Humana Medicare Supplement Plan

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1 Humana Medicare Supplement Plan Outline of Medicare Supplement Coverage for TEXAS residents Medicare supplement benefit plans: A, B, C, F, High Deductible F, K, and L TX81077RR 506

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3 TX81077RR Humana Insurance Company Outline of Medicare Supplement Coverage - Cover Page: 1 of 2 Benefit Plans A, B, C, F, and High Deductible F, K, and L 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. Basic Benefits for Plans A-J: 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. Blood: First three pints of blood each year. A Basic benefits B Basic benefits Part A deductible C Basic benefits Skilled Nursing Facility coinsurance Part A deductible Part B deductible Foreign travel emergency D Basic benefits Skilled Nursing Facility coinsurance Part A deductible Foreign travel emergency At-home recovery E Basic benefits Skilled Nursing Facility coinsurance Part A deductible Foreign travel emergency Preventive care NOT covered by Medicare F F* Basic benefits Skilled Nursing Facility coinsurance Part A deductible Part B deductible Part B excess () Foreign travel emergency J J* Basic benefits Skilled Nursing Facility coinsurance Part A deductible Part B deductible Part B excess () Foreign travel emergency At-home recovery Preventive care NOT covered by Medicare *Plans F and J also have an option called a High Deductible Plan F and a High Deductible Plan J. These high deductible plans pay the same or offer the same benefits as Plans F and J after one has paid a calendar year $1,900 deductible. Benefits from High Deductible Plans F and J will not begin until out-of-pocket expenses are $1,900. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. These expenses include the Medicare deductibles for Part A and Part B, but do not include, the plan's separate foreign travel emergency deductible. G Basic benefits Skilled Nursing Facility coinsurance Part A deductible Part B excess (80%) Foreign travel emergency At-home recovery H Basic benefits Skilled Nursing Facility coinsurance Part A deductible Foreign travel emergency I Basic benefits Skilled Nursing Facility coinsurance Part A deductible Part B excess () Foreign travel emergency At-home recovery

4 2 TX81077RR 506 Humana Insurance Company Outline of Medicare Supplement Coverage - Cover Page 2 Basic Benefits for Plans K and L include similar services as plans A-J, but cost sharing for the basic benefits is at different levels. K** of Part A Hospitalization coinsurance plus coverage for 365 days after Medicare benefits end 50% Hospice cost-sharing 50% of Medicare-eligible expenses for the first three pints of blood 50% Part B coinsurance, except coinsurance for Part B Preventive 50% Skilled Nursing Facility coinsurance 50% Part A deductible $4,440 out-of-pocket annual limit*** L** of Part A Hospitalization coinsurance plus coverage for 365 days after Medicare benefits end 75% Hospice cost-sharing 75% of Medicare-eligible expenses for the first three pints of blood 75% Part B coinsurance, except coinsurance for Part B Preventive 75% Skilled Nursing Facility coinsurance 75% Part A deductible $2,220 out-of-pocket annual limit*** ** Plans K and L provide for different cost-sharing for items and services than Plans A-J. Once you reach the annual limit, the plan pays of the Medicare copayments, coinsurance, and deductibles for the rest of the calendar year. The out-of-pocket annual limit does NOT include charges from your provider that exceed Medicare-approved amounts, called "Excess Charges". You will be responsible for paying excess charges. *** The out-of-pocket annual limit will increase each year for inflation. See Outlines of Coverage for details and exceptions.

5 Humana Medicare Supplement Monthly Premiums for Area 1 Area 1 includes the following counties: Austin, Bailey, Brazoria, Chambers, Colorado, Fort Bend, Galveston, Hardin, Harris, Jefferson, Liberty, Matagorda, Montgomery, Orange, San Jacinto, Walker, Waller, Washington, Wharton Plan A Area 1 Rates <65 Male n/a $379 <65 Female n/a $ Male $169 $ Female $160 $ Male $133 $ Female $125 $ Male $149 $ Female $141 $ Unisex $156 $ Unisex $180 $ Unisex $199 $ Unisex $213 $318 Plan B Area 1 Rates <65 Male n/a n/a <65 Female n/a n/a 65 Male $178 $ Female $168 $ Male $140 $ Female $132 $ Male $157 $ Female $148 $ Unisex $165 $ Unisex $190 $ Unisex $210 $ Unisex $225 $335 Plan C Area 1 Rates <65 Male n/a n/a <65 Female n/a n/a 65 Male $206 $ Female $195 $ Male $162 $ Female $152 $ Male $181 $ Female $172 $ Unisex $191 $ Unisex $220 $ Unisex $243 $ Unisex $260 $388 Plan F Area 1 Rates <65 Male n/a n/a <65 Female n/a n/a 65 Male $208 $ Female $196 $ Male $163 $ Female $153 $ Male $182 $ Female $173 $ Unisex $192 $ Unisex $221 $ Unisex $245 $ Unisex $262 $391 TX81077RR 506 3

6 Humana Medicare Supplement Monthly Premiums for Area 1 (Continued) HIGH DEDUCTIBLE Plan F Area 1 Rates <65 Male n/a n/a <65 Female n/a n/a 65 Male $82 $ Female $78 $ Male $65 $ Female $61 $ Male $72 $ Female $68 $ Unisex $76 $ Unisex $87 $ Unisex $96 $ Unisex $103 $153 Plan K Area 1 Rates <65 Male n/a n/a <65 Female n/a n/a 65 Male $78 $ Female $74 $ Male $80 $ Female $75 $ Male $89 $ Female $84 $ Unisex $94 $ Unisex $108 $ Unisex $119 $ Unisex $127 $189 Plan L Area 1 Rates <65 Male n/a n/a <65 Female n/a n/a 65 Male $112 $ Female $106 $ Male $115 $ Female $108 $ Male $128 $ Female $122 $ Unisex $135 $ Unisex $155 $ Unisex $172 $ Unisex $184 $274 4 TX81077RR 506

7 Humana Medicare Supplement Monthly Premiums for Area 2 Area 2 includes the following counties: Andrews, Aransas, Bee, Borden, Brooks, Calhoun, Camp, Clay, Collin, Comal, Cooke, Crane, Dallas, Delta, Denton, DeWitt, Duval, Ector, Ellis, Fannin, Franklin, Glasscock, Grayson, Guadalupe, Hopkins, Howard, Hunt, Jackson, Jeff Davis, Jim Hogg, Jim Wells, Karnes, Kaufman, Kenedy, Kleberg, Lamar, Lavaca, Loving, Martin, Midland, Montague, Navarro, Nueces, Pecos, Rains, Red River, Reeves, Refugio, Rockwall, San Patricio, Titus, Upton, Van Zandt, Victoria, Ward, Wilson, Winkler, Wood Plan A Area 2 Rates <65 Male n/a $342 <65 Female n/a $ Male $153 $ Female $144 $ Male $120 $ Female $113 $ Male $134 $ Female $127 $ Unisex $142 $ Unisex $163 $ Unisex $180 $ Unisex $193 $287 Plan C Area 2 Rates <65 Male n/a n/a <65 Female n/a n/a 65 Male $187 $ Female $176 $ Male $147 $ Female $138 $ Male $164 $ Female $155 $ Unisex $173 $ Unisex $199 $ Unisex $220 $ Unisex $235 $351 Plan B Area 2 Rates <65 Male n/a n/a <65 Female n/a n/a 65 Male $161 $ Female $152 $ Male $127 $ Female $119 $ Male $142 $ Female $134 $ Unisex $149 $ Unisex $172 $ Unisex $190 $ Unisex $203 $303 Plan F Area 2 Rates <65 Male n/a n/a <65 Female n/a n/a 65 Male $188 $ Female $177 $ Male $148 $ Female $139 $ Male $165 $ Female $156 $ Unisex $174 $ Unisex $200 $ Unisex $221 $ Unisex $237 $353 TX81077RR 506 5

8 Humana Medicare Supplement Monthly Premiums for Area 2 (Continued) HIGH DEDUCTIBLE Plan F Area 2 Rates <65 Male n/a n/a <65 Female n/a n/a 65 Male $74 $ Female $70 $ Male $59 $ Female $55 $ Male $65 $ Female $62 $ Unisex $69 $ Unisex $79 $ Unisex $87 $ Unisex $93 $139 Plan K Area 2 Rates <65 Male n/a n/a <65 Female n/a n/a 65 Male $71 $ Female $67 $ Male $72 $ Female $68 $ Male $81 $ Female $76 $ Unisex $85 $ Unisex $98 $ Unisex $108 $ Unisex $115 $171 Plan L Area 2 Rates <65 Male n/a n/a <65 Female n/a n/a 65 Male $102 $ Female $96 $ Male $104 $ Female $98 $ Male $116 $ Female $110 $ Unisex $122 $ Unisex $141 $ Unisex $155 $ Unisex $166 $248 6 TX81077RR 506

9 Humana Medicare Supplement Monthly Premiums for Area 3 Area 3 includes the following counties: Anderson, Angelina, Archer, Armstrong, Atascosa, Bandera, Bastrop, Baylor, Bell, Bexar, Blanco, Bosque, Bowie, Brazos, Brewster, Briscoe, Brown, Burleson, Burnet, Caldwell, Callahan, Cameron, Carson, Cass, Castro, Cherokee, Childress, Cochran, Coke, Coleman, Collingsworth, Comanche, Concho, Coryell, Cottle, Crockett, Crosby, Culberson, Dallam, Dawson, Deaf Smith, Dickens, Dimmit, Donley, Eastland, Edwards, El Paso, Erath, Falls, Fayette, Fisher, Floyd, Foard, Freestone, Frio, Gaines, Garza, Gillespie, Goliad, Gonzales, Gray, Gregg, Grimes, Hale, Hall, Hamilton, Hansford, Hardeman, Harrison, Hartley, Haskell, Hays, Hemphill, Henderson, Hidalgo, Hill, Hockley, Hood, Houston, Hudspeth, Hutchinson, Irion, Jack, Jasper, Johnson, Jones, Kendall, Kent, Kerr, Kimble, King, Kinney, Knox, La Salle, Lamb, Lampasas, Lee, Leon, Limestone, Lipscomb, Live Oak, Llano, Lubbock, Lynn, Madison, Marion, Mason, Maverick, McCulloch, McLennan, McMullen, Medina, Menard, Milam, Mills, Mitchell, Moore, Morris, Motley, Nacogdoches, Newton, Nolan, Ochiltree, Oldham, Palo Pinto, Panola, Parker, Parmer, Polk, Potter, Presidio, Randall, Reagan, Real, Roberts, Robertson, Runnels, Rusk, Sabine, San Augustine, San Saba, Schleicher, Scurry, Shackelford, Shelby, Sherman, Plan A Area 3 Rates <65 Male n/a $309 <65 Female n/a $ Male $138 $ Female $131 $ Male $109 $ Female $102 $ Male $122 $ Female $115 $ Unisex $128 $ Unisex $147 $ Unisex $163 $ Unisex $174 $259 Smith, Somervell, Starr, Stephens, Sterling, Stonewall, Sutton, Swisher, Tarrant, Taylor, Terrell, Terry, Throckmorton, Tom Green, Travis, Trinity, Tyler, Upshur, Uvalde, Val Verde, Webb, Wheeler, Wichita, Wilbarger, Willacy, Williamson, Wise, Yoakum, Young, Zapata, Zavala Plan B Area 3 Rates <65 Male n/a n/a <65 Female n/a n/a 65 Male $146 $ Female $138 $ Male $115 $ Female $108 $ Male $128 $ Female $121 $ Unisex $135 $ Unisex $155 $ Unisex $171 $ Unisex $184 $274 Plan C Area 3 Rates <65 Male n/a n/a <65 Female n/a n/a 65 Male $169 $ Female $159 $ Male $132 $ Female $125 $ Male $148 $ Female $140 $ Unisex $156 $ Unisex $180 $ Unisex $199 $ Unisex $213 $317 TX81077RR 506 7

10 Humana Medicare Supplement Monthly Premiums for Area 3 (Continued) Plan F Area 3 Rates <65 Male n/a n/a <65 Female n/a n/a 65 Male $170 $ Female $160 $ Male $133 $ Female $125 $ Male $149 $ Female $141 $ Unisex $157 $ Unisex $181 $ Unisex $200 $ Unisex $214 $319 Plan K Area 3 Rates <65 Male n/a n/a <65 Female n/a n/a 65 Male $64 $95 65 Female $60 $ Male $65 $ Female $62 $ Male $73 $ Female $69 $ Unisex $77 $ Unisex $88 $ Unisex $97 $ Unisex $104 $155 HIGH DEDUCTIBLE Plan F Area 3 Rates <65 Male n/a n/a <65 Female n/a n/a 65 Male $67 $ Female $64 $ Male $53 $ Female $50 $ Male $59 $ Female $56 $ Unisex $62 $ Unisex $72 $ Unisex $79 $ Unisex $85 $125 Plan L Area 3 Rates <65 Male n/a n/a <65 Female n/a n/a 65 Male $92 $ Female $87 $ Male $94 $ Female $88 $ Male $105 $ Female $100 $ Unisex $111 $ Unisex $127 $ Unisex $141 $ Unisex $150 $224 8 TX81077RR 506

11 Medicare Supplement Outline of Coverage Premium Information We, Humana Insurance Company, can only change the renewal premium for your policy if we also change the renewal premium for all policies that we issue like yours on a Class basis. No change in premium will be made because of the number of claims you file, nor because of a change in your health or your type of work. Your premiums will also be adjusted following your 66th, 68th, 70th, 75th, 80th and 85th birthdays. Benefits and premiums under this policy maybe suspended for up to 24 months if you become entitled to benefits under Medicaid. You must request that your policy be suspended within 90 days of becoming entitled to Medicaid. If you lose (are no longer entitled to) benefits from Medicaid, this policy can be reinstated if you request reinstatement within 90 days of the loss of such benefits and pay the required premium. Disclosure 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 Humana Insurance Company. Right to return policy We want you to fully understand and be satisfied with your policy. If for any reason you are not satisfied, return it to your agent or mail it to: Humana Insurance Company Attn: Medicare Enrollments P.O. Box Louisville, KY within 30 days of its delivery. If you do so, the policy will be void from the effective date. We will refund your premium to you less any claims paid. Policy replacement If you are replacing another health insurance policy or other health coverage, 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 Humana 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 the Medicare & You handbook for more details. Limitations and Exclusions Please see page 10 of this outline of coverage for more details. Refund of premiums This policy does not contain a provision for a refund of premiums. Complete answers are very important When you fill out the application for the new policy, be sure to truthfully and completely answer 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. TX81077RR 506 9

12 Exclusions and Limitations Unless specifically stated otherwise, this Policy does not cover any service or portion of a service that is not a Medicare Eligible Expense, including but not limited to: 1. that are provided before Your coverage begins or after it ends. 2. or supplies for any Injury or Sickness that is covered by Worker s Compensation or a similar law. 3. Custodial care, transportation, or routine physical exams and routine immunizations not covered by Medicare. 4. Treatment of alcoholism and drug dependence, except to the extent covered by Medicare. 5. or supplies for cosmetic surgery, unless a. You receive an Injury which results in bodily damage requiring the surgery; or b. it qualifies as reconstructive surgery performed following surgery, and both the surgery and the reconstructive surgery are Medically Necessary and covered by Medicare. 6. Charges made by a Hospital owned or run by the United States Government or a state government unless You are legally required to pay for such charges. 7. Charges in connection with education or training or medical services provided by a member of your family. 8. Charges for which You are paid or entitled to payment by or through a public program, other than Medicaid. 9. Charges for eyeglasses, hearing aids, contact lenses or the examination or fitting of such aids, not covered by Medicare. 10. Dental care or treatment, except as related to surgery of the jaw or related structures or setting fractures of the jaw or facial bones. 11. Charges for which benefits are payable for those expenses under the mandatory part of any auto insurance policy written to comply with a. a no fault insurance law or b. an uninsured motorist insurance law. 12. Foot care in connection with corns, calluses, flat feet, fallen arches, weak feet, chronic foot strain or symptomatic complaints of the feet not covered by Medicare. 13. Chiropractic care in connection with detection and correction of structural imbalance, distortion, misalignment or subluxation of the vertebrae to remove nerve interference and its effects unless covered by Medicare. 14. Home health care, or private duty nursing, including full-time nursing at home. 15. Prescription drugs. 16. Treatment of any Injury or Sickness caused by war or any act of war, whether declared or undeclared. 17. Charges paid for by Medicare or charges that would have been paid for by Medicare if You were enrolled in Parts A and B of Medicare. 18. The Medicare Part A and Part B Deductibles. 19. Physician charges in excess of Medicare Eligible Expenses, except for Plan F or High Deductible Plan F. 20. Care received outside the United States. 21. Charges which You are not legally required to pay or which would not have been made in the absence of insurance. If, as of the date of application, You had a Continuous Period of Creditable Coverage or had prior coverage under a Medicare Supplement policy for at least 90 days, we will not exclude benefits based on a Preexisting Condition. If, as of the date of application, You had a Continuous Period of Creditable Coverage or had prior coverage under a Medicare Supplement policy for less than 90 days, we will reduce the period of the preexisting condition limitation by the time covered under such prior coverage. 10 TX81077RR 506

13 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. indicates your liability for covered charges. You are responsible for all other non-covered charges. HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,024 $1,024 (Part A deductible) 61st through 90th day All but $256 a day $256 a day 91st day and after while using 60 lifetime reserve days once lifetime reserve days are used: - additional 365 days All but $512 a day $512 a day of Medicare eligible expenses ** - beyond the additional 365 days SKILLED NURSING FACILITY CARE* You must meet Medicare s requirements, including having been in a hospital for at least three days and entered a Medicare-approved facility within 30 days after leaving the hospital First 20 days All approved amounts 21st through 100th day All but $128 a day Up to $128 a day 101st day and after BLOOD First three pints Three pints Additional amounts HOSPICE CARE Available as long as your doctor certifies you are terminally ill and you elect to receive these services All but very limited coinsurance for outpatient drugs and inpatient respite care Balance **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. TX81077RR

14 PLAN A MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR *Once you have been billed $135 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. indicates your liability for covered charges. You are responsible for all other non-covered charges. 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 $135 of Medicare-approved amounts* $135 (Part B deductible) Generally 80% Generally 20% PART B EXCESS CHARGES (above Medicare-approved amounts) BLOOD First three pints Next $135 of Medicare-approved amounts* $135 (Part B deductible) 80% 20% CLINICAL LABORATORY SERVICES TESTS FOR DIAGNOSTIC SERVICES HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medicare Parts A & B Medically necessary skilled care services and medical supplies Durable medical equipment First $135 of Medicare-approved amounts* $135 (Part B deductible) 80% 20% 12 TX81077RR 506

15 PLAN B 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. indicates your liability for covered charges. You are responsible for all other non-covered charges. HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,024 $1,024 (Part A deductible) 61st through 90th day All but $256 a day $256 a day 91st day and after while using 60 lifetime reserve days once lifetime reserve days are used: - additional 365 days All but $512 a day $512 a day of Medicare eligible expenses ** - beyond the additional 365 days SKILLED NURSING FACILITY CARE* You must meet Medicare s requirements, including having been in a hospital for at least three days and entered a Medicare-approved facility within 30 days after leaving the hospital First 20 days All approved amounts 21st through 100th day All but $128 a day Up to $128 a day 101st day and after BLOOD First three pints Three pints Additional amounts HOSPICE CARE Available as long as your doctor certifies you are terminally ill and you elect to receive these services All but very limited coinsurance for outpatient drugs and inpatient respite care Balance **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. TX81077RR

16 PLAN B MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR *Once you have been billed $135 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. indicates your liability for covered charges. You are responsible for all other non-covered charges. 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 $135 of Medicare-approved amounts* $135 (Part B deductible) Generally 80% Generally 20% PART B EXCESS CHARGES (above Medicare-approved amounts) BLOOD First three pints Next $135 of Medicare-approved amounts* $135 (Part B deductible) 80% 20% CLINICAL LABORATORY SERVICES TESTS FOR DIAGNOSTIC SERVICES HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medicare Parts A & B Medically necessary skilled care services and medical supplies Durable medical equipment First $135 of Medicare-approved amounts* $135 (Part B deductible) 80% 20% 14 TX81077RR 506

17 PLAN 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. indicates your liability for covered charges. You are responsible for all other non-covered charges. HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,024 $1,024 (Part A deductible) 61st through 90th day All but $256 a day $256 a day 91st day and after while using 60 lifetime reserve days once lifetime reserve days are used: - additional 365 days All but $512 a day $512 a day of Medicare eligible expenses ** - beyond the additional 365 days SKILLED NURSING FACILITY CARE* You must meet Medicare s requirements, including having been in a hospital for at least three days and entered a Medicare-approved facility within 30 days after leaving the hospital First 20 days All approved amounts 21st through 100th day All but $128 a day Up to $128 a day 101st day and after BLOOD First three pints Three pints Additional amounts HOSPICE CARE Available as long as your doctor certifies you are terminally ill and you elect to receive these services All but very limited coinsurance for outpatient drugs and inpatient respite care Balance **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. TX81077RR

18 PLAN C MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR *Once you have been billed $135 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. indicates your liability for covered charges. You are responsible for all other non-covered charges. 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 $135 of Medicare-approved amounts* $135 (Part B deductible) Generally 80% Generally 20% PART B EXCESS CHARGES (above Medicare-approved amounts) BLOOD First three pints Next $135 of Medicare-approved amounts* $135 (Part B deductible) 80% 20% CLINICAL LABORATORY SERVICES TESTS FOR DIAGNOSTIC SERVICES HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medicare Parts A & B Medically necessary skilled care services and medical supplies Durable medical equipment First $135 of Medicare-approved amounts* $135 (Part B deductible) 80% 20% 16 TX81077RR 506

19 PLAN C FOREIGN TRAVEL NOT COVERED BY MEDICARE Other Benefits - 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 $250 Remainder of charges 80% to a lifetime maximum benefit of $50,000 20% and amounts over the $50,000 lifetime maximum TX81077RR

20 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. indicates your liability for covered charges. You are responsible for all other non-covered charges. HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,024 $1,024 (Part A deductible) 61st through 90th day All but $256 a day $256 a day 91st day and after while using 60 lifetime reserve days once lifetime reserve days are used: - additional 365 days All but $512 a day $512 a day of Medicare eligible expenses ** - beyond the additional 365 days SKILLED NURSING FACILITY CARE* You must meet Medicare s requirements, including having been in a hospital for at least three days and entered a Medicare-approved facility within 30 days after leaving the hospital First 20 days All approved amounts 21st through 100th day All but $128 a day Up to $128 a day 101st day and after BLOOD First three pints Three pints Additional amounts HOSPICE CARE Available as long as your doctor certifies you are terminally ill and you elect to receive these services All but very limited coinsurance for outpatient drugs and inpatient respite care Balance **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. 18 TX81077RR 506

21 PLAN F MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR *Once you have been billed $135 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. indicates your liability for covered charges. You are responsible for all other non-covered charges. 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 $135 of Medicare-approved amounts* $135 (Part B deductible) Generally 80% Generally 20% PART B EXCESS CHARGES (above Medicare-approved amounts) BLOOD First three pints Next $135 of Medicare-approved amounts* $135 (Part B deductible) 80% 20% CLINICAL LABORATORY SERVICES TESTS FOR DIAGNOSTIC SERVICES HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medicare Parts A & B Medically necessary skilled care services and medical supplies Durable medical equipment First $135 of Medicare-approved amounts* $135 (Part B deductible) 80% 20% TX81077RR

22 PLAN F FOREIGN TRAVEL NOT COVERED BY MEDICARE Other Benefits - 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 $250 Remainder of charges 80% to a lifetime maximum benefit of $50,000 20% and amounts over the $50,000 lifetime maximum 20 TX81077RR 506

23 HIGH DEDUCTIBLE 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. **This high deductible plan pays the same or offers the same benefits as Plan F after one has paid a calendar year $1,900 deductible. Benefits from the high deductible plan F will not begin until out-of-pocket expenses are $1,900. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include the plan s separate foreign travel emergency deductible. indicates your liability for covered charges. You are responsible for all other non-covered charges. After You Pay $1,900 Deductible,** In Addition To $1,900 Deductible,** HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,024 $1,024 (Part A deductible) 61st through 90th day All but $256 a day $256 a day 91st day and after while using 60 lifetime reserve days once lifetime reserve days are used: - additional 365 days All but $512 a day $512 a day of Medicare eligible expenses *** - beyond the additional 365 days SKILLED NURSING FACILITY CARE* You must meet Medicare s requirements, including having been in a hospital for at least three days and entered a Medicare-approved facility within 30 days after leaving the hospital First 20 days All approved amounts 21st through 100th day All but $128 a day Up to $128 a day 101st day and after ***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. TX81077RR

24 HIGH DEDUCTIBLE PLAN F MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD (CONTINUED) **This high deductible plan pays the same or offers the same benefits as Plan F after one has paid a calendar year $1,900 deductible. Benefits from the high deductible plan F will not begin until out-of-pocket expenses are $1,900. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include the plan s separate foreign travel emergency deductible. indicates your liability for covered charges. You are responsible for all other non-covered charges. After You Pay $1,900 Deductible,** In Addition To $1,900 Deductible,** BLOOD First three pints Three pints Additional amounts HOSPICE CARE Available as long as your doctor certifies you are terminally ill and you elect to receive these services All but very limited coinsurance for outpatient drugs and inpatient respite care Balance 22 TX81077RR 506

25 HIGH DEDUCTIBLE PLAN F MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR *Once you have been billed $135 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. **This high deductible plan pays the same or offers the same benefits as Plan F after one has paid a calendar year $1,900 deductible. Benefits from the high deductible plan F will not begin until out-of-pocket expenses are $1,900. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include the plan s separate foreign travel emergency deductible. indicates your liability for covered charges. You are responsible for all other non-covered charges. After You Pay $1,900 Deductible,** In Addition To $1,900 Deductible,** 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 $135 of Medicare-approved amounts* $135 (Part B deductible) Generally 80% Generally 20% PART B EXCESS CHARGES (above Medicare-approved amounts) BLOOD First three pints Next $135 of Medicare-approved amounts* $135 (Part B deductible) 80% 20% CLINICAL LABORATORY SERVICES TESTS FOR DIAGNOSTIC SERVICES TX81077RR

26 HIGH DEDUCTIBLE PLAN F MEDICARE (PARTS A AND B) *Once you have been billed $135 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. **This high deductible plan pays the same or offers the same benefits as Plan F after one has paid a calendar year $1,900 deductible. Benefits from the high deductible plan F will not begin until out-of-pocket expenses are $1,900. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include the plan s separate foreign travel emergency deductible. indicates your liability for covered charges. You are responsible for all other non-covered charges. After You Pay $1,900 Deductible,** In Addition To $1,900 Deductible,** HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies Durable medical equipment First $135 of Medicare-approved amounts* $135 (Part B deductible) 80% 20% Other Benefits - Not Covered By Medicare After You Pay $1,900 Deductible,** In Addition To $1,900 Deductible,** 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 $250 Remainder of charges 80% to a lifetime maximum benefit of $50,000 20% and amounts over the $50,000 lifetime maximum 24 TX81077RR 506

27 PLAN K *You will pay half of the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $4,440 each calendar year. The amounts that count toward your annual limit are noted with diamonds ( u ) in the chart below. Once you reach the annual limit, the plan pays of your Medicare copayment and coinsurance for the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called "Excess Charges") and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service. 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. indicates your liability for covered charges. You are responsible for all other non-covered charges. You Pay* HOSPITALIZATION** Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,024 $512 (50% of Part A deductible) $512 (50% of Part A deductible) u 61st through 90th day All but $256 a day $256 a day 91st day and after while using 60 lifetime reserve days once lifetime reserve days are used: - additional 365 days All but $512 a day $512 a day of Medicare eligible expenses *** - beyond the additional 365 days SKILLED NURSING FACILITY CARE** You must meet Medicare s requirements, including having been in a hospital for at least three days and entered a Medicare-approved facility within 30 days after leaving the hospital First 20 days All approved amounts 21st through 100th day All but $128 a day Up to $64 a day Up to $64 a day u 101st day and after TX81077RR

28 PLAN K MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD (CONTINUED) You Pay* BLOOD First three pints 50% 50% u Additional amounts HOSPICE CARE Available as long as your doctor certifies you are terminally ill and you elect to receive these services Generally, most Medicare eligible expenses for outpatient drugs and inpatient respite care 50% of coinsurance or copayments 50% of coinsurance or copayments u ***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. 26 TX81077RR 506

29 PLAN K MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR ****Once you have been billed $135 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. indicates your liability for covered charges. You are responsible for all other non-covered charges. 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 $135 of Medicare-approved amounts**** $135 (Part B deductible)**** u Preventive Benefits for Medicare covered services Generally 75% or more of Medicare approved amounts Remainder of Medicare approved amounts above Medicare approved amounts Generally 80% Generally 10% Generally 10% u PART B EXCESS CHARGES (above Medicare-approved amounts) (and they do not count toward annual out-of-pocket limit of $4,440)* BLOOD First three pints 50% 50% u Next $135 of Medicare-approved amounts**** $135 (Part B deductible)**** u Generally 80% Generally 10% Generally 10% u CLINICAL LABORATORY SERVICES TESTS FOR DIAGNOSTIC SERVICES *This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $4,440 per year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called "Excess Charges") and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service. TX81077RR

30 PLAN K HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medicare Parts A & B You Pay* Medically necessary skilled care services and medical supplies Durable medical equipment First $135 of Medicare-approved amounts***** $135 (Part B deductible) u 80% 10% 10% u 28 TX81077RR 506

31 PLAN L *You will pay one-fourth of the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $2,220 each calendar year. The amounts that count toward your annual limit are noted with diamonds (u) in the chart below. Once you reach the annual limit, the plan pays of your Medicare copayment and coinsurance for the rest of the calendar year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called "Excess Charges") and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service. 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. indicates your liability for covered charges. You are responsible for all other non-covered charges. You Pay* HOSPITALIZATION** Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,024 $768 (75% of Part A deductible) $256 (25% of Part A deductible) u 61st through 90th day All but $256 a day $256 a day 91st day and after while using 60 lifetime reserve days once lifetime reserve days are used: - additional 365 days All but $512 a day $512 a day of Medicare eligible expenses *** - beyond the additional 365 days SKILLED NURSING FACILITY CARE** You must meet Medicare s requirements, including having been in a hospital for at least three days and entered a Medicare-approved facility within 30 days after leaving the hospital First 20 days All approved amounts 21st through 100th day All but $128 a day Up to $96 a day Up to $32 a day u 101st day and after TX81077RR

32 PLAN L MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD (CONTINUED) You Pay* BLOOD First three pints 75% 25% u Additional amounts HOSPICE CARE Available as long as your doctor certifies you are terminally ill and you elect to receive these services Generally, most Medicare eligible expenses for outpatient drugs and inpatient respite care 75% of coinsurance or copayments 25% of coinsurance or copayments u ***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. 30 TX81077RR 506

33 PLAN L MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR ****Once you have been billed $135 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year. indicates your liability for covered charges. You are responsible for all other non-covered charges. 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 $135 of Medicare-approved amounts**** $135 (Part B deductible)**** u Preventive Benefits for Medicare covered services Generally 75% or more of Medicare approved amounts Remainder of Medicare approved amounts above Medicare approved amounts Generally 80% Generally 15% Generally 5% u PART B EXCESS CHARGES (above Medicare-approved amounts) (and they do not count toward annual out-of-pocket limit of $2,220)* BLOOD First three pints 75% 25% u Next $135 of Medicare-approved amounts**** $135 (Part B deductible)**** u Generally 80% Generally 15% Generally 5% u CLINICAL LABORATORY SERVICES TESTS FOR DIAGNOSTIC SERVICES *This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $2,220 per year. However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called "Excess Charges") and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service. TX81077RR

34 PLAN L HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medicare Parts A & B You Pay* Medically necessary skilled care services and medical supplies Durable medical equipment First $135 of Medicare-approved amounts***** $135 (Part B deductible) u 80% 15% 5% u 32 TX81077RR 506

35

36 TX81077RR 506 Insured by Humana Insurance Company 108

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