 57, 59-66, 7, 7, 74, 79-8, 90, 9, 9-95, , 4, -, 8, 9. Then move to Column and locate the last two digits of your Zip Code.. Column is your Rating. (note: Some zip codes are assigned Multiple Rating s.*) 804 0, 0, 9, 5,, 7, 5, 54, 57, , 66, 7, ,,, 4, 6-0,, 4-6, 8, 40, 4-44, 46, 47-49, 5, 5, 56, 59, 6, 6, 67-69, 7-80, 8, 8, 87, 88, 97, ,, 9, 70,, * 805 0, 0, 0-, 5, 7, -, 5-8,,, 5, 6, 8-4, 44, 45, 47, , 0, 0, 4, 4, 46, , 04,, 6, 4, 4, 7, 49, 50, * 806 0, 0, 4, 40 * Counties With Zip Codes That Cross Rating Boundaries: Adams, Arapahoe, Broomfield, Douglas, and Jefferson. Boulder, Larimer, and Pueblo. Clear Creek, Crowley, Custer, El Paso, Elbert, Fremont, Gilpin, Morgan, Otero, Park, and Weld. 4. See Premium Chart for your area. 0 Outline of Medicare Supplement Coverage ,, 5, 0-4, -4, 8, 9, 44-46, ,, 4, 4, 54,, * , 0-, 6-9, -7, 40-47, 49-5, 54, 55, , * 808 0, 0, 04, 05, 07-0, -6, 40, 4, 60-64, , 49-5, 60, 6, 70, 77, 95, , 9,,, 5, ,, 4, 7, 9, 0,, 4, 6, 8, 40, 4, 4-47, 49, 50, 5, 54, 55, 57-59, 6, 64, 67, 7, 7, 76, 77, 8, 8, 84, 87, 89-9

5 Administrative Office: PO Box 906, Oxnard, CA Toll Free Telephone Number: Effective January, 0 5-Digit Zip Code Guide (Continued) To determine your premium, refer to the zip code listing to determine which area you live in, then select your age as of your requested policy effective date from the prior pages.. Go to Column and locate the (first digits of your Zip Code) (P.O. Box addresses are not acceptable.) 80 08, 9, 6, * 8 0, 0, 0-, 5-8, 40, 4, 4, 44, 46-49, 5-55, 57. Then move to Column and locate the last two digits of your Zip Code. 8 0, 0-, 5, 0-8, 0-, 5-7, 9-44, 47,. Column is your Rating. (note: Some zip codes are assigned Multiple Rating s.*) 48, 5, 5, , * 8 0-0, 0,, -, 4, 5 4. See Premium Chart for your area , 0,, -6, 8-0, , , 0, 0-, 5, 0,,, 4-6, 0-, 5-4, 45-50, 5-58 * Counties With Zip Codes That Cross Rating Boundaries: Adams, Arapahoe, Broomfield, Douglas, and Jefferson. Boulder, Larimer, and Pueblo. Clear Creek, Crowley, Custer, El Paso, Elbert, Fremont, Gilpin, Morgan, Otero, Park, and Weld. 0 Outline of Medicare Supplement Coverage 7