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GOVERNMENT PERSONNEL MUTUAL LIFE INSURANCE COMPANY OUTLINE OF MEDICARE SUPPLEMENT COVERAGE COVER PAGE BENEFIT PLANS A, C, F, G, AND N These charts show the benefits included in each of the standard Medicare supplement plans. Every company must make available Plan A. Some plans may not be available in your state. See Outlines of Coverage sections for details about ALL plans. 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 copayments for hospital outpatient services. Plans K, L, and N require insureds to pay a portion of Part B coinsurance or copayments. Blood: First 3 pints of blood each year. Hospice: Part A coinsurance. A B C D F F* G K L M N Basic, Basic, Basic, Basic, Basic, Hospitalization and Hospitalization Basic, including including including including including preventive care and preventive including 100% 100% 100% 100% 100% paid at 100%; other care paid at 100% Part Part B coinsurancinsurancinsurancinsurancinsurance at 50% benefits paid at insurance Part B co- Part B co- Part B co- Part B co- basic benefits paid 100%; other basic B co- * 75% Basic, including 100% Part B co-insurance Part A Skilled Nursing Facility Coinsurance Part A Part B Foreign Travel Emergency Skilled Nursing Facility Coinsurance Part A Foreign Travel Emergency Skilled Nursing Facility Coinsurance Part A Part B Part B Excess (100%) Foreign Travel Emergency Skilled Nursing Facility Coinsurance Part A Part B Excess (100%) Foreign Travel Emergency 50% Skilled Nursing Facility Coinsurance 50% Part A Out-of-pocket limit $4,640; paid at 100% after limit reached 75% Skilled Nursing Facility Coinsurance 75% Part A Out-of-pocket limit $2,320; paid at 100% after limit reached Skilled Nursing Facility Coinsurance 50% Part A Foreign Travel Emergency Basic, including 100% Part B coinsurance, except up to $20 copayment for office visit, and up to $50 copayment for ER Skilled Nursing Facility Coinsurance Part A 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 $2,000 deductible. Benefits from high deductible Plan F will not begin until out-of-pocket expenses exceed $2,000. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy/certificate. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plans' separate foreign travel emergency deductible. 1 T04_387_OR_0911R

MONTHLY NON-TOBACCO RATES ZIP CODES: 973-979 FEMALE MALE Plan A Plan C Plan F Plan G Plan N Attained Plan A Plan C Plan F Plan G Plan N MTP20 MTP22 MTP24 MTP25 MTP31 Age MTP20 MTP22 MTP24 MTP25 MTP31 82.52 109.49 112.24 85.00 74.98 Thru 64 94.85 125.85 129.01 97.70 86.18 82.52 109.49 112.24 85.00 74.98 65 94.85 125.85 129.01 97.70 86.18 82.52 109.49 112.24 85.00 74.98 66 94.85 125.85 129.01 97.70 86.18 82.52 109.49 112.24 85.00 74.98 67 94.85 125.85 129.01 97.70 86.18 85.23 113.10 115.95 87.80 77.45 68 97.96 130.00 133.28 100.92 89.03 87.85 116.81 119.76 90.71 80.04 69 100.98 134.27 137.66 104.27 92.00 90.35 120.42 123.47 93.54 82.58 70 103.85 138.42 141.91 107.52 94.92 92.72 123.91 127.02 96.27 85.02 71 106.58 142.42 146.00 110.66 97.73 95.91 128.53 131.77 99.90 88.27 72 110.24 147.74 151.46 114.82 101.46 99.87 134.23 137.60 104.36 92.27 73 114.80 154.29 158.17 119.96 106.05 103.65 139.83 143.33 108.75 96.21 74 119.14 160.72 164.75 125.00 110.59 107.20 145.21 148.86 113.01 100.04 75 123.22 166.91 171.10 129.89 114.99 111.76 152.02 155.83 118.35 104.85 76 128.46 174.74 179.12 136.03 120.52 114.22 156.04 159.95 121.54 107.74 77 131.29 179.36 183.85 139.70 123.84 116.62 159.95 163.97 124.64 110.58 78 134.05 183.85 188.47 143.26 127.10 120.01 165.28 169.41 128.85 114.38 79 137.94 189.97 194.72 148.10 131.47 123.44 170.70 174.97 133.13 118.27 80 141.88 196.21 201.11 153.02 135.94 126.83 176.13 180.54 137.44 122.19 81 145.79 202.45 207.51 157.98 140.44 130.16 181.57 186.11 141.75 126.11 82 149.61 208.70 213.92 162.93 144.95 133.42 186.95 191.61 146.01 129.99 83 153.36 214.88 220.24 167.82 149.41 135.51 190.78 195.55 149.08 132.84 84 155.76 219.29 224.76 171.36 152.69 137.57 194.59 199.44 152.13 135.65 85 158.13 223.67 229.25 174.86 155.92 139.61 198.42 203.37 155.21 138.50 86 160.47 228.07 233.76 178.40 159.19 141.68 202.39 207.43 158.39 141.45 87 162.86 232.63 238.42 182.06 162.59 143.76 206.34 211.46 161.55 144.39 88 165.24 237.17 243.06 185.69 165.96 145.88 210.39 215.62 164.81 147.41 89 167.68 241.83 247.84 189.43 169.43 148.03 214.52 219.85 168.18 150.53 90 170.15 246.58 252.70 193.31 173.03 150.21 218.71 224.13 171.60 153.72 91 172.66 251.39 257.62 197.24 176.69 152.45 223.04 228.57 175.15 157.02 92 175.23 256.37 262.72 201.32 180.48 154.74 227.48 233.11 178.79 160.40 93 177.86 261.47 267.94 205.50 184.37 157.07 232.10 237.85 182.57 163.94 94 180.54 266.79 273.39 209.85 188.43 159.41 236.78 242.64 186.41 167.52 95 183.23 272.16 278.90 214.26 192.55 161.72 241.48 247.45 190.27 171.13 96 185.88 277.57 284.42 218.70 196.70 163.94 246.09 252.17 194.05 174.67 97 188.43 282.86 289.85 223.05 200.77 166.15 250.79 256.97 197.92 178.30 98 190.97 288.27 295.37 227.50 204.95 168.39 255.61 261.90 201.90 182.03 99+ 193.55 293.80 301.03 232.06 209.23 To obtain annual, semiannual, and quarterly premiums, multiply the above-quoted premiums by 12, 6, and 3, respectively. 2 T04_387_OR_0911R

MONTHLY TOBACCO RATES ZIP CODES: 973-979 FEMALE MALE Plan A Plan C Plan F Plan G Plan N Attained Plan A Plan C Plan F Plan G Plan N MTP20 MTP22 MTP24 MTP25 MTP31 Age MTP20 MTP22 MTP24 MTP25 MTP31 94.85 125.85 129.01 97.70 86.18 Thru 64 109.02 144.65 148.29 112.30 99.06 94.85 125.85 129.01 97.70 86.18 65 109.02 144.65 148.29 112.30 99.06 94.85 125.85 129.01 97.70 86.18 66 109.02 144.65 148.29 112.30 99.06 94.85 125.85 129.01 97.70 86.18 67 109.02 144.65 148.29 112.30 99.06 97.96 130.00 133.28 100.92 89.03 68 112.60 149.42 153.19 116.00 102.33 100.98 134.27 137.66 104.27 92.00 69 116.07 154.33 158.23 119.85 105.75 103.85 138.42 141.91 107.52 94.92 70 119.37 159.10 163.12 123.58 109.10 106.58 142.42 146.00 110.66 97.73 71 122.50 163.70 167.82 127.19 112.33 110.24 147.74 151.46 114.82 101.46 72 126.71 169.81 174.09 131.98 116.62 114.80 154.29 158.17 119.96 106.05 73 131.95 177.34 181.80 137.88 121.90 119.14 160.72 164.75 125.00 110.59 74 136.94 184.74 189.37 143.68 127.11 123.22 166.91 171.10 129.89 114.99 75 141.63 191.85 196.67 149.30 132.17 128.46 174.74 179.12 136.03 120.52 76 147.65 200.85 205.88 156.36 138.53 131.29 179.36 183.85 139.70 123.84 77 150.91 206.16 211.32 160.57 142.35 134.05 183.85 188.47 143.26 127.10 78 154.08 211.32 216.63 164.67 146.09 137.94 189.97 194.72 148.10 131.47 79 158.55 218.36 223.82 170.23 151.12 141.88 196.21 201.11 153.02 135.94 80 163.08 225.53 231.16 175.89 156.25 145.79 202.45 207.51 157.98 140.44 81 167.57 232.70 238.52 181.58 161.43 149.61 208.70 213.92 162.93 144.95 82 171.96 239.89 245.89 187.27 166.61 153.36 214.88 220.24 167.82 149.41 83 176.27 246.99 253.15 192.90 171.74 155.76 219.29 224.76 171.36 152.69 84 179.03 252.06 258.35 196.96 175.50 158.13 223.67 229.25 174.86 155.92 85 181.76 257.09 263.50 200.99 179.22 160.47 228.07 233.76 178.40 159.19 86 184.45 262.15 268.69 205.06 182.98 162.86 232.63 238.42 182.06 162.59 87 187.19 267.39 274.05 209.26 186.88 165.24 237.17 243.06 185.69 165.96 88 189.93 272.61 279.38 213.44 190.76 167.68 241.83 247.84 189.43 169.43 89 192.73 277.96 284.87 217.74 194.75 170.15 246.58 252.70 193.31 173.03 90 195.57 283.42 290.46 222.19 198.88 172.66 251.39 257.62 197.24 176.69 91 198.46 288.95 296.11 226.71 203.09 175.23 256.37 262.72 201.32 180.48 92 201.41 294.68 301.98 231.40 207.45 177.86 261.47 267.94 205.50 184.37 93 204.44 300.54 307.98 236.21 211.92 180.54 266.79 273.39 209.85 188.43 94 207.52 306.65 314.24 241.21 216.59 183.23 272.16 278.90 214.26 192.55 95 210.61 312.83 320.57 246.28 221.32 185.88 277.57 284.42 218.70 196.70 96 213.66 319.04 326.92 251.38 226.09 188.43 282.86 289.85 223.05 200.77 97 216.59 325.13 333.16 256.38 230.77 190.97 288.27 295.37 227.50 204.95 98 219.51 331.34 339.50 261.49 235.57 193.55 293.80 301.03 232.06 209.23 99+ 222.47 337.70 346.01 266.74 240.49 To obtain annual, semiannual, and quarterly premiums, multiply the above-quoted premiums by 12, 6, and 3, respectively. 3 T04_387_OR_0911R

MONTHLY NON-TOBACCO RATES ZIP CODES: 970-972 FEMALE MALE Plan A Plan C Plan F Plan G Plan N Attained Plan A Plan C Plan F Plan G Plan N MTP20 MTP22 MTP24 MTP25 MTP31 Age MTP20 MTP22 MTP24 MTP25 MTP31 85.82 113.87 116.73 88.40 77.98 Thru 64 98.64 130.88 134.17 101.61 89.63 85.82 113.87 116.73 88.40 77.98 65 98.64 130.88 134.17 101.61 89.63 85.82 113.87 116.73 88.40 77.98 66 98.64 130.88 134.17 101.61 89.63 85.82 113.87 116.73 88.40 77.98 67 98.64 130.88 134.17 101.61 89.63 88.64 117.62 120.59 91.31 80.55 68 101.88 135.20 138.61 104.96 92.59 91.37 121.49 124.56 94.34 83.24 69 105.02 139.64 143.17 108.44 95.68 93.97 125.24 128.40 97.28 85.88 70 108.01 143.95 147.59 111.82 98.71 96.43 128.86 132.10 100.12 88.42 71 110.84 148.12 151.84 115.08 101.64 99.74 133.67 137.04 103.89 91.80 72 114.65 153.64 157.52 119.42 105.52 103.87 139.60 143.11 108.54 95.96 73 119.39 160.46 164.49 124.75 110.30 107.80 145.42 149.07 113.10 100.06 74 123.90 167.15 171.34 130.00 115.01 111.49 151.02 154.81 117.53 104.04 75 128.15 173.59 177.95 135.09 119.59 116.23 158.10 162.06 123.08 109.05 76 133.59 181.73 186.28 141.47 125.34 118.79 162.28 166.35 126.40 112.05 77 136.54 186.53 191.20 145.28 128.80 121.29 166.35 170.53 129.62 115.00 78 139.41 191.20 196.01 148.99 132.18 124.81 171.89 176.19 134.00 118.96 79 143.46 197.57 202.51 154.02 136.73 128.37 177.53 181.96 138.46 123.00 80 147.56 204.06 209.15 159.15 141.38 131.91 183.18 187.76 142.94 127.07 81 151.62 210.55 215.81 164.29 146.06 135.36 188.84 193.56 147.41 131.15 82 155.59 217.05 222.48 169.44 150.75 138.76 194.43 199.27 151.85 135.19 83 159.49 223.48 229.05 174.54 155.39 140.93 198.42 203.37 155.04 138.15 84 161.99 228.06 233.76 178.21 158.79 143.08 202.38 207.42 158.21 141.08 85 164.46 232.62 238.42 181.86 162.16 145.20 206.36 211.51 161.42 144.04 86 166.89 237.19 243.11 185.54 165.56 147.35 210.48 215.73 164.72 147.11 87 169.37 241.94 247.96 189.34 169.09 149.51 214.59 219.92 168.01 150.16 88 171.85 246.66 252.78 193.12 172.60 151.71 218.80 224.24 171.40 153.30 89 174.38 251.50 257.75 197.01 176.21 153.95 223.10 228.64 174.90 156.55 90 176.95 256.44 262.81 201.04 179.95 156.22 227.46 233.09 178.46 159.87 91 179.57 261.44 267.92 205.13 183.76 158.55 231.97 237.71 182.15 163.30 92 182.24 266.63 273.23 209.37 187.70 160.93 236.58 242.43 185.94 166.82 93 184.98 271.93 278.66 213.72 191.75 163.36 241.39 247.36 189.88 170.50 94 187.76 277.46 284.33 218.25 195.97 165.79 246.25 252.35 193.87 174.22 95 190.56 283.05 290.05 222.83 200.25 168.19 251.14 257.34 197.88 177.97 96 193.32 288.67 295.80 227.45 204.57 170.50 255.93 262.26 201.82 181.66 97 195.97 294.18 301.44 231.97 208.80 172.79 260.82 267.25 205.84 185.44 98 198.61 299.80 307.18 236.60 213.14 175.12 265.83 272.37 209.97 189.31 99+ 201.29 305.55 313.07 241.35 217.60 To obtain annual, semiannual, and quarterly premiums, multiply the above-quoted premiums by 12, 6, and 3, respectively. 4 T04_387_OR_0911R

MONTHLY TOBACCO RATES ZIP CODES: 970-972 FEMALE MALE Plan A Plan C Plan F Plan G Plan N Attained Plan A Plan C Plan F Plan G Plan N MTP20 MTP22 MTP24 MTP25 MTP31 Age MTP20 MTP22 MTP24 MTP25 MTP31 98.64 130.88 134.17 101.61 89.63 Thru 64 113.38 150.44 154.22 116.79 103.02 98.64 130.88 134.17 101.61 89.63 65 113.38 150.44 154.22 116.79 103.02 98.64 130.88 134.17 101.61 89.63 66 113.38 150.44 154.22 116.79 103.02 98.64 130.88 134.17 101.61 89.63 67 113.38 150.44 154.22 116.79 103.02 101.88 135.20 138.61 104.96 92.59 68 117.10 155.40 159.32 120.64 106.42 105.02 139.64 143.17 108.44 95.68 69 120.71 160.50 164.56 124.64 109.98 108.01 143.95 147.59 111.82 98.71 70 124.15 165.46 169.65 128.52 113.46 110.84 148.12 151.84 115.08 101.64 71 127.40 170.25 174.53 132.28 116.82 114.65 153.64 157.52 119.42 105.52 72 131.78 176.60 181.05 137.26 121.29 119.39 160.46 164.49 124.75 110.30 73 137.23 184.43 189.07 143.40 126.78 123.90 167.15 171.34 130.00 115.01 74 142.42 192.13 196.95 149.43 132.19 128.15 173.59 177.95 135.09 119.59 75 147.30 199.52 204.54 155.27 137.46 133.59 181.73 186.28 141.48 125.34 76 153.56 208.88 214.12 162.61 144.07 136.54 186.53 191.20 145.28 128.80 77 156.95 214.41 219.77 166.99 148.04 139.41 191.20 196.01 148.99 132.18 78 160.24 219.77 225.30 171.26 151.93 143.46 197.57 202.51 154.02 136.73 79 164.89 227.09 232.77 177.04 157.17 147.56 204.06 209.15 159.15 141.38 80 169.60 234.55 240.41 182.93 162.50 151.62 210.55 215.81 164.29 146.06 81 174.27 242.01 248.06 188.84 167.89 155.59 217.05 222.48 169.44 150.75 82 178.84 249.49 255.73 194.76 173.27 159.49 223.48 229.05 174.54 155.39 83 183.32 256.87 263.28 200.62 178.61 161.99 228.06 233.76 178.21 158.79 84 186.19 262.14 268.68 204.84 182.52 164.46 232.62 238.42 181.86 162.16 85 189.03 267.37 274.04 209.03 186.39 166.89 237.19 243.11 185.54 165.56 86 191.83 272.64 279.44 213.26 190.30 169.37 241.93 247.96 189.34 169.09 87 194.68 278.09 285.01 217.63 194.36 171.85 246.66 252.78 193.12 172.60 88 197.53 283.51 290.56 221.98 198.39 174.38 251.50 257.75 197.01 176.21 89 200.44 289.08 296.27 226.45 202.54 176.95 256.44 262.81 201.04 179.95 90 203.39 294.76 302.08 231.08 206.84 179.57 261.44 267.92 205.13 183.76 91 206.40 300.51 307.95 235.78 211.21 182.24 266.63 273.23 209.37 187.70 92 209.47 306.47 314.06 240.66 215.75 184.98 271.93 278.66 213.72 191.75 93 212.62 312.56 320.30 245.66 220.40 187.76 277.46 284.33 218.25 195.97 94 215.82 318.92 326.81 250.86 225.25 190.56 283.05 290.05 222.83 200.25 95 219.03 325.34 333.39 256.13 230.17 193.32 288.67 295.80 227.45 204.57 96 222.21 331.80 340.00 261.44 235.13 195.97 294.18 301.44 231.97 208.80 97 225.25 338.14 346.49 266.64 240.00 198.61 299.80 307.18 236.60 213.14 98 228.29 344.59 353.08 271.95 244.99 201.29 305.55 313.07 241.35 217.60 99+ 231.37 351.21 359.85 277.41 250.11 To obtain annual, semiannual, and quarterly premiums, multiply the above-quoted premiums by 12, 6, and 3, respectively. 5 T04_387_OR_0911R

Disclosures Use this outline to compare benefits and premiums among policies. Premium Information We, Government Personnel Mutual Life, can only raise your premium if we raise the premium for all the policies like yours in the same geographic area of the state where you live. This type of premium change can occur on any Policy Renewal Date, but will only occur once in a 12-month period. Until you are age 99, your premium may also change each year due to your attained age. This change will only be made on the first renewal date that coincides with or follows each anniversary of the policy date. Schedules of rates may vary depending upon your policy date. There will be a one-time policy fee of $25.00 added to the first premium. 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. Right to Return Policy If you find that you are not satisfied with your policy, you may return it to Government Personnel Mutual Life Insurance Company at our administrative office, 3316 Farnam Street, Omaha, NE 68175. 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. 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 Government Personnel Mutual Life 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 & 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. Renewal We will renew this policy each time you pay us the premium. It must be paid by the date it is due or during the 31 days that follow. 6 T04_387_OR_0911R

PLANS A AND C MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD *A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. Services Medicare Pays Plan A Pays You Pay Plan C Pays You Pay HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,132 $0 $1,132 (Part A $1,132 (Part A $0 ) ) 61 st through 90 th day All but $283 a day $283 a day $0 $283 a day $0 91 st day and after: While using 60 lifetime reserve days All but $566 a day $566 a day $0 $566 a day $0 Once lifetime reserve days are used: Additional 365 days $0 100% of Medicare Eligible Expenses $0** 100% of Medicare $0** Eligible Expenses Beyond the additional 365 days $0 $0 All costs $0 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 $0 $0 $0 $0 21 st through 100 th day All but $141.50 a day $0 Up to $566 a day Up to $566 a day $0 101 st day and after $0 $0 All costs $0 All costs BLOOD First 3 pints $0 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 $0 $0 HOSPICE CARE You must meet Medicare's requirements, including a doctor's certification of terminal illness. All but very limited copayment/coinsuran ce for outpatient drugs and inpatient respite care **NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy/certificate's "Core Benefits." Medicare copayment/ coinsurance $0 Medicare copayment/ coinsurance 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. $0 7 T04_387_OR_0911R

PLANS A AND C MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR *Once you have been billed $162 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 A Pays You Pay Plan C 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 $162 of Medicare Approved Amounts* $0 $0 $162 (Part B $162 (Part B $0 ) ) Remainder of Medicare Approved Amounts Generally 80% Generally 20% $0 Generally 20% $0 Part B Excess Charges (above Medicare Approved Amounts) $0 $0 All costs $0 All costs BLOOD First 3 pints $0 All costs $0 All costs $0 Next $162 of Medicare Approved Amounts* $0 $0 $162 (Part B $162 (Part B $0 ) ) Remainder of Medicare Approved Amounts 80% 20% $0 20% $0 CLINICAL LABORATORY SERVICES TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 $0 $0 PARTS A AND B HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies 100% $0 $0 $0 $0 Durable medical equipment First $162 of Medicare Approved Amounts* $0 $0 $162 (Part B $162 (Part B $0 ) ) Remainder of Medicare Approved Amounts 80% 20% $0 20% $0 8 T04_387_OR_0911R

PLANS A AND C MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR OTHER BENEFITS NOT COVERED BY MEDICARE Services Medicare Pays Plan A Pays You Pay Plan C Pays You Pay 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 $0 N/A All Costs $0 $250 Remainder of charges $0 N/A All Costs 80% to a lifetime Maximum Benefit of $50,000 20% and amounts over the $50,000 lifetime Maximum Benefit 9 T04_387_OR_0911R

PLANS F AND 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 F Pays You Pay Plan G Pays You Pay HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,132 $1,132 (Part A $0 $1,132 (Part A $0 ) ) 61 st through 90 th day All but $283 a day $283 a day $0 $283 a day $0 91 st day and after: While using 60 lifetime reserve days All but $566 a day $566 a day $0 $566 a day $0 Once lifetime reserve days are used: Additional 365 days $0 100% of Medicare Eligible Expenses $0** 100% of Medicare $0** Eligible Expenses Beyond the additional 365 days $0 $0 All costs $0 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 $0 $0 $0 $0 21 st through 100 th day All but $566 a day Up to $566 a day $0 Up to $566 a day $0 101 st day and after $0 $0 All costs $0 All costs BLOOD First 3 pints $0 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 $0 $0 HOSPICE CARE You must meet Medicare's requirements, including a doctor's certification of terminal illness. All but very limited copayment/coinsuran ce for outpatient drugs and inpatient respite care **NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy/certificate's "Core Benefits." Medicare copayment/coinsuran ce $0 Medicare copayment/coinsura nce 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. $0 10 T04_387_OR_0911R

PLANS F AND G MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR *Once you have been billed $162 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 F Pays You Pay Plan G 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 $162 of Medicare Approved Amounts* $0 $162 (Part B ) $0 $0 $162 (Part B ) Remainder of Medicare Approved Amounts Generally 80% Generally 20% $0 Generally 20% $0 Part B Excess Charges (above Medicare Approved Amounts) $0 100% $0 100% $0 BLOOD First 3 pints $0 All costs $0 All costs $0 Next $162 of Medicare Approved Amounts* $0 $162 (Part B ) $0 $0 $162 (Part B ) Remainder of Medicare Approved Amounts 80% 20% $0 20% $0 CLINICAL LABORATORY SERVICES TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 $0 $0 PARTS A AND B HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies 100% $0 $0 $0 $0 Durable medical equipment First $162 of Medicare Approved Amounts* $0 $162 (Part B ) $0 $0 $162 (Part B ) Remainder of Medicare Approved Amounts 80% 20% $0 20% $0 11 T04_387_OR_0911R

PLANS F AND G MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR OTHER BENEFITS NOT COVERED BY MEDICARE Services Medicare Pays Plan F Pays You Pay Plan G Pays You Pay 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 $0 $0 $250 $0 $250 Remainder of charges $0 80% to a lifetime Maximum Benefit of $50,000 20% and amounts over the $50,000 lifetime Maximum Benefit 80% to a lifetime Maximum Benefit of $50,000 20% and amounts over the $50,000 lifetime Maximum Benefit 12 T04_387_OR_0911R

PLAN N 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 N Pays You Pay HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,132 $1,132 (Part A $0 ) 61 st through 90 th day All but $283 a day $283 a day $0 91 st day and after: While using 60 lifetime reserve days All but $566 a day $566 a day $0 Once lifetime reserve days are used: Additional 365 days $0 100% of Medicare Eligible Expenses Beyond the additional 365 days $0 $0 All costs SKILLED NURSING FACILITY CARE* You must meet Medicare s requirements, including having been in a hospital for at least 3 days and entered a Medicare approved facility within 30 days after leaving the hospital. First 20 days All approved amounts $0 $0 21 st through 100 th day All but $566 a day Up to $566 a day $0 101 st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE You must meet Medicare's requirements, including a doctor's certification of terminal illness. **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/certificate's "Core Benefits." All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care Medicare copayment/coinsurance $0** 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. $0 13 T04_387_OR_0911R

PLAN N MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR *Once you have been billed $162 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 N 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 $162 of Medicare Approved Amounts* $0 $0 $162 (Part B ) Remainder of Medicare Approved Amounts Generally 80% Balance, other than up to $20 per office visit and up to $50 per emergency room visit. The copayment of up to $50 is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense. Part B Excess Charges (above Medicare Approved Amounts) $0 $0 All costs Up to $20 per office visit and up to $50 per emergency room visit. The copayment of up to $50 is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense. BLOOD First 3 pints $0 All costs $0 Next $162 of Medicare Approved Amounts* $0 $0 $162 (Part B ) Remainder of Medicare Approved Amounts 80% 20% $0 CLINICAL LABORATORY SERVICES TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 PARTS A AND B HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies 100% $0 $0 Durable medical equipment First $162 of Medicare Approved Amounts* $0 $0 $162 (Part B ) Remainder of Medicare Approved Amounts 80% 20% $0 14 T04_387_OR_0911R

PLAN N MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR OTHER BENEFITS NOT COVERED BY MEDICARE Services Medicare Pays Plan N Pays You Pay 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 $0 $0 $250 Remainder of charges $0 80% to a lifetime Maximum Benefit of $50,000 20% and amounts over the $50,000 lifetime Maximum Benefit 15 T04_387_OR_0911R

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