AETNA HEALTH AND LIFE INSURANCE COMPANY 800 Crescent Centre Dr., Suite 200, Franklin, Tennessee, 37067 Telephone: 800 264.4000 OUTLINE OF MEDICARE SUPPLEMENT INSURANCE OUTLINE OF COVERAGE FOR POLICY FORM AHLMSP17BC WI MEDICARE SUPPLEMENT INSURANCE The Wisconsin Insurance Commissioner has set standards for Medicare Supplement Insurance. This policy meets these standards. It, along with Medicare, may not cover all your medical costs. You should review carefully all policy limitations. For an explanation of these standards and other important information, see Wisconsin Guide to Health Insurance for People with Medicare, given to you when you applied for the policy. Do not buy the policy if you did not get this guide. PREMIUM INFORMATION - We, Aetna Health and Life Insurance Company can only raise your premium if we raise the premium for all policies like yours in the same geographic area in this state. Your premium will change each year. The new premium will be based on your age. DISCLOSURES - Use this outline to compare benefits and premiums among policies. READ YOUR POLICY VERY CAREFULLY - This is only an Outline of Coverage describing your policy s most important features. This is not your insurance contract. You must read the policy itself to understand all of the rights and duties of both you and your insurance company. RIGHT TO RETURN POLICY - If you find you are not satisfied with your policy, you may return it to Aetna Health and Life Insurance Company, P.O. Box 14770, Lexington, KY 40512-4770. 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 payments directly to you. 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 - The policy may not fully cover all of your medical costs. NEITHER AETNA HEALTH AND 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. 1
AETNA HEALTH AND LIFE INSURANCE COMPANY OUTLINE OF MEDICARE SUPPLEMENT INSURANCE BASIC PLAN 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. *NOTICE: When your Medicare Part A hospital benefits are exhausted, the issuer stands in the place of Medicare and will pay whatever amount Medicare would have paid as provided in the policy s Core Benefits. **These are optional riders. You purchased this benefit if the box is checked and you paid the premium. MEDICARE PART A BENEFITS HOSPITALIZATION Semiprivate room and board, general nursing and miscellaneous hospital services and supplies (Does not include personal items) First 60 days MEDICARE All but $1340 THIS POLICY or [ ] Part A ** YOU PAY $1340 (Part A ) or 61 st through 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 All but $335 a day All but $670 a day $335 a day $670 a day 100% of Medicare Eligible Expenses* All costs 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 All approved amounts 21 st through 100 th day All but $167.50 a day Up to $167.50 a day 101 st day and after All Costs 2
MEDICARE PART A BENEFITS INPATIENT PSYCHIATRIC CARE Inpatient psychiatric care in a participating psychiatric hospital BLOOD First 3 pints Additional Amounts HOSPICE CARE Available as long as your doctor certifies you are terminally ill and you elect to receive these services MEDICARE THIS POLICY 190 days per lifetime 175 days per lifetime 100% All but very limited coinsurance or copayment for outpatient drugs and inpatient respite care First 3 pints Medicare copayment / coinsurance YOU PAY All charges not covered by policy nor by Medicare 3
BASIC PLAN MEDICARE (PART B) MEDICAL SERVICES PER CALENDAR YEAR Once you have been billed $183 of Medicare-approved amounts for covered services, your Medicare deductible will have been met for the calendar year. **These are optional riders. You purchased this benefit if the box is checked and you paid the premium. MEDICARE PART B BENEFITS MEDICAL EXPENSES Eligible expense for physician s services, in-patient and out-patient medical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $183 of Medicare-approved amounts MEDICARE or THIS POLICY [ ] Optional ** $183 or or YOU PAY Remainder of Medicare-approved amounts Generally 80% Generally 20% Charges in excess of 20% up to the limiting charge [ ] Optional Medicare Copayment or Coinsurance ** Up to $20 per office visit and up to $50 per emergency room visit. BLOOD First 3 pints Next $183 of Medicare-approved amounts [ ] Optional Medicare Excess Charges ** All costs or [ ] Optional ** Balance, if any, or expenses if not covered by Medicare or this policy $183 or Remainder of Medicare-approved amounts 80% 20% Charges not covered by the policy or Medicare 4
MEDICARE PART B BENEFITS CLINICAL LABORATORY SERVICES Tests for diagnostic services HOME HEALTH CARE MEDICARE THIS POLICY 100% 100% of charges for visits considered medically necessary by Medicare 40 visits or [ ] Optional Additional Home Health Care ** YOU PAY Charges not covered by policy or Medicare **These are optional riders. You purchased this benefit if the box is checked and you paid the premium. 5
BASIC PLAN OTHER BENEFITS NOT COVERED BY MEDICARE PREVENTIVE MEDICAL CARE BENEFIT- NOT COVERED BY MEDICARE Some annual physical and preventive tests and services administered or ordered by your doctor when not covered by Medicare First $120 each calendar year Additional charges 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 MEDICARE $120 THIS POLICY YOU PAY Charges not covered by policy or Medicare $250 Remainder of charges or [ ] Optional Foreign Travel Emergency ** (80% to a lifetime maximum benefit of $50,000) All costs or 20% and amounts over the $50,000 lifetime maximum **These are optional riders. You purchased this benefit if the box is checked and you paid the premium. 6
THE FOLLOWING BENEFITS ARE MANDATED BY YOUR STATE: SKILLED NURSING FACILITY BENEFITS FOR NON-MEDICARE ELIGIBLE CONFINEMENT - We will pay the expenses you incur during any Medicare benefit period for confinement in a Wisconsin state licensed Skilled Nursing Facility, up to a maximum of 30 days. The daily rate payable shall be no less than the maximum daily rate established for skilled nursing care in that facility by the Department of Health and Social Services. Your confinement must be certified initially as Medically Necessary by the attending Physician and recertified every 7 days. Benefits are not payable for services provided by or paid for by the Veterans Administration or Custodial Care or Skilled Nursing Facility confinement certified by Medicare. KIDNEY DISEASE BENEFITS - We will pay the expenses you incur for treatment of kidney Disease by dialysis, transplantation and/or donor related services as defined by the Wisconsin Department of Health and Social Services, up to a maximum of $30,000 each calendar year. We will not pay for charges covered by another policy covering kidney disease expenses or for charges covered by Medicare. DIABETES BENEFITS - We will pay the usual and customary charges for expenses incurred, and not covered by Medicare, for the installation and use of an insulin infusion pump or other equipment or supplies, including insulin or any other prescription medication, used in the treatment of diabetes and coverage of diabetic selfmanagement education programs. Coverage for an insulin infusion pump is limited to one pump per year and is subject to a 30 day trial period prior to purchase. Benefits are not payable under clause (1) if the equipment and supplies are covered under the Medicare Part D Prescription Drug program, whether or not the insured person is enrolled in a Medicare Part D plan. CHIROPRACTIC BENEFITS - When Medicare does not pay for Medically Necessary Services received from a Chiropractor, we will 100% of the usual and customary charges for chiropractor services. Benefits are not payable for that portion of expense for which benefits were paid by Medicare or under any other part of this policy. HOSPITAL AND AMBULATORY SURGICAL CENTER CHARGES - We will pay the usual and customary charges incurred, and anesthetics provided, in conjunction with dental care that is provided to a covered individual in a Hospital or Ambulatory Surgical Center, if any of the Following applies: a. you have a chronic disability that is attributable to a mental or physical impairment which results in a substantial functional limitation in an area of your major life activity, and the disability is likely to continue indefinitely. b. you have a medical condition that requires hospitalization or general anesthesia for dental care. BREAST RECONSTRUCTION BENEFITS - We will pay the usual and customary charges Incurred, not payable under Medicare, in the manner recommended by the attending Physician or Oncologist for breast reconstruction of the affected tissue incident to a mastectomy. 7
COLORECTAL EXAMS We will pay your expense incurred for colorectal screening exams and lab tests if you are over 50 years of age or if you are under 50 years of age and are symptomatic or in a high-risk category. This coverage is subject to any deductible, coinsurance, co-payment, or other limitation on coverage applicable to other coverages under this policy. Benefits are not payable for that portion of expense for which benefits were paid by Medicare or under any other part of this policy. CANCER CLINICAL TRIAL - We will provide coverage for the cost of any routine patient care that is administered to an insured in a cancer clinical trial satisfying the following criteria and would be covered under the policy, plan, or contract if the insured were not enrolled in the cancer clinical trial: a. The purpose of the trial is to test whether the intervention potentially improves the trial participants health outcomes. b. The treatment provided as part of the trial is given with the intention of improving the trial participants health outcomes. c. The trial has therapeutic intent and is not designed exclusively to test toxicity or disease pathophysiology. d. The trial does one of the following: 1. Tests how to administer a health care service, item, or drug for the treatment of cancer. 2. Tests responses to a health care service, item, or drug for the treatment of cancer. 3. Compares the effectiveness of health care services, items, or drugs for the treatment of cancer with that of other health care services, items, or drugs for the treatment of cancer. 4. Studies new uses of health care services, items, or drugs for the treatment of cancer. e. The trial is approved by one of the following: 1. A National Institute of Health, or one of its cooperative groups or centers, under the federal department of health and human services. 2. The Federal Food and Drug Administration. 3. The Federal Department of Defense. 4. The Federal Department of Veterans Affairs. EXCEPTIONS, REDUCTIONS AND LIMITATIONS OF THE POLICY - We will not pay benefits for: (1) expenses deemed unnecessary or unreasonable by Medicare, except in the Benefit Provisions and in Optional s, if any; (2) expenses incurred prior to the coverage effective date; (3) drugs (other than prescription drugs furnished during a hospital or skilled nursing facility stay); (4) custodial care, dental care (except as provided in the mandated benefits) eye or ear examinations to prescribe or fit eyeglasses or hearing aids, routine immunizations, cosmetic surgery or routine foot care; (5) services for which a charge is normally not make when there is no insurance; (6) nursing home care costs (beyond what is covered by Medicare and the Wisconsin 30-day skilled nursing mandated by Wisconsin 632.895(3); (7) home health care above the number of visits covered by Medicare and the 40-visits mandated by Wisconsin 632.895(2), unless you select the Additional Home Health Care ; (8) care received outside the USA Benefits will be increased to match any increases in Medicare deductible amounts or co-payment charges. The premium may automatically increase to correspond with these increases. 8
Renewability of the Policy - We will renew the policy each time you send us the premium. It must be paid on or before the date it is due or during the 31 days that follow. Your premium will change on the first renewal date that coincides with or follows the anniversary date of the policy. Material Misrepresentation - in the event of a material misrepresentation, the coverage will be cancelled as of the coverage effective date. A material misrepresentation occurs when a condition or combination of conditions you were requested to name on the application was not named and which, if named, would have caused us to deny issuing the coverage. This limitation for material misrepresentation is subject to the Time Limit for Certain defenses provision. Review and Appeal - In the event of the denial of a claim under the Policy, You may appeal such denial by submitting a written request, which may be in any form and which may include supporting material, for our review. We will provide a description of the review and notification to you regarding the results of the review within 30 days after receiving your request. Grievance - A grievance may be made by you or on your behalf in writing to us. A grievance is any dissatisfaction regarding our services, decision to rescind a policy, or claims practices. IN ADDITION TO THIS OUTLINE OF COVERAGE, AETNA HEALTH AND LIFE INSURANCE COMPANY WILL SEND AN ANNUAL NOTICE TO YOU, 30 DAYS PRIOR TO THE EFFECTIVE DATE OF MEDICARE CHANGES, WHICH WILL DESCRIBE THESE CHANGES AND THE CHANGES IN YOUR MEDICARE SUPPLEMENT COVERAGE. 9
MEDICARE SUPPLEMENT PREMIUM INFORMATION ANNUAL PREMIUM $ BASIC MEDICARE SUPPLEMENT COVERAGE OPTIONAL BENEFITS FOR MEDICARE SUPPLEMENT POLICY - Each of these riders may be purchased separately. $ $ $ $ $ $ $ MEDICARE PART A DEDUCTIBLE RIDER - 100% of Part A MEDICARE PART B DEDUCTIBLE RIDER - 100% of MEDICARE PART B EXCESS CHARGES RIDER - Difference between what Medicare pays and the amount charged by the provider which shall be no greater than the actual charge or the limiting charge allowed by Medicare, whichever is less. ADDITIONAL HOME HEALTH CARE RIDER - An aggregate of 365 visits per year including those covered by Medicare. FOREIGN TRAVEL EMERGENCY RIDER - After a deductible of not greater than $250, covers at least 80% of expenses associated with emergency medical care received outside the United States during the first 60 days of a trip with a maximum of at least $50,000. MEDICARE PART B COPAYMENT OR COINSURANCE RIDER - Pays the coinsurance subject to a copayment or coinsurance of no more than $20 per office visit and no more than $50 per emergency room visit or the Medicare coinsurance that is in addition to the Medicare medical deductible and in addition to out-ofpocket maximums. TOTAL FOR BASIC POLICY, POLICY FEE AND SELECTED OPTIONAL RIDERS Total Premium, if other than Annual Mode (at time of application), including premium for any Optional selected above: $ EFT $ Quarterly $ Semi-annual 10
Age Basic Policy Preferred Basic Policy with Copayment Part A Excess Age Basic Policy Standard Basic Policy with Copayment Part A Under 65 6,383 4,800 945 300 Under 65 7,092 5,334 1,050 333 65 1,369 1,138 225 71 65 1,521 1,264 250 79 66 1,369 1,138 225 71 66 1,521 1,264 250 79 67 1,369 1,138 225 71 67 1,521 1,264 250 79 68 1,390 1,153 228 72 68 1,545 1,281 253 80 69 1,423 1,176 232 73 69 1,581 1,307 258 81 70 1,466 1,208 238 76 70 1,628 1,343 264 84 71 1,515 1,245 245 78 71 1,684 1,383 273 86 72 1,568 1,283 254 80 72 1,743 1,425 282 90 73 1,627 1,326 261 83 73 1,808 1,474 290 92 74 1,690 1,372 270 86 74 1,877 1,525 300 96 75 1,757 1,422 281 89 75 1,952 1,580 312 98 76 1,825 1,471 290 92 76 2,028 1,635 322 103 77 1,895 1,522 300 94 77 2,105 1,691 333 105 78 1,962 1,571 310 98 78 2,181 1,745 345 109 79 2,032 1,623 320 101 79 2,257 1,803 355 113 80 2,102 1,673 330 104 80 2,335 1,860 367 116 81 2,172 1,725 341 107 81 2,414 1,916 379 119 82 2,246 1,778 352 111 82 2,495 1,975 391 123 83 2,320 1,834 362 114 83 2,577 2,038 402 127 84 2,397 1,890 373 118 84 2,663 2,100 414 131 85 2,484 1,954 386 122 85 2,760 2,171 428 135 86 2,561 2,011 396 125 86 2,845 2,234 440 139 87 2,637 2,067 408 130 87 2,930 2,297 453 144 88 2,716 2,124 420 133 88 3,018 2,360 467 149 89 2,798 2,184 432 137 89 3,108 2,427 480 152 90 2,880 2,244 444 140 90 3,200 2,493 493 156 91 2,965 2,306 455 144 91 3,295 2,562 506 160 92 3,050 2,368 467 149 92 3,389 2,631 519 165 93 3,136 2,431 480 152 93 3,485 2,701 533 169 94 3,226 2,496 492 156 94 3,585 2,773 546 173 95 3,315 2,561 505 160 95 3,683 2,845 562 178 96 3,405 2,628 518 164 96 3,784 2,919 576 182 97 3,496 2,694 532 169 97 3,885 2,994 591 188 98 3,591 2,762 545 172 98 3,990 3,069 605 191 99+ 3,685 2,831 559 177 99+ 4,095 3,146 622 197 Age Additional Home Health Care Preferred Foreign Travel Age Additional Home Health Care Standard Foreign Travel All 8 183 6 All 9 183 7 Modal Factors: Semi-Annual: 0.5200 Quarterly: 0.2650 Monthly: 0.0833 The above rates do not include the $20 one-time policy fee. Aetna Health and Life Insurance Company Annual Premiums For Use in ZIP Codes: 530-534 Female Rates Rates Effective 02/01/2018 To calculate a Household discount: Annual premium x modal factor = modal premium (round to nearest whole cent) Modal premium x.93 = discounted premium Excess If applying during Open Enrollment or Guaranteed Issue Period, use Preferred rates. 11
Aetna Health and Life Insurance Company Annual Premiums For Use in ZIP Codes: 530-534 Male Rates Rates Effective 02/01/2018 Age Basic Policy Preferred Standard Basic Policy Basic Policy with Part A with Copayment Excess Copayment Age Basic Policy Part A Under 65 7,340 5,520 1,087 345 Under 65 8,156 6,134 1,208 382 65 1,574 1,309 260 81 65 1,749 1,454 288 91 66 1,574 1,309 260 81 66 1,749 1,454 288 91 67 1,574 1,309 260 81 67 1,749 1,454 288 91 68 1,599 1,326 262 83 68 1,776 1,474 290 92 69 1,637 1,353 268 84 69 1,818 1,503 297 93 70 1,685 1,390 274 87 70 1,873 1,545 304 97 71 1,743 1,431 282 90 71 1,936 1,591 314 99 72 1,803 1,475 291 92 72 2,005 1,639 325 103 73 1,871 1,526 300 96 73 2,079 1,694 334 106 74 1,943 1,578 310 99 74 2,159 1,753 345 110 75 2,020 1,635 323 101 75 2,244 1,817 359 112 76 2,099 1,692 334 106 76 2,333 1,881 371 118 77 2,179 1,751 345 109 77 2,421 1,945 382 120 78 2,256 1,807 356 112 78 2,508 2,007 396 125 79 2,336 1,866 368 117 79 2,596 2,073 408 130 80 2,417 1,925 380 119 80 2,686 2,138 422 133 81 2,498 1,984 392 124 81 2,777 2,204 435 137 82 2,582 2,045 405 127 82 2,869 2,272 450 142 83 2,668 2,109 417 132 83 2,964 2,343 463 146 84 2,756 2,174 428 136 84 3,063 2,415 477 151 85 2,857 2,247 444 139 85 3,174 2,497 492 155 86 2,945 2,313 455 144 86 3,272 2,569 506 160 87 3,033 2,378 470 150 87 3,369 2,642 522 165 88 3,123 2,443 483 153 88 3,472 2,714 537 171 89 3,218 2,512 497 157 89 3,574 2,792 552 175 90 3,312 2,581 510 162 90 3,680 2,867 568 179 91 3,410 2,651 524 165 91 3,789 2,946 582 184 92 3,508 2,723 537 171 92 3,898 3,027 597 190 93 3,607 2,795 552 175 93 4,007 3,106 614 194 94 3,710 2,870 566 179 94 4,123 3,190 628 199 95 3,811 2,945 581 184 95 4,235 3,272 645 205 96 3,916 3,022 596 189 96 4,352 3,357 662 209 97 4,020 3,098 612 194 97 4,467 3,443 680 216 98 4,129 3,177 627 198 98 4,588 3,529 696 219 99+ 4,237 3,256 643 204 99+ 4,709 3,618 715 227 Age Additional Home Health Care Preferred Foreign Travel Age Additional Home Health Care Standard Foreign Travel All 8 183 6 All 9 183 7 Modal Factors: Semi-Annual: 0.5200 Quarterly: 0.2650 Monthly: 0.0833 The above rates do not include the $20 one-time policy fee. To calculate a Household discount: Annual premium x modal factor = modal premium (round to nearest whole cent) Modal premium x.93 = discounted premium Excess If applying during Open Enrollment or Guaranteed Issue Period, use Preferred rates. 12
Age Basic Policy Preferred Basic Policy with Copayment Part A Excess Age Basic Policy Standard Basic Policy with Copayment Part A Under 65 5,409 4,068 801 254 Under 65 6,010 4,520 890 282 65 1,160 964 191 60 65 1,289 1,071 212 67 66 1,160 964 191 60 66 1,289 1,071 212 67 67 1,160 964 191 60 67 1,289 1,071 212 67 68 1,178 977 193 61 68 1,309 1,086 214 68 69 1,206 997 197 62 69 1,340 1,108 219 69 70 1,242 1,024 202 64 70 1,380 1,138 224 71 71 1,284 1,055 208 66 71 1,427 1,172 231 73 72 1,329 1,087 215 68 72 1,477 1,208 239 76 73 1,379 1,124 221 70 73 1,532 1,249 246 78 74 1,432 1,163 229 73 74 1,591 1,292 254 81 75 1,489 1,205 238 75 75 1,654 1,339 264 83 76 1,547 1,247 246 78 76 1,719 1,386 273 87 77 1,606 1,290 254 80 77 1,784 1,433 282 89 78 1,663 1,331 263 83 78 1,848 1,479 292 92 79 1,722 1,375 271 86 79 1,913 1,528 301 96 80 1,781 1,418 280 88 80 1,979 1,576 311 98 81 1,841 1,462 289 91 81 2,046 1,624 321 101 82 1,903 1,507 298 94 82 2,114 1,674 331 104 83 1,966 1,554 307 97 83 2,184 1,727 341 108 84 2,031 1,602 316 100 84 2,257 1,780 351 111 85 2,105 1,656 327 103 85 2,339 1,840 363 114 86 2,170 1,704 336 106 86 2,411 1,893 373 118 87 2,235 1,752 346 110 87 2,483 1,947 384 122 88 2,302 1,800 356 113 88 2,558 2,000 396 126 89 2,371 1,851 366 116 89 2,634 2,057 407 129 90 2,441 1,902 376 119 90 2,712 2,113 418 132 91 2,513 1,954 386 122 91 2,792 2,171 429 136 92 2,585 2,007 396 126 92 2,872 2,230 440 140 93 2,658 2,060 407 129 93 2,953 2,289 452 143 94 2,734 2,115 417 132 94 3,038 2,350 463 147 95 2,809 2,170 428 136 95 3,121 2,411 476 151 96 2,886 2,227 439 139 96 3,207 2,474 488 154 97 2,963 2,283 451 143 97 3,292 2,537 501 159 98 3,043 2,341 462 146 98 3,381 2,601 513 162 99+ 3,123 2,399 474 150 99+ 3,470 2,666 527 167 Age Additional Home Health Care Preferred Foreign Travel Age Additional Home Health Care Standard Foreign Travel All 7 183 5 All 8 183 6 Modal Factors: Semi-Annual: 0.5200 Quarterly: 0.2650 Monthly: 0.0833 The above rates do not include the $20 one-time policy fee. Aetna Health and Life Insurance Company Annual Premiums For Use in: Rest of State Female Rates Rates Effective 02/01/2018 To calculate a Household discount: Annual premium x modal factor = modal premium (round to nearest whole cent) Modal premium x.93 = discounted premium Excess If applying during Open Enrollment or Guaranteed Issue Period, use Preferred rates. 13
Aetna Health and Life Insurance Company Annual Premiums For Use in: Rest of State Male Rates Rates Effective 02/01/2018 Age Basic Policy Preferred Standard Basic Policy Basic Policy with Part A with Copayment Excess Copayment Age Basic Policy Part A Under 65 6,220 4,678 921 292 Under 65 6,912 5,198 1,024 324 65 1,334 1,109 220 69 65 1,482 1,232 244 77 66 1,334 1,109 220 69 66 1,482 1,232 244 77 67 1,334 1,109 220 69 67 1,482 1,232 244 77 68 1,355 1,124 222 70 68 1,505 1,249 246 78 69 1,387 1,147 227 71 69 1,541 1,274 252 79 70 1,428 1,178 232 74 70 1,587 1,309 258 82 71 1,477 1,213 239 76 71 1,641 1,348 266 84 72 1,528 1,250 247 78 72 1,699 1,389 275 87 73 1,586 1,293 254 81 73 1,762 1,436 283 90 74 1,647 1,337 263 84 74 1,830 1,486 292 93 75 1,712 1,386 274 86 75 1,902 1,540 304 95 76 1,779 1,434 283 90 76 1,977 1,594 314 100 77 1,847 1,484 292 92 77 2,052 1,648 324 102 78 1,912 1,531 302 95 78 2,125 1,701 336 106 79 1,980 1,581 312 99 79 2,200 1,757 346 110 80 2,048 1,631 322 101 80 2,276 1,812 358 113 81 2,117 1,681 332 105 81 2,353 1,868 369 116 82 2,188 1,733 343 108 82 2,431 1,925 381 120 83 2,261 1,787 353 112 83 2,512 1,986 392 124 84 2,336 1,842 363 115 84 2,596 2,047 404 128 85 2,421 1,904 376 118 85 2,690 2,116 417 131 86 2,496 1,960 386 122 86 2,773 2,177 429 136 87 2,570 2,015 398 127 87 2,855 2,239 442 140 88 2,647 2,070 409 130 88 2,942 2,300 455 145 89 2,727 2,129 421 133 89 3,029 2,366 468 148 90 2,807 2,187 432 137 90 3,119 2,430 481 152 91 2,890 2,247 444 140 91 3,211 2,497 493 156 92 2,973 2,308 455 145 92 3,303 2,565 506 161 93 3,057 2,369 468 148 93 3,396 2,632 520 164 94 3,144 2,432 480 152 94 3,494 2,703 532 169 95 3,230 2,496 492 156 95 3,589 2,773 547 174 96 3,319 2,561 505 160 96 3,688 2,845 561 177 97 3,407 2,625 519 164 97 3,786 2,918 576 183 98 3,499 2,692 531 168 98 3,888 2,991 590 186 99+ 3,591 2,759 545 173 99+ 3,991 3,066 606 192 Age Additional Home Health Care Preferred Foreign Travel Age Additional Home Health Care Standard Foreign Travel All 7 183 5 All 8 183 6 Modal Factors: Semi-Annual: 0.5200 Quarterly: 0.2650 Monthly: 0.0833 The above rates do not include the $20 one-time policy fee. To calculate a Household discount: Annual premium x modal factor = modal premium (round to nearest whole cent) Modal premium x.93 = discounted premium Excess If applying during Open Enrollment or Guaranteed Issue Period, use Preferred rates. 14