Companion Life Insurance Company Administrative Office PO Box 14158 Clearwater, Florida 33766-4158 (888) 220-0466 Outline of Medicare Supplement Coverage Cover Page Benefit Plans A, B, F and G - See Outlines of Coverage sections for details about ALL plans This chart shows the benefits included in each of the standard Medicare supplement plans. Every company must make available Plan A, B and C or F. Some plans may not be available in your state. Basic Benefits: 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 copayment for hospital outpatient services. Plans K, L and N require insured to pay a portion of Part B coinsurance or copayments. Blood: First three pints of blood each year. Hospice: Part A coinsurance. A B C D F F* G K L M N Basic, including 100% Part B Basic, including 100% Part B Part A Basic, including 100% Part B Skilled Nursing Facility Part A Part B Foreign Travel Emergency Basic, including 100% Part B Skilled Nursing Facility Part A Foreign Travel Emergency Basic, including 100% Part B Skilled Nursing Facility Part A Part B Part B Excess (100%) Foreign Travel Emergency Basic, including 100% Part B Skilled Nursing Facility Part A Part B Excess (100%) Foreign Travel Emergency * Plan F also has an option called a high deductible Plan F. This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,200 deductible. Benefits from high deductible Plan F will not begin until out-of-pocket expenses exceed $2,200. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. These expenses include Medicare deductibles for Part A and Part B, but do not include the plan s separate foreign travel emergency deductible. Basic, including 100% Part B Co- Insurance; other basic benefits paid at 50% 50% Skilled Nursing Facility 50% Part A Out-of-Pocket limit $5120; paid at 100% after limit reached Basic, including 100% Part B Co- Insurance; other basic benefits paid at 75% 75% Skilled Nursing Facility 75% Part A Out-of-Pocket limit $2560; paid at 100% after limit reached Basic, Including 100% Part B Co- Insurance Skilled Nursing Facility 50% Part A Foreign Travel Emergency Basic, including 100%Part B, except up to $20 copayment for office visit, and up to $50 copayment for ER Skilled Nursing Facility Part A Foreign Travel Emergency MSP-900-OUTLINE-PA 315 Page 1 1017 PA
PREMIUM INFORMATION We, Companion Life Insurance Company, can only raise Your premium if (a) We change the premium rates which apply to all policies of this form issued by Us and in-force in Pennsylvania; (b) coverage under Medicare changes; or (c) You move to a different ZIP code location. We will notify You thirty (30) days prior to any premium change. The premium rate is based upon your attained age, the premium will increase as you age from Age 65 through Age 99. This annual change will occur on each Policy Renewal Date. The Policy Renewal Date coincides with or follows the policy anniversary date. There will be a one-time enrollment fee of $25.00 added to the first premium. HOUSEHOLD PREMIUM DISCOUNT You are eligible for a household premium discount if you currently have a household resident (at least one not more than three): (a) With whom you reside and to whom you are either married or in a civil union partnership; or (b) Who has an existing Medicare Supplement policy or is applying for such a policy with us. We may request additional documentation to determine eligibility. The discounted rates will be 5% lower than the rates illustrated. Your policy s household premium discount will be terminated if no other adult who is age 50 or over or your legal spouse continues to reside with you (other than in the case of his or her death). DISCLOSURES Use this Outline to compare benefits and premiums among policies. READ YOUR POLICY VERY CAREFULLY This is only an Outline, describing Your Policy s most important features. The Policy is Your insurance contract. You must read the Policy itself to understand all of the rights and duties of both You and Your insurance company. 30-DAY RIGHT TO RETURN POLICY If You find that You are not satisfied with Your policy, You may return it to Companion Life Insurance Company, If You send the policy back to Us within 30 days after You receive it, We will treat the policy as if it had never been issued and return all of Your premiums. CANCELLATION BY YOU You may cancel your policy at any time by giving us written notice. Cancellation will be effective when we receive your notice or on a later date that you may specify. Upon cancellation or upon death, we will promptly return any unearned premium which will be based on a pro rata calculation. Cancellation will not affect an existing claim. POLICY REPLACEMENT If You are replacing another health insurance policy, do NOT cancel it until You have actually received Your new Policy and are sure You want to keep it. NOTICE This Policy may not fully cover all of Your medical costs. Neither Companion Life Insurance Company nor its agents are connected with Medicare. This Outline of Coverage does not give all the details of Medicare coverage. Contact Your local Social Security Office or consult Medicare and You for more details. COMPLETE ANSWERS ARE VERY IMPORTANT When You fill out the application for the new Policy, be sure to answer truthfully and completely all questions about Your medical and health history. The Company may cancel Your policy and refuse to pay any claims if You leave out or falsify important medical information. Review the application carefully before You sign it. Be certain that all information has been properly recorded. RENEWABILITY This Policy is guaranteed renewable for life. Page 2 1017 PA
Companion Life Insurance Company Pennsylvania Medicare Supplement Monthly Standard Non-Tobacco Rates for Zip Codes 155, 157-188, 195-196 Female Rates Male Rates Attained Age Plan A Plan B Plan F Plan G Attained Age Plan A Plan B Plan F Plan G Form No. MSP-900-A Form No. MSP-900-B Form No. MSP-900-F Form No. MSP-900-G Form No. MSP-900-A Form No. MSP-900-B Form No. MSP-900-F Form No. MSP-900-G 65 $105.18 $129.17 $148.35 $136.72 65 $115.82 $142.09 $163.18 $150.45 66 $105.18 $129.17 $148.35 $136.72 66 $115.82 $142.09 $163.18 $150.45 67 $105.18 $129.17 $148.35 $136.72 67 $115.82 $142.09 $163.18 $150.45 68 $105.18 $129.17 $148.35 $136.72 68 $115.82 $142.09 $163.18 $150.45 69 $107.81 $132.36 $151.99 $140.08 69 $118.64 $145.63 $167.17 $154.17 70 $110.45 $135.63 $155.72 $143.54 70 $121.54 $149.17 $171.35 $157.91 71 $113.54 $139.63 $160.37 $147.91 71 $124.90 $153.72 $176.44 $162.72 72 $116.73 $143.90 $165.27 $152.36 72 $128.45 $158.26 $181.72 $167.54 73 $120.08 $148.27 $170.18 $156.99 73 $132.08 $163.09 $187.18 $172.63 74 $123.45 $152.72 $175.35 $161.63 74 $135.81 $167.99 $192.91 $177.81 75 $126.81 $157.26 $180.72 $166.54 75 $139.53 $173.09 $198.72 $183.27 76 $130.08 $161.81 $186.18 $171.63 76 $142.99 $177.90 $204.72 $188.72 77 $133.27 $166.36 $191.71 $176.72 77 $146.55 $183.08 $210.90 $194.45 78 $136.63 $171.18 $197.53 $182.08 78 $150.26 $188.27 $217.17 $200.27 79 $140.00 $175.99 $203.44 $187.44 79 $153.98 $193.62 $223.71 $206.26 80 $143.54 $180.99 $209.53 $193.09 80 $157.81 $199.17 $230.44 $212.44 81 $146.72 $185.53 $215.45 $198.54 81 $161.36 $204.08 $236.89 $218.44 82 $149.90 $190.08 $221.45 $204.17 82 $164.90 $209.16 $243.62 $224.63 83 $153.27 $194.90 $227.72 $209.98 83 $168.62 $214.35 $250.45 $230.90 84 $156.73 $199.81 $234.08 $215.81 84 $172.26 $219.72 $257.44 $237.36 85 $160.18 $204.72 $240.63 $221.89 85 $176.08 $225.26 $264.71 $243.99 86 $163.18 $209.45 $247.36 $227.99 86 $179.53 $230.35 $271.99 $250.81 87 $166.26 $214.17 $254.17 $234.27 87 $182.91 $235.53 $279.62 $257.72 88 $169.45 $218.99 $261.35 $240.90 88 $186.45 $240.90 $287.44 $264.99 89 $172.63 $223.90 $268.72 $247.71 89 $189.90 $246.26 $295.45 $272.44 90 $175.99 $228.90 $275.63 $254.17 90 $193.62 $251.81 $303.25 $279.54 91 $178.72 $233.54 $282.80 $260.72 91 $196.63 $256.90 $311.07 $286.81 92 $181.62 $238.18 $290.08 $267.44 92 $199.81 $261.99 $319.07 $294.25 93 $184.44 $242.90 $297.62 $274.45 93 $202.99 $267.18 $327.44 $301.81 94 $187.44 $247.80 $305.34 $281.53 94 $206.26 $272.53 $335.98 $309.71 95 $190.44 $252.80 $313.35 $288.90 95 $209.53 $278.08 $344.71 $317.80 96 $192.91 $256.62 $321.44 $296.35 96 $212.17 $282.26 $353.62 $325.98 97 $195.44 $262.62 $329.89 $304.17 97 $214.98 $288.80 $362.89 $334.43 98 $197.99 $268.72 $338.44 $311.99 98 $217.81 $295.53 $372.25 $343.17 99 $200.53 $274.90 $347.17 $319.98 99 $220.63 $302.35 $381.80 $351.99 to Disability $105.18 $129.17 $148.35 $136.72 to Disability $115.82 $142.09 $163.18 $150.45 See PREMIUM INFORMATION regarding Household Premium Discount rating. Policies may be issued on an annual, semi-annual, quarterly or monthly mode. To obtain annual, semiannual, or quarterly premiums, multiply the Monthly Premium Amount by 12, 6, or 3, respectively Standard Non-Tobacco Rates will be charged for Open Enrollment and Guaranteed Issue business. A one time $25 Application Fee will be charged for each Insured. Effective: 10/1/2017 Page 3 1017 PA
Companion Life Insurance Company Pennsylvania Medicare Supplement Monthly Standard Tobacco Rates for Zip Codes 155, 157-188, 195-196 Female Rates Male Rates Attained Age Plan A Plan B Plan F Plan G Attained Age Plan A Plan B Plan F Plan G Form No. MSP-900-A Form No. MSP-900-B Form No. MSP-900-F Form No. MSP-900-G Form No. MSP-900-A Form No. MSP-900-B Form No. MSP-900-F Form No. MSP-900-G 65 $115.82 $142.09 $163.18 $150.45 65 $127.36 $156.26 $179.45 $165.45 66 $115.82 $142.09 $163.18 $150.45 66 $127.36 $156.26 $179.45 $165.45 67 $115.82 $142.09 $163.18 $150.45 67 $127.36 $156.26 $179.45 $165.45 68 $115.82 $142.09 $163.18 $150.45 68 $127.36 $156.26 $179.45 $165.45 69 $118.64 $145.63 $167.17 $154.17 69 $130.55 $160.18 $183.90 $169.54 70 $121.54 $149.17 $171.35 $157.91 70 $133.72 $164.08 $188.45 $173.72 71 $124.90 $153.72 $176.44 $162.72 71 $137.44 $168.99 $194.08 $178.90 72 $128.45 $158.26 $181.72 $167.54 72 $141.36 $174.17 $199.90 $184.27 73 $132.08 $163.09 $187.18 $172.63 73 $145.36 $179.35 $206.00 $189.81 74 $135.81 $167.99 $192.91 $177.81 74 $149.27 $184.81 $212.17 $195.53 75 $139.53 $173.09 $198.72 $183.27 75 $153.45 $190.35 $218.62 $201.44 76 $142.99 $177.90 $204.72 $188.72 76 $157.26 $195.72 $225.16 $207.54 77 $146.55 $183.08 $210.90 $194.45 77 $161.17 $201.36 $231.99 $213.80 78 $150.26 $188.27 $217.17 $200.27 78 $165.27 $207.17 $238.98 $220.26 79 $153.98 $193.62 $223.71 $206.26 79 $169.35 $213.08 $246.08 $226.89 80 $157.81 $199.17 $230.44 $212.44 80 $173.62 $218.99 $253.44 $233.72 81 $161.36 $204.08 $236.89 $218.44 81 $177.54 $224.53 $260.63 $240.27 82 $164.90 $209.16 $243.62 $224.63 82 $181.36 $230.08 $267.99 $247.07 83 $168.62 $214.35 $250.45 $230.90 83 $185.45 $235.81 $275.44 $253.99 84 $172.26 $219.72 $257.44 $237.36 84 $189.63 $241.71 $283.26 $261.08 85 $176.08 $225.26 $264.71 $243.99 85 $193.72 $247.80 $291.17 $268.44 86 $179.53 $230.35 $271.99 $250.81 86 $197.45 $253.36 $299.27 $275.90 87 $182.91 $235.53 $279.62 $257.72 87 $201.26 $259.17 $307.52 $283.53 88 $186.45 $240.90 $287.44 $264.99 88 $205.08 $265.08 $316.16 $291.53 89 $189.90 $246.26 $295.45 $272.44 89 $208.99 $270.99 $324.98 $299.71 90 $193.62 $251.81 $303.25 $279.54 90 $212.99 $276.99 $333.62 $307.44 91 $196.63 $256.90 $311.07 $286.81 91 $216.26 $282.62 $342.25 $315.53 92 $199.81 $261.99 $319.07 $294.25 92 $219.72 $288.17 $351.07 $323.62 93 $202.99 $267.18 $327.44 $301.81 93 $223.26 $293.90 $360.08 $331.99 94 $206.26 $272.53 $335.98 $309.71 94 $226.89 $299.80 $369.53 $340.72 95 $209.53 $278.08 $344.71 $317.80 95 $230.53 $305.89 $379.17 $349.53 96 $212.17 $282.26 $353.62 $325.98 96 $233.44 $310.44 $388.98 $358.53 97 $214.98 $288.80 $362.89 $334.43 97 $236.53 $317.70 $399.06 $367.98 98 $217.81 $295.53 $372.25 $343.17 98 $239.54 $325.08 $409.53 $377.52 99 $220.63 $302.35 $381.80 $351.99 99 $242.62 $332.62 $420.06 $387.26 to Disability $115.82 $142.09 $163.18 $150.45 to Disability $127.36 $156.26 $179.45 $165.45 See PREMIUM INFORMATION regarding Household Premium Discount rating. Policies may be issued on an annual, semi-annual, quarterly or monthly mode. To obtain annual, semiannual, or quarterly premiums, multiply the Monthly Premium Amount by 12, 6, or 3, respectively A one time $25 Application Fee will be charged for each Insured. Effective: 10/1/2017 Page 3a 1017 PA
Companion Life Insurance Company Pennsylvania Medicare Supplement Monthly Standard Non-Tobacco Rates for Zip Codes 150-154,156 Female Rates Male Rates Attained Age Plan A Plan B Plan F Plan G Attained Age Plan A Plan B Plan F Plan G Form No. MSP-900-A Form No. MSP-900-B Form No. MSP-900-F Form No. MSP-900-G Form No. MSP-900-A Form No. MSP-900-B Form No. MSP-900-F Form No. MSP-900-G 65 $122.10 $149.94 $172.21 $158.71 65 $134.44 $164.93 $189.42 $174.64 66 $122.10 $149.94 $172.21 $158.71 66 $134.44 $164.93 $189.42 $174.64 67 $122.10 $149.94 $172.21 $158.71 67 $134.44 $164.93 $189.42 $174.64 68 $122.10 $149.94 $172.21 $158.71 68 $134.44 $164.93 $189.42 $174.64 69 $125.16 $153.65 $176.44 $162.61 69 $137.71 $169.06 $194.07 $178.97 70 $128.21 $157.44 $180.77 $166.63 70 $141.08 $173.16 $198.92 $183.30 71 $131.80 $162.10 $186.15 $171.68 71 $145.00 $178.45 $204.83 $188.90 72 $135.49 $167.04 $191.85 $176.85 72 $149.11 $183.73 $210.94 $194.48 73 $139.40 $172.12 $197.54 $182.24 73 $153.33 $189.31 $217.28 $200.40 74 $143.30 $177.28 $203.56 $187.62 74 $157.65 $195.02 $223.93 $206.41 75 $147.21 $182.56 $209.78 $193.33 75 $161.98 $200.92 $230.68 $212.75 76 $151.01 $187.83 $216.11 $199.23 76 $166.00 $206.51 $237.64 $219.07 77 $154.70 $193.11 $222.56 $205.13 77 $170.10 $212.53 $244.83 $225.72 78 $158.60 $198.71 $229.31 $211.37 78 $174.44 $218.54 $252.09 $232.47 79 $162.51 $204.30 $236.17 $217.59 79 $178.76 $224.77 $259.70 $239.44 80 $166.63 $210.10 $243.24 $224.14 80 $183.19 $231.21 $267.50 $246.61 81 $170.32 $215.37 $250.10 $230.47 81 $187.31 $236.90 $274.99 $253.57 82 $174.02 $220.65 $257.06 $237.01 82 $191.42 $242.81 $282.81 $260.75 83 $177.92 $226.25 $264.34 $243.76 83 $195.75 $248.83 $290.72 $268.04 84 $181.93 $231.95 $271.73 $250.51 84 $199.96 $255.05 $298.84 $275.53 85 $185.94 $237.64 $279.33 $257.59 85 $204.39 $261.49 $307.29 $283.23 86 $189.42 $243.13 $287.13 $264.66 86 $208.41 $267.40 $315.73 $291.14 87 $193.00 $248.62 $295.05 $271.93 87 $212.32 $273.42 $324.60 $299.17 88 $196.70 $254.21 $303.38 $279.64 88 $216.44 $279.64 $333.67 $307.61 89 $200.40 $259.91 $311.93 $287.56 89 $220.45 $285.87 $342.96 $316.27 90 $204.30 $265.72 $319.96 $295.05 90 $224.77 $292.30 $352.04 $324.50 91 $207.47 $271.10 $328.29 $302.64 91 $228.24 $298.21 $361.11 $332.94 92 $210.84 $276.48 $336.73 $310.46 92 $231.95 $304.13 $370.39 $341.60 93 $214.11 $281.97 $345.50 $318.59 93 $235.64 $310.14 $380.10 $350.34 94 $217.59 $287.66 $354.46 $326.82 94 $239.44 $316.37 $390.03 $359.53 95 $221.08 $293.46 $363.75 $335.36 95 $243.24 $322.80 $400.15 $368.92 96 $223.93 $297.90 $373.15 $344.02 96 $246.30 $327.66 $410.50 $378.42 97 $226.88 $304.87 $382.96 $353.09 97 $249.57 $335.26 $421.27 $388.23 98 $229.84 $311.93 $392.87 $362.16 98 $252.83 $343.07 $432.13 $398.37 99 $232.80 $319.11 $403.01 $371.46 99 $256.11 $350.97 $443.21 $408.60 to Disability $122.10 $149.94 $172.21 $158.71 to Disability $134.44 $164.93 $189.42 $174.64 See PREMIUM INFORMATION regarding Household Premium Discount rating. Policies may be issued on an annual, semi-annual, quarterly or monthly mode. To obtain annual, semiannual, or quarterly premiums, multiply the Monthly Premium Amount by 12, 6, or 3, respectively Standard Non-Tobacco Rates will be charged for Open Enrollment and Guaranteed Issue business. A one time $25 Application Fee will be charged for each Insured. Effective: 10/1/2017 Page 3b 1017 PA
Companion Life Insurance Company Pennsylvania Medicare Supplement Monthly Standard Tobacco Rates for Zip Codes 150-154,156 Female Rates Male Rates Attained Age Plan A Plan B Plan F Plan G Attained Age Plan A Plan B Plan F Plan G Form No. MSP-900-A Form No. MSP-900-B Form No. MSP-900-F Form No. MSP-900-G Form No. MSP-900-A Form No. MSP-900-B Form No. MSP-900-F Form No. MSP-900-G 65 $134.44 $164.93 $189.42 $174.64 65 $147.83 $181.41 $208.31 $192.06 66 $134.44 $164.93 $189.42 $174.64 66 $147.83 $181.41 $208.31 $192.06 67 $134.44 $164.93 $189.42 $174.64 67 $147.83 $181.41 $208.31 $192.06 68 $134.44 $164.93 $189.42 $174.64 68 $147.83 $181.41 $208.31 $192.06 69 $137.71 $169.06 $194.07 $178.97 69 $151.53 $185.94 $213.49 $196.80 70 $141.08 $173.16 $198.92 $183.30 70 $155.23 $190.48 $218.76 $201.66 71 $145.00 $178.45 $204.83 $188.90 71 $159.55 $196.17 $225.29 $207.67 72 $149.11 $183.73 $210.94 $194.48 72 $164.09 $202.18 $232.06 $213.90 73 $153.33 $189.31 $217.28 $200.40 73 $168.74 $208.21 $239.12 $220.34 74 $157.65 $195.02 $223.93 $206.41 74 $173.28 $214.53 $246.30 $226.99 75 $161.98 $200.92 $230.68 $212.75 75 $178.13 $220.98 $253.79 $233.84 76 $166.00 $206.51 $237.64 $219.07 76 $182.56 $227.20 $261.39 $240.91 77 $170.10 $212.53 $244.83 $225.72 77 $187.09 $233.74 $269.31 $248.19 78 $174.44 $218.54 $252.09 $232.47 78 $191.85 $240.49 $277.42 $255.69 79 $178.76 $224.77 $259.70 $239.44 79 $196.60 $247.36 $285.66 $263.40 80 $183.19 $231.21 $267.50 $246.61 80 $201.56 $254.21 $294.20 $271.30 81 $187.31 $236.90 $274.99 $253.57 81 $206.09 $260.65 $302.55 $278.90 82 $191.42 $242.81 $282.81 $260.75 82 $210.53 $267.09 $311.09 $286.82 83 $195.75 $248.83 $290.72 $268.04 83 $215.27 $273.73 $319.74 $294.85 84 $199.96 $255.05 $298.84 $275.53 84 $220.13 $280.59 $328.81 $303.07 85 $204.39 $261.49 $307.29 $283.23 85 $224.88 $287.66 $338.00 $311.62 86 $208.41 $267.40 $315.73 $291.14 86 $229.20 $294.11 $347.39 $320.27 87 $212.32 $273.42 $324.60 $299.17 87 $233.63 $300.86 $357.00 $329.14 88 $216.44 $279.64 $333.67 $307.61 88 $238.07 $307.71 $367.03 $338.42 89 $220.45 $285.87 $342.96 $316.27 89 $242.61 $314.57 $377.25 $347.91 90 $224.77 $292.30 $352.04 $324.50 90 $247.25 $321.54 $387.28 $356.89 91 $228.24 $298.21 $361.11 $332.94 91 $251.05 $328.07 $397.30 $366.29 92 $231.95 $304.13 $370.39 $341.60 92 $255.05 $334.52 $407.54 $375.67 93 $235.64 $310.14 $380.10 $350.34 93 $259.17 $341.16 $417.99 $385.38 94 $239.44 $316.37 $390.03 $359.53 94 $263.40 $348.02 $428.97 $395.51 95 $243.24 $322.80 $400.15 $368.92 95 $267.61 $355.10 $440.15 $405.75 96 $246.30 $327.66 $410.50 $378.42 96 $271.00 $360.37 $451.54 $416.19 97 $249.57 $335.26 $421.27 $388.23 97 $274.58 $368.81 $463.26 $427.16 98 $252.83 $343.07 $432.13 $398.37 98 $278.05 $377.36 $475.39 $438.25 99 $256.11 $350.97 $443.21 $408.60 99 $281.65 $386.12 $487.64 $449.55 to Disability $134.44 $164.93 $189.42 $174.64 to Disability $147.83 $181.41 $208.31 $192.06 See PREMIUM INFORMATION regarding Household Premium Discount rating. Policies may be issued on an annual, semi-annual, quarterly or monthly mode. To obtain annual, semiannual, or quarterly premiums, multiply the Monthly Premium Amount by 12, 6, or 3, respectively A one time $25 Application Fee will be charged for each Insured. Effective: 10/1/2017 Page 3c 1017 PA
Companion Life Insurance Company Pennsylvania Medicare Supplement Monthly Standard Non-Tobacco Rates for Zip Codes 189-191, 193-194 Female Rates Male Rates Attained Age Plan A Plan B Plan F Plan G Attained Age Plan A Plan B Plan F Plan G Form No. MSP-900-A Form No. MSP-900-B Form No. MSP-900-F Form No. MSP-900-G Form No. MSP-900-A Form No. MSP-900-B Form No. MSP-900-F Form No. MSP-900-G 65 $133.45 $163.89 $188.22 $173.47 65 $146.94 $180.27 $207.03 $190.88 66 $133.45 $163.89 $188.22 $173.47 66 $146.94 $180.27 $207.03 $190.88 67 $133.45 $163.89 $188.22 $173.47 67 $146.94 $180.27 $207.03 $190.88 68 $133.45 $163.89 $188.22 $173.47 68 $146.94 $180.27 $207.03 $190.88 69 $136.79 $167.93 $192.84 $177.74 69 $150.51 $184.77 $212.12 $195.62 70 $140.13 $172.08 $197.58 $182.12 70 $154.21 $189.27 $217.41 $200.34 71 $144.06 $177.16 $203.46 $187.65 71 $158.48 $195.04 $223.88 $206.45 72 $148.09 $182.58 $209.69 $193.31 72 $162.97 $200.80 $230.55 $212.57 73 $152.36 $188.11 $215.91 $199.19 73 $167.59 $206.92 $237.48 $219.02 74 $156.63 $193.77 $222.48 $205.07 74 $172.32 $213.15 $244.74 $225.61 75 $160.89 $199.54 $229.29 $211.30 75 $177.04 $219.60 $252.14 $232.52 76 $165.05 $205.30 $236.21 $217.76 76 $181.43 $225.72 $259.74 $239.45 77 $169.09 $211.07 $243.24 $224.21 77 $185.92 $232.28 $267.59 $246.70 78 $173.35 $217.18 $250.63 $231.02 78 $190.65 $238.87 $275.54 $254.10 79 $177.62 $223.30 $258.13 $237.83 79 $195.39 $245.67 $283.84 $261.70 80 $182.12 $229.64 $265.86 $244.97 80 $200.23 $252.71 $292.39 $269.55 81 $186.16 $235.41 $273.35 $251.90 81 $204.72 $258.93 $300.56 $277.16 82 $190.19 $241.18 $280.96 $259.04 82 $209.23 $265.39 $309.11 $284.99 83 $194.46 $247.28 $288.92 $266.43 83 $213.96 $271.97 $317.76 $292.96 84 $198.85 $253.52 $297.00 $273.81 84 $218.56 $278.77 $326.63 $301.14 85 $203.22 $259.74 $305.30 $281.54 85 $223.41 $285.81 $335.87 $309.57 86 $207.03 $265.74 $313.83 $289.27 86 $227.80 $292.27 $345.09 $318.22 87 $210.96 $271.73 $322.49 $297.23 87 $232.06 $298.83 $354.77 $326.98 88 $214.98 $277.85 $331.60 $305.65 88 $236.56 $305.65 $364.71 $336.22 89 $219.02 $284.08 $340.93 $314.30 89 $240.94 $312.44 $374.84 $345.67 90 $223.30 $290.43 $349.71 $322.49 90 $245.67 $319.49 $384.77 $354.65 91 $226.76 $296.31 $358.81 $330.78 91 $249.48 $325.94 $394.68 $363.89 92 $230.44 $302.19 $368.04 $339.32 92 $253.52 $332.41 $404.84 $373.35 93 $234.02 $308.19 $377.62 $348.21 93 $257.55 $338.98 $415.44 $382.91 94 $237.83 $314.41 $387.42 $357.20 94 $261.70 $345.78 $426.29 $392.97 95 $241.64 $320.75 $397.56 $366.55 95 $265.86 $352.83 $437.35 $403.22 96 $244.74 $325.59 $407.84 $376.00 96 $269.20 $358.12 $448.67 $413.60 97 $247.98 $333.21 $418.57 $385.92 97 $272.77 $366.44 $460.43 $424.33 98 $251.21 $340.93 $429.40 $395.83 98 $276.34 $374.96 $472.31 $435.40 99 $254.44 $348.78 $440.47 $405.99 99 $279.93 $383.61 $484.42 $446.59 to Disability $133.45 $163.89 $188.22 $173.47 to Disability $146.94 $180.27 $207.03 $190.88 See PREMIUM INFORMATION regarding Household Premium Discount rating. Policies may be issued on an annual, semi-annual, quarterly or monthly mode. To obtain annual, semiannual, or quarterly premiums, multiply the Monthly Premium Amount by 12, 6, or 3, respectively Standard Non-Tobacco Rates will be charged for Open Enrollment and Guaranteed Issue business. A one time $25 Application Fee will be charged for each Insured. Effective: 10/1/2017 Page 3d 1017 PA
Companion Life Insurance Company Pennsylvania Medicare Supplement Monthly Standard Tobacco Rates for Zip Codes 189-191, 193-194 Female Rates Male Rates Attained Age Plan A Plan B Plan F Plan G Attained Age Plan A Plan B Plan F Plan G Form No. MSP-900-A Form No. MSP-900-B Form No. MSP-900-F Form No. MSP-900-G Form No. MSP-900-A Form No. MSP-900-B Form No. MSP-900-F Form No. MSP-900-G 65 $146.94 $180.27 $207.03 $190.88 65 $161.59 $198.27 $227.68 $209.92 66 $146.94 $180.27 $207.03 $190.88 66 $161.59 $198.27 $227.68 $209.92 67 $146.94 $180.27 $207.03 $190.88 67 $161.59 $198.27 $227.68 $209.92 68 $146.94 $180.27 $207.03 $190.88 68 $161.59 $198.27 $227.68 $209.92 69 $150.51 $184.77 $212.12 $195.62 69 $165.63 $203.22 $233.33 $215.10 70 $154.21 $189.27 $217.41 $200.34 70 $169.67 $208.18 $239.10 $220.41 71 $158.48 $195.04 $223.88 $206.45 71 $174.38 $214.42 $246.24 $226.99 72 $162.97 $200.80 $230.55 $212.57 72 $179.35 $220.99 $253.63 $233.79 73 $167.59 $206.92 $237.48 $219.02 73 $184.43 $227.57 $261.35 $240.83 74 $172.32 $213.15 $244.74 $225.61 74 $189.38 $234.48 $269.20 $248.10 75 $177.04 $219.60 $252.14 $232.52 75 $194.69 $241.52 $277.39 $255.60 76 $181.43 $225.72 $259.74 $239.45 76 $199.54 $248.32 $285.69 $263.32 77 $185.92 $232.28 $267.59 $246.70 77 $204.49 $255.48 $294.35 $271.27 78 $190.65 $238.87 $275.54 $254.10 78 $209.69 $262.85 $303.22 $279.47 79 $195.39 $245.67 $283.84 $261.70 79 $214.87 $270.34 $312.22 $287.88 80 $200.23 $252.71 $292.39 $269.55 80 $220.29 $277.85 $321.56 $296.53 81 $204.72 $258.93 $300.56 $277.16 81 $225.26 $284.88 $330.67 $304.83 82 $209.23 $265.39 $309.11 $284.99 82 $230.09 $291.92 $340.01 $313.48 83 $213.96 $271.97 $317.76 $292.96 83 $235.29 $299.18 $349.48 $322.26 84 $218.56 $278.77 $326.63 $301.14 84 $240.60 $306.68 $359.39 $331.25 85 $223.41 $285.81 $335.87 $309.57 85 $245.79 $314.41 $369.42 $340.58 86 $227.80 $292.27 $345.09 $318.22 86 $250.51 $321.45 $379.70 $350.06 87 $232.06 $298.83 $354.77 $326.98 87 $255.36 $328.82 $390.19 $359.74 88 $236.56 $305.65 $364.71 $336.22 88 $260.19 $336.33 $401.14 $369.89 89 $240.94 $312.44 $374.84 $345.67 89 $265.16 $343.82 $412.33 $380.28 90 $245.67 $319.49 $384.77 $354.65 90 $270.24 $351.44 $423.28 $390.08 91 $249.48 $325.94 $394.68 $363.89 91 $274.38 $358.59 $434.25 $400.34 92 $253.52 $332.41 $404.84 $373.35 92 $278.77 $365.62 $445.43 $410.60 93 $257.55 $338.98 $415.44 $382.91 93 $283.27 $372.88 $456.86 $421.21 94 $261.70 $345.78 $426.29 $392.97 94 $287.88 $380.39 $468.85 $432.29 95 $265.86 $352.83 $437.35 $403.22 95 $292.49 $388.11 $481.08 $443.47 96 $269.20 $358.12 $448.67 $413.60 96 $296.20 $393.88 $493.52 $454.89 97 $272.77 $366.44 $460.43 $424.33 97 $300.11 $403.10 $506.33 $466.89 98 $276.34 $374.96 $472.31 $435.40 98 $303.92 $412.45 $519.59 $479.00 99 $279.93 $383.61 $484.42 $446.59 99 $307.84 $422.03 $532.97 $491.35 to Disability $146.94 $180.27 $207.03 $190.88 to Disability $161.59 $198.27 $227.68 $209.92 See PREMIUM INFORMATION regarding Household Premium Discount rating. Policies may be issued on an annual, semi-annual, quarterly or monthly mode. To obtain annual, semiannual, or quarterly premiums, multiply the Monthly Premium Amount by 12, 6, or 3, respectively A one time $25 Application Fee will be charged for each Insured. Effective: 10/1/2017 Page 3e 1017 PA
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 61 st thru 90 th day 91 st day and after: While using 60 lifetime reserve days Once lifetime reserve days are used: - Additional 365 days - Beyond the additional 365 days SKILLED NURSING FACILITY CARE* You must meet Medicare s requirements, including having been in a hospital for at least 3 days and entered a Medicare approved facility within 30 days after leaving the hospital. First 20 days 21 st thru 100 th day 101 st day and after BLOOD First 3 pints Additional amounts All but $1,316 All but $329 a day All but $658 a day All approved amounts All but $164.50 a day 100% $329 a day $658 a day 100% of Medicare Eligible Expenses 3 pints $1,316 (Part A ) ** Up to $164.50 a day HOSPICE CARE You must meet Medicare s requirements, including a doctor s certification of terminal illness All but very limited coinsurance for outpatient drugs and inpatient respite care Medicare copayment/ coinsurance **NOTICE: When Your Medicare Part A hospital benefits are exhausted, the insurer stands in 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. Page 4 1017 PA
PLAN A MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR * Once You have been billed $183 of Medicare-approved amounts for covered services (which are noted with an asterisk), Your Part B 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 $183 of Medicare-approved amounts* Generally 80% Generally 20% Part B Excess Charges (Above Medicare-approved amounts) All costs BLOOD First 3 pints Next $183 of Medicare-approved amounts* 80% 20% CLINICAL LABORATORY SERVICES TESTS FOR DIAGNOSTIC SERVICES 100% PARTS A & B HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable medical equipment First $183 of Medicare-approved amounts* 100% 80% 20% Page 5 1017 PA
PLAN B - BENEFITS CHART 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 61 st thru 90 th day 91 st day and after: While using 60 lifetime reserve days Once lifetime reserve days are used: - Additional 365 days - Beyond the additional 365 days SKILLED NURSING FACILITY CARE* You must meet Medicare s requirements, including having been in a hospital for at least 3 days and entered a Medicare approved facility within 30 days after leaving the hospital. First 20 days 21 st thru 100 th day 101 st day and after BLOOD First 3 pints Additional amounts HOSPICE CARE You must meet Medicare s requirements, including a doctor s certification of terminal illness All but $1,316 All but $329 a day All but $658 a day All approved amounts All but $164.50 a day 100% All but very limited coinsurance for outpatient drugs and inpatient respite care $329 a day $658 a day 100% of Medicare Eligible Expenses 3 pints Medicare copayment/ coinsurance $1,316 (Part A ) ** Up to $164.50 a day **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. Page 6 1017 PA
PLAN B - BENEFITS CHART MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR *Once You have been billed $183 of Medicare-approved amounts for covered services (which are noted with an asterisk), Your Part B 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 $183 of Medicare-Approved Amounts* Remainder of Medicare-Approved Amounts Generally 80% Generally 20% PART B EXCESS CHARGES (Above Medicare-Approved Amounts) All costs BLOOD First 3 pints Next $183 of Medicare-Approved Amounts* Remainder of Medicare-Approved Amounts CLINICAL LABORATORY SERVICES TESTS FOR DIAGNOSTIC SERVICES 80% All costs 20% 100% PARTS A & B HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable medical equipment First $183 of Medicare-Approved Amounts* Remainder of Medicare-Approved Amounts 100% 80% 20% Page 7 1017 PA
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 61 st thru 90 th day 91 st day and after: While using 60 lifetime reserve days Once lifetime reserve days are used: - Additional 365 days - Beyond the additional 365 days SKILLED NURSING FACILITY CARE* You must meet Medicare s requirements, including having been in a hospital for at least 3 days and entered a Medicare approved facility within 30 days after leaving the hospital. First 20 days 21 st thru 100 th day 101 st day and after BLOOD First 3 pints Additional amounts HOSPICE CARE You must meet Medicare s requirements, including a doctor s certification of terminal illness All but $1,316 All but $329 a day All but $658 a day All approved amounts All but $164.50 a day 100% All but very limited coinsurance for outpatient drugs and inpatient respite care $1,316 (Part A ) $329 a day $658 a day 100% of Medicare Eligible Expenses Up to $164.50 a day 3 pints Medicare copayment/ coinsurance ** **NOTICE: When Your Medicare Part A hospital benefits are exhausted, the insurer stands in 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. Page 8 1017 PA
PLAN F MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR * Once You have been billed $183 of Medicare-approved amounts for covered services (which are noted with an asterisk), Your Part B 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 $183 of Medicare-approved amounts* Generally 80% Generally 20% Part B Excess Charges (Above Medicare-approved amounts) 100% BLOOD First 3 pints Next $183 of Medicare-approved amounts* 80% 20% CLINICAL LABORATORY SERVICES TESTS FOR DIAGNOSTIC SERVICES 100% HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable medical equipment First $183 of Medicare-approved amounts* 100% 80% PARTS A & B 20% OTHER BENEFITS NOT COVERED BY MEDICARE FOREIGN TRAVEL NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year Remainder of charges 80% to a lifetime maximum benefit of $50,000 $250 20% and amounts over the $50,000 lifetime maximum Page 9 1017 PA
PLAN G 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 61 st thru 90 th day 91 st day and after: While using 60 lifetime reserve days Once lifetime reserve days are used: - Additional 365 days - Beyond the additional 365 days SKILLED NURSING FACILITY CARE* You must meet Medicare s requirements, including having been in a hospital for at least 3 days and entered a Medicare approved facility within 30 days after leaving the hospital. First 20 days 21 st thru 100 th day 101 st day and after BLOOD First 3 pints Additional amounts HOSPICE CARE You must meet Medicare s requirements, including a doctor s certification of terminal illness All but $1,316 All but $329 a day All but $658 a day All approved amounts All but $164.50 a day 100% All but very limited coinsurance for outpatient drugs and inpatient respite care $1,316 (Part A ) $329 a day $658 a day 100% of Medicare Eligible Expenses Up to $164.50 a day 3 pints ** Medicare coinsurance **NOTICE: When Your Medicare Part A hospital benefits are exhausted, the insurer stands in 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. Page 10 1017 PA
PLAN G MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR * Once You have been billed $183 of Medicare-approved amounts for covered services (which are noted with an asterisk), Your Part B 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 $183 of Medicare-approved amounts* Generally 80% Generally 20% Part B Excess Charges (Above Medicare-approved amounts) 100% BLOOD First 3 pints Next $183 of Medicare-approved amounts* 80% 20% CLINICAL LABORATORY SERVICES TESTS FOR DIAGNOSTIC SERVICES 100% HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable medical equipment First $183 of Medicare-approved amounts* 100% 80% PARTS A & B 20% OTHER BENEFITS NOT COVERED BY MEDICARE FOREIGN TRAVEL NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year Remainder of charges 80% to a lifetime maximum benefit of $50,000 $250 20% and amounts over the $50,000 lifetime maximum Page 11 1017 PA