Basic Benefits Skilled Nursing Facility Coinsurance Part A Deductible

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1 MUTUAL OF OMAHA INSURANCE COMPANY OUTLINE OF MEDICARE SUPPLEMENT COVERAGE - COVER PAGE 1 STANDARDIZED BENEFIT PLAN A AND SELECT BENEFIT PLANS B, C, D, E, F AND G 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: Included in Plans A through J. HOSPITALIZATION: 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 3 pints of blood each year. Plan A Plan B* * Plan D* * * ** * Plan H Plan I Plan J Plan J** M181 M299 M300 M301 M302 M303 M304 Part B At-home Recovery Preventive Care NOT Covered by Medicare Part B Part B Excess (100%) Part B Excess (80%) At-home Recovery Part B Excess (100%) At-home Recovery Part B Part B Excess (100%) At-home Recovery Preventive Care NOT Covered by Medicare *SELECT PLANS B, C, D, E, F and G contain restrictions on your use of providers. Standardized Plan A is also available. NOTICE TO BUYER: This policy may not cover all costs associated with medical care incurred by the buyer during the period of coverage. The buyer is advised to review all policy limitations. **Plans F and J also have an option called a high deductible and a high deductible Plan J. These high deductible plans pay the same benefits as Plans F and J after one has paid a calendar year $1,790 deductible. from high deductible Plans F and J will not begin until out-of-pocket expenses are $1,790. Out-ofpocket expenses for this deductible are expenses that would ordinarily be paid by the policy. These expenses include the Medicare deductibles for and Part B, but do not include the plans separate foreign travel emergency deductible. M21345 MS

2 MUTUAL OF OMAHA INSURANCE COMPANY OUTLINE OF MEDICARE SUPPLEMENT COVERAGE COVER PAGE 2 BASIC BENEFITS: for Plans K and L include similar services as Plans A through J, but cost sharing for the basic benefits is at different levels. K** L** 100% of Hospitalization plus coverage for 365 days after Medicare end 50% Hospice cost-sharing 50% of Medicare eligible expenses for the first three pints of Blood 50% Part B, except 100% for Part B Preventive Services 100% of Hospitalization plus coverage for 365 days after Medicare end 75% Hospice cost-sharing 75% of Medicare eligible expenses for the first three pints of Blood 75% Part B, except 100% for Part B Preventive Services 50% 75% 50% 75% Part B Part B Excess (100%) At-Home Recovery Preventive Care NOT Covered by Medicare $4,000 Out of Pocket Annual Limit *** $2,000 Out of Pocket Annual Limit *** **Plans K and L provide for different cost-sharing for items and services than Plans A through J. Once you reach the annual limit, the plan pays 100% 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. M21345 MS

3 PLANS A, B, C, D, E, F and G PREMIUMS Instructions: Look for the chart which applies to your zip code (first three digits). Then look for the Plan you have decided to purchase and match up your age at issue with the premium mode you will use to pay your premiums. PLAN BEING PURCHASED IS PLAN. INITIAL PREMIUM IS $ ZIP CODES: , 396, 397 NON-TOBACCO ANNUAL RATES FEMALE MALE PLAN A PLAN B* PLAN C* PLAN D* PLAN E* PLAN F* PLAN G* Attained PLAN A PLAN B* PLAN C* PLAN D* PLAN E* PLAN F* PLAN G* M181 M299 M300 M301 M302 M303 M304 Age M181 M299 M300 M301 M302 M303 M304 Through $2, $2, $2, $2, $2, $2, $2, $2, $2, $2, $2, $3, $2, $2, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , and Over 1, , , , , , , *SELECT Plans M21345 MS

4 PLANS A, B, C, D, E, F and G PREMIUMS Instructions: Look for the chart which applies to your zip code (first three digits). Then look for the Plan you have decided to purchase and match up your age at issue with the premium mode you will use to pay your premiums. PLAN BEING PURCHASED IS PLAN. INITIAL PREMIUM IS $ ZIP CODES: , 396, 397 TOBACCO ANNUAL RATES FEMALE MALE PLAN A PLAN B* PLAN C* PLAN D* PLAN E* PLAN F* PLAN G* Attained PLAN A PLAN B* PLAN C* PLAN D* PLAN E* PLAN F* PLAN G* M181 M299 M300 M301 M302 M303 M304 Age M181 M299 M300 M301 M302 M303 M304 Through $2, $2, $2, $2, $3, $2, $2, $2, $3, $3, $3, $3, $3, $3, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , and Over 1, , , , , , , *SELECT Plans M21345 MS

5 PLANS A, B, C, D, E, F and G PREMIUMS Instructions: Look for the chart which applies to your zip code (first three digits). Then look for the Plan you have decided to purchase and match up your age at issue with the premium mode you will use to pay your premiums. PLAN BEING PURCHASED IS PLAN. INITIAL PREMIUM IS $ ZIP CODES: 394, 395 NON-TOBACCO ANNUAL RATES FEMALE MALE PLAN A PLAN B* PLAN C* PLAN D* PLAN E* PLAN F* PLAN G* Attained PLAN A PLAN B* PLAN C* PLAN D* PLAN E* PLAN F* PLAN G* M181 M299 M300 M301 M302 M303 M304 Age M181 M299 M300 M301 M302 M303 M304 Through $2, $2, $3, $2, $3, $3, $2, $2, $3, $3, $3, $3, $3, $3, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , and 1, , , , , , , Over 2, , , , , , , *SELECT Plans M21345 MS

6 PLANS A, B, C, D, E, F and G PREMIUMS Instructions: Look for the chart which applies to your zip code (first three digits). Then look for the Plan you have decided to purchase and match up your age at issue with the premium mode you will use to pay your premiums. PLAN BEING PURCHASED IS PLAN. INITIAL PREMIUM IS $ ZIP CODES: 394, 395 TOBACCO ANNUAL RATES FEMALE MALE PLAN A PLAN B* PLAN C* PLAN D* PLAN E* PLAN F* PLAN G* Attained PLAN A PLAN B* PLAN C* PLAN D* PLAN E* PLAN F* PLAN G* M181 M299 M300 M301 M302 M303 M304 Age M181 M299 M300 M301 M302 M303 M304 Through $2, $3, $3, $3, $3, $3, $3, $3, $3, $4, $3, $4, $4, $3, , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , and Over 2, , , , , , , *SELECT Plans M21345 MS

7 MUTUAL OF OMAHA INSURANCE COMPANY OMAHA, NEBRASKA PREMIUM INFORMATION We, Mutual of Omaha, can only raise your premium if we raise the premium for all policies like yours in the same geographic area of the state where you live. Until you are age 80, your premium may change each year. 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. DISCLOSURES Use this outline to compare benefits and premiums among policies. READ YOUR POLICY VERY CAREFULLY This is only an outline describing your policy s most important features. The policy is your insurance contract. You must read the policy itself to understand all of the rights and duties of both you and your Insurance Company. RIGHT TO RETURN POLICY If you find that you are not satisfied with your policy, you may return it to Mutual of Omaha, Mutual of Omaha Plaza, Omaha, NE 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 Mutual of Omaha 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. This paragraph does not apply under the following conditions: a) you are 65 or older and within 6 months of enrolling in Part B Medicare; b) you are 65, have been enrolled in Medicare by reason of disability prior to age 65 and are applying for coverage within 6 months of your 65 th birthday. Review the application carefully before you sign it. Be certain that all information has been properly recorded. M21345 MS

8 MEDICARE SELECT DISCLOSURE STATEMENT RESTRICTED NETWORK PROVISIONS The benefits under our Medicare Select policies are payable in full if the insured is hospitalized in a hospital participating in our network. Reduced benefits are payable if the insured is hospitalized in a non-participating Hospital. The reduced benefits require the insured to pay the entire amount. EMERGENCY CARE are not reduced if hospitalization is for emergency care. care is defined as care which is needed immediately because of an injury or illness or sudden and unexpected onset. URGENTLY NEEDED CARE The full benefits of your coverage will be paid anywhere if the services are for symptoms requiring emergency care or are immediately required because of an injury or illness of sudden or unexpected onset. REFERRALS There are no restrictions on referrals to other hospitals if referred by a Network hospital and this referral is approved by us. Additionally, there are no restrictions on referrals for outpatient providers regardless of whether that provider is in the service area. AVAILABILITY OF OTHER MEDICARE SUPPLEMENT PLANS Mutual of Omaha Insurance Company also offers Standard Medicare Supplement Plans A, C, D, F and G which do not contain a restricted network provision. We offer the Medicare Select coverage under Plans B, C, D, E, F and G. These plans do have a restricted network provision. You have the right to initially or subsequently purchase any of the plans for Standard or Select coverage. If you purchase one of the Select plans, you will have the right to convert to a Standard plan offered by us which is of comparable or lesser benefits. A policy is considered to have comparable or lesser benefits unless it has one or more significant benefits not included in the policy being replaced. You will not have to provide evidence of insurability after the Medicare Select plan has been in force for six (6) months. In the event the Secretary of Health and Human Services determines that Medicare Select Policies issued should be discontinued due to either the failure of the Medicare Select Program to be re-authorized or its substantial amendment, Mutual of Omaha Insurance Company would continue your coverage for a Period of one (1) year from the date we are notified of such discontinuance. Following the one (1) year period, your Medicare Select Policy can be converted to a Medicare Supplement Policy offered by us which has comparable or lesser benefits and which does not contain a restricted network provision. QUALITY ASSURANCE All participating hospitals within the network must be approved for reimbursement of Medicare. They must also comply with the criteria set forth by The Joint Commission on Accreditation of Healthcare Organizations (JCAHO). M21345 MS

9 GRIEVANCE PROCEDURE We have a customer service program which provides information to you, handles complaints and helps to satisfy your concerns. This Grievance Procedure is intended to provide an opportunity for you to achieve mutual agreement for settlement of disputes that have not been settled through the customer service program, or that you desire to have settled by means of a written grievance. The following procedures are aimed at achieving mutual agreement for settlement of disputes: (a) All grievances shall be presented to us in written form and must contain the words "This is a Grievance" or other words that clearly state that the intention of the communication is to serve as a written grievance to be handled according to this procedure. (b) A grievance shall be filed by submitting the complete details in writing to: Grievance Review Mutual of Omaha Insurance Company P. O. Box 3608 Omaha, Nebraska (c) Each grievance shall be processed within a maximum of 60 days after it is first received by us. Each level of the grievance process shall have a person with problem-solving authority. A Physician other than your primary care physician, must be involved in reviewing any medically related grievances. (d) If a grievance is found to be valid, corrective action shall be taken promptly. (e) All concerned parties will be notified about the results of a grievance. (f) You shall have the right to appeal to the Department of Insurance after first completing our grievance process. (g) If, after completing all the steps in the Grievance Procedure, the problem is not satisfactorily resolved, you may request arbitration. Arbitration shall be conducted in accordance with the applicable provisions of your state law, if any. (h) Any meeting with you shall be scheduled at a location or in a manner which is convenient and does not necessitate excessive travel or hardship for you. (i) The time for filing a grievance shall be limited to a period of not less than one year from the date of occurrence. M21345 MS

10 PLANS A, B AND C MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD In 2006 Medicare Pays Plan A Pays You Pay Services HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $ $ ( ) Plan B and Pay $ ( ) 61 st through 90 th day All but $ a day $ a day $ a day 91 st day and after: While using 60 lifetime reserve days All but $ a day $ a day $ a day Once lifetime reserve days are used: Additional 365 days 100% of Medicare Eligible Expenses ** 100% 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 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 $ a day Up to $ a day Plan B Up to $ a day You Pay Plan B Up to $ a day 101 st day and after BLOOD First 3 pints 3 pints 3 pints Additional amounts 100% 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 Balance *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 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." 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. M21345 MS

11 PLANS A, B AND C MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR Once you have been billed of Medicare Approved Amounts for covered services (which are noted with an asterisk), your Part B will have been met for the calendar year. In 2006 Medicare Pays Plan A Pays You Pay Plan B and Pay Services MEDICAL EXPENSES IN OR OUT OF THE HOSPITAL AND Plan B 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 (Part B First of Medicare Approved Amounts* ) (Part B Ded.) Remainder of Medicare Approved Amounts 80% 20% 20% Part B Excess Charges (above Medicare Approved Amounts) BLOOD First 3 pints Next of Medicare Approved Amounts* (Part B ) Plan B (Part B Ded.) Remainder of Medicare Approved Amounts 80% 20% 20% CLINICAL LABORATORY SERVICES TESTS FOR DIAGNOSTIC SERVICES 100% You Pay Plan B (Part B Ded.) Plan C Plan B (Part B Ded.) M21345 MS

12 PLANS A, B and C MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR Once you have been billed of Medicare Approved Amounts for covered services (which are noted with an asterisk), your Part B will have been met for the calendar year. PARTS A AND B Services In 2006 Medicare Pays Plan A Pays You Pay Plan B and Pay HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies 100% Durable medical equipment First of Medicare Approved Amounts* (Part B.) Plan B (Part B Ded.) Remainder of Medicare Approved Amounts 80% 20% 20% OTHER BENEFITS - NOT COVERED BY MEDICARE Plan B (Part B Ded.) FOREIGN TRAVEL NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $ each calendar year $ $ Remainder of charges Plan B 80% to a lifetime maximum benefit of $50, Plan B You Pay 20% and amounts over the $50, lifetime maximum M21345 MS

13 PLANS D, E, F and G MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD In 2006 Medicare Pays Plan D and Pay Services HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $ $ ( ) You Pay and Pay $ ( ) 61 st through 90 th day All but $ a day $ a day $ a day 91 st day and after: While using 60 lifetime reserve days All but $ a day $ a day $ a day Once lifetime reserve days are used: Additional 365 days 100% of Medicare Eligible Expenses ** 100% 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 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 $ a day Up to $ a day Up to $ a day 101 st day and after BLOOD First 3 pints 3 pints 3 pints Additional amounts 100% 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 Balance You Pay *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 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." 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. M21345 MS

14 PLANS D, E, F AND G MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR Once you have been billed 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 In 2006 Medicare Pays Plan D and Pay You Pay and Pay 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 (Part B and speech therapy, diagnostic tests, durable medical equipment (Part B Ded.) First of Medicare Approved Amounts* ) Remainder of Medicare Approved Amounts 80% 20% 20% Part B Excess Charges (above Medicare Approved Amounts) 100% BLOOD First 3 pints Next of Medicare Approved Amounts* (Part B ) (Part B Ded.) Remainder of Medicare Approved Amounts 80% 20% 20% CLINICAL LABORATORY SERVICES TESTS FOR DIAGNOSTIC SERVICES 100% PARTS A AND B HOME HEALTH CARE MEDICARE APPROVED SERVICES Medically necessary skilled care services and medical supplies 100% Durable medical equipment First of Medicare Approved Amounts* (Part B ) (Part B Ded.) Remainder of Medicare Approved Amounts 80% 20% 20% M21345 MS % (Part B Ded.) 20% (Part B Ded.) (Part B Ded.)

15 Services HOME HEALTH CARE AT-HOME RECOVERY SERVICES NOT COVERED BY MEDICARE Home care certified by your doctor for personal care during recovery from an injury or sickness for which Medicare approved a Home Care Treatment Plan Benefit for each visit Number of visits covered (must be received within 8 weeks of last Medicare approved visit) PLANS D, E, F and G, PARTS A and B (continued) In 2006 Plan D and Medicare Pays Pay You Pay Plan D Actual Plan D Charges Balance to $40.00 a visit Plan D Up to the number of Medicare approved visits not to exceed 7 each week Calendar year maximum Plan D $1, Plan D Balance Plan D Balance and Pay Actual Charges to $40.00 a visit Up to the number of Medicare approved visits, not to exceed 7 each week You Pay lan G $1, OTHER BENEFITS NOT COVERED BY MEDICARE FOREIGN TRAVEL NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $ each calendar year $ $ Remainder of charges 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 $ each calendar year 80% to a lifetime Maximum Benefit of $50, Plan D 20% and amounts over the $50, lifetime Maximum Benefit Plan D 80% to a lifetime Maximum Benefit of $50, Balance Balance Balance 20% and amounts over the $50, lifetime Maximum Benefit $120 $120 Additional charges M21345 MS