OUTLINE OF MEDICARE SUPPLEMENT COVERAGE - COVER PAGE 1 BENEFIT PLANS A, C, D, 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: 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 3 pints of blood each year. Policy Form Policy Form Policy Form Policy Form Policy Form M221 M222 M285 M223 M376 A B C D E F F* G H I J J* Skilled Nursing Facility Skilled Nursing Facility Skilled Nursing Facility Skilled Nursing Facility Skilled Nursing Facility Skilled Nursing Facility Skilled Nursing Facility Skilled Nursing Facility Coinsurance Coinsurance Coinsurance Coinsurance Coinsurance Coinsurance Coinsurance Coinsurance Part A Part A Part A Part A Part A Part A Part A Part A Part A Deductible Deductible Deductible Deductible Deductible Deductible Deductible Deductible Deductible Part B Deductible Part B Deductible Part B Deductible Part B Excess Part B Excess Part B Excess Part B Excess (100%) (80%) (100%) (100%) Foreign Travel Foreign Travel Foreign Travel Foreign Travel Foreign Travel Foreign Travel Foreign Travel Foreign Travel Emergency Emergency Emergency Emergency Emergency Emergency Emergency Emergency At-home Recovery Preventive Care NOT Covered by Medicare At-home Recovery At-home Recovery 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 benefits as Plans F and J after one has paid a calendar year $1,860 deductible. from high deductible Plans F and J will not begin until out-of-pocket expenses are $1,860 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 plans separate foreign travel emergency deductible. M21335-1 TX 0-07 - 1 -
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 Part A Hospitalization Coinsurance 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 Coinsurance, except 100% Coinsurance for Part B Preventive Services 100% of Part A Hospitalization Coinsurance 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 Coinsurance, except 100% Coinsurance for Part B Preventive Services Skilled Nursing Facility Coinsurance 50% Skilled Nursing Facility Coinsurance 75% Skilled Nursing Facility Coinsurance Part A Deductible 50% Part A Deductible 75% Part A Deductible Part B Deductible Part B Excess (100%) Foreign Travel Emergency At-Home Recovery Preventive Care NOT Covered by Medicare $4,140 Out of Pocket Annual Limit *** $2,070 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. M21335-1 TX 0-07 - 2 -
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 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. M221 (Plan A) M222 (Plan C) NON-TOBACCO ANNUAL RATES FEMALE MALE M285 M223 M376 Attained M221 M222 M285 (Plan D) (Plan F) (Plan G) Age (Plan A) (Plan C) (Plan D) $2,579.02 Through 64 $2,964.39 M223 (Plan F) M376 (Plan G) 1,348.36 $1,516.66 $1,329.60 $1,339.38 $1,098.25 65 1,549.84 $1,743.29 $1,528.29 $1,539.53 $1,262.35 1,348.36 1,516.66 1,329.60 1,339.38 1,098.25 66 1,549.84 1,743.29 1,528.29 1,539.53 1,262.35 1,406.80 1,582.14 1,387.08 1,397.02 1,145.37 67 1,617.02 1,818.55 1,594.34 1,605.78 1,316.53 1,469.53 1,652.15 1,448.60 1,458.95 1,196.47 68 1,689.12 1,899.02 1,665.06 1,676.95 1,375.25 1,534.04 1,724.82 1,512.62 1,523.78 1,249.49 69 1,763.26 1,982.55 1,738.64 1,751.47 1,436.20 1,599.68 1,798.46 1,576.88 1,588.20 1,302.36 70 1,838.72 2,067.20 1,812.51 1,825.52 1,496.97 1,664.51 1,871.21 1,640.66 1,652.46 1,355.15 71 1,913.23 2,150.82 1,885.82 1,899.39 1,557.65 1,729.42 1,944.29 1,704.77 1,716.98 1,407.93 72 1,987.85 2,234.81 1,959.51 1,973.53 1,618.32 1,794.74 2,017.29 1,768.71 1,781.40 1,460.89 73 2,062.92 2,318.72 2,033.00 2,047.59 1,679.18 1,827.08 2,054.31 1,801.20 1,814.22 1,487.64 74 2,100.08 2,361.28 2,070.36 2,085.31 1,709.93 1,860.38 2,091.65 1,834.03 1,847.12 1,514.64 75 2,138.37 2,404.20 2,108.08 2,123.13 1,740.97 1,893.28 2,128.59 1,866.37 1,879.54 1,541.07 76 2,176.18 2,446.67 2,145.25 2,160.39 1,771.35 1,926.50 2,165.46 1,898.78 1,912.52 1,568.24 77 2,214.38 2,489.04 2,182.51 2,198.30 1,802.57 1,958.67 2,202.32 1,931.35 1,945.02 1,594.91 78 2,251.35 2,531.40 2,219.95 2,235.65 1,833.23 1,994.98 2,242.90 1,966.52 1,980.75 1,624.26 79 2,293.08 2,578.04 2,260.36 2,276.72 1,866.96 2,142.34 2,408.61 2,112.03 2,126.90 1,743.98 80 and Over 2,462.46 2,768.52 2,427.61 2,444.71 2,004.57 To obtain semiannual and quarterly premiums, divide the above-quoted premiums by 2 and 4, respectively. To obtain the monthly premium for bank service plan issues, including all attached riders, divide the total annual premium by 12. ZIP CODES: 754-759, 762-769,778- M21335-1 TX 0-07 - 3-781, 783, 785, 786, 788-792, 795-799, 885
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 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. TOBACCO ANNUAL RATES FEMALE MALE M221 (Plan A) M222 (Plan C) M285 (Plan D) M223 (Plan F) M376 (Plan G) Attained Age M221 (Plan A) $2,964.39 Through 64 $3,407.35 M222 (Plan C) M285 (Plan D) M223 (Plan F) M376 (Plan G) 1,549.84 $1,743.29 $1,528.28 $1,539.52 $1,262.36 65 1,781.42 $2,003.78 $1,756.65 $1,769.57 $1,450.98 1,549.84 1,743.29 1,528.28 1,539.52 1,262.36 66 1,781.42 2,003.78 1,756.65 1,769.57 1,450.98 1,617.01 1,818.55 1,594.35 1,605.77 1,316.52 67 1,858.64 2,090.29 1,832.58 1,845.72 1,513.25 1,689.12 1,899.02 1,665.06 1,676.95 1,375.25 68 1,941.52 2,182.78 1,913.86 1,927.53 1,580.75 1,763.27 1,982.55 1,738.64 1,751.47 1,436.20 69 2,026.74 2,278.79 1,998.44 2,013.18 1,650.81 1,838.71 2,067.19 1,812.51 1,825.52 1,496.97 70 2,113.47 2,376.09 2,083.35 2,098.30 1,720.65 1,913.23 2,150.82 1,885.82 1,899.38 1,557.64 71 2,199.12 2,472.21 2,167.61 2,183.21 1,790.40 1,987.84 2,234.82 1,959.50 1,973.54 1,618.31 72 2,284.88 2,568.75 2,252.31 2,268.43 1,860.14 2,062.92 2,318.72 2,033.00 2,047.59 1,679.18 73 2,371.17 2,665.19 2,336.78 2,353.55 1,930.09 2,100.09 2,361.28 2,070.35 2,085.31 1,709.93 74 2,413.89 2,714.11 2,379.72 2,396.91 1,965.44 2,138.37 2,404.20 2,108.08 2,123.13 1,740.96 75 2,457.90 2,763.45 2,423.08 2,440.38 2,001.11 2,176.18 2,446.66 2,145.25 2,160.39 1,771.35 76 2,501.36 2,812.26 2,465.80 2,483.21 2,036.04 2,214.37 2,489.04 2,182.50 2,198.30 1,802.57 77 2,545.26 2,860.96 2,508.63 2,526.78 2,071.92 2,251.35 2,531.40 2,219.94 2,235.65 1,833.23 78 2,587.76 2,909.66 2,551.67 2,569.71 2,107.16 2,293.08 2,578.05 2,260.37 2,276.72 1,866.96 79 2,635.72 2,963.27 2,598.12 2,616.92 2,145.93 2,462.46 2,768.52 2,427.62 2,444.71 2,004.57 80 and Over 2,830.41 3,182.21 2,790.36 2,810.01 2,304.10 To obtain semiannual and quarterly premiums, divide the above-quoted premiums by 2 and 4, respectively. To obtain the monthly premium for bank service plan issues, including all attached riders, divide the total annual premium by 12. ZIP CODES: 754-759, 762-769,778-, M21335-1 TX 0-07 - 4-781, 783, 785, 786, 788-792, 795-799, 885
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 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. M221 (Plan A) M222 (Plan C) NON-TOBACCO ANNUAL RATES FEMALE MALE M285 M223 M376 Attained M221 M222 M285 (Plan D) (Plan F) (Plan G) Age (Plan A) (Plan C) (Plan D) $2,955.74 Through 64 $3,397.39 M223 (Plan F) M376 (Plan G) 1,545.31 $1,738.20 $1,523.81 $1,535.03 $1,258.67 65 1,776.22 $1,997.93 $1,751.52 $1,764.40 $1,446.75 1,545.31 1,738.20 1,523.81 1,535.03 1,258.67 66 1,776.22 1,997.93 1,751.52 1,764.40 1,446.75 1,612.29 1,813.25 1,589.69 1,601.08 1,312.67 67 1,853.21 2,084.18 1,827.23 1,840.33 1,508.83 1,684.19 1,893.47 1,660.19 1,672.04 1,371.22 68 1,935.85 2,176.40 1,908.27 1,921.90 1,576.13 1,758.11 1,976.75 1,733.56 1,746.35 1,432.00 69 2,020.82 2,272.14 1,992.60 2,007.30 1,645.99 1,833.34 2,061.15 1,807.22 1,820.19 1,492.60 70 2,107.29 2,369.15 2,077.26 2,092.17 1,715.63 1,907.64 2,144.53 1,880.31 1,893.83 1,553.09 71 2,192.70 2,464.99 2,161.28 2,176.83 1,785.16 1,982.03 2,228.29 1,953.78 1,967.77 1,613.59 72 2,278.21 2,561.25 2,245.72 2,261.81 1,854.70 2,056.90 2,311.95 2,027.07 2,041.60 1,674.27 73 2,364.24 2,657.41 2,329.96 2,346.68 1,924.45 2,093.95 2,354.38 2,064.30 2,079.22 1,704.94 74 2,406.84 2,706.18 2,372.77 2,389.91 1,959.70 2,132.12 2,397.18 2,101.92 2,116.93 1,735.88 75 2,450.71 2,755.38 2,416.00 2,433.25 1,995.27 2,169.82 2,439.51 2,138.98 2,154.08 1,766.18 76 2,494.06 2,804.04 2,458.59 2,475.95 2,030.08 2,207.90 2,481.76 2,176.13 2,191.88 1,797.31 77 2,537.82 2,852.60 2,501.29 2,519.40 2,065.87 2,244.77 2,524.01 2,213.46 2,229.12 1,827.88 78 2,580.20 2,901.16 2,544.21 2,562.21 2,101.01 2,286.38 2,570.51 2,253.76 2,270.06 1,861.50 79 2,628.02 2,954.62 2,590.53 2,609.28 2,139.66 2,455.27 2,760.43 2,420.52 2,437.57 1,998.72 80 and Over 2,822.14 3,172.92 2,782.21 2,801.81 2,297.37 To obtain semiannual and quarterly premiums, divide the above-quoted premiums by 2 and 4, respectively. To obtain the monthly premium for bank service plan issues, including all attached riders, divide the total annual premium by 12. M21335-1 TX 0-07 - 5 - ZIP CODES: 733, 750, 751, 760, 761, 774, 784, 787, 793
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 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. M221 (Plan A) M222 (Plan C) TOBACCO ANNUAL RATES FEMALE MALE M285 M223 M376 Attained M221 M222 M285 (Plan D) (Plan F) (Plan G) Age (Plan A) (Plan C) (Plan D) $3,397.40 Through 64 $3,905.05 M223 (Plan F) M376 (Plan G) 1,776.22 $1,997.93 $1,751.51 $1,764.40 $1,446.75 65 2,041.63 $2,296.47 $2,013.24 $2,028.05 $1,662.93 1,776.22 1,997.93 1,751.51 1,764.40 1,446.75 66 2,041.63 2,296.47 2,013.24 2,028.05 1,662.93 1,853.21 2,084.19 1,827.23 1,840.32 1,508.82 67 2,130.13 2,395.61 2,100.26 2,115.32 1,734.29 1,935.85 2,176.40 1,908.27 1,921.89 1,576.12 68 2,225.11 2,501.61 2,193.41 2,209.08 1,811.64 2,020.82 2,272.13 1,992.60 2,007.30 1,645.98 69 2,322.78 2,611.65 2,290.35 2,307.24 1,891.94 2,107.29 2,369.14 2,077.26 2,092.17 1,715.63 70 2,422.17 2,723.16 2,387.66 2,404.79 1,971.99 2,192.69 2,464.98 2,161.28 2,176.82 1,785.16 71 2,520.34 2,833.32 2,484.23 2,502.10 2,051.91 2,278.20 2,561.25 2,245.72 2,261.81 1,854.70 72 2,618.63 2,943.96 2,581.29 2,599.78 2,131.84 2,364.25 2,657.41 2,329.96 2,346.67 1,924.45 73 2,717.52 3,054.49 2,678.11 2,697.33 2,212.01 2,406.84 2,706.18 2,372.76 2,389.91 1,959.70 74 2,766.48 3,110.55 2,727.32 2,747.02 2,252.53 2,450.71 2,755.38 2,416.00 2,433.25 1,995.26 75 2,816.91 3,167.10 2,777.01 2,796.84 2,293.41 2,494.05 2,804.04 2,458.60 2,475.95 2,030.09 76 2,866.73 3,223.04 2,825.97 2,845.92 2,333.43 2,537.82 2,852.60 2,501.30 2,519.40 2,065.87 77 2,917.04 3,278.85 2,875.05 2,895.86 2,374.56 2,580.20 2,901.16 2,544.21 2,562.21 2,101.01 78 2,965.75 3,334.67 2,924.38 2,945.07 2,414.95 2,628.02 2,954.61 2,590.53 2,609.27 2,139.66 79 3,020.71 3,396.11 2,977.62 2,999.17 2,459.38 2,822.15 3,172.91 2,782.21 2,801.81 2,297.38 80 and Over 3,243.84 3,647.03 3,197.94 3,220.47 2,640.66 To obtain semiannual and quarterly premiums, divide the above-quoted premiums by 2 and 4, respectively. To obtain the monthly premium for bank service plan issues, including all attached riders, divide the total annual premium by 12. M21335-1 TX 0-07 - 6 - ZIP CODES: 733, 750, 751, 760, 761, 774, 784, 787, 793
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 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. M221 (Plan A) M222 (Plan C) NON-TOBACCO ANNUAL RATES FEMALE MALE M285 M223 M376 Attained M221 M222 M285 (Plan D) (Plan F) (Plan G) Age (Plan A) (Plan C) (Plan D) $3,361.42 Through 64 $3,863.70 M223 (Plan F) M376 (Plan G) 1,757.41 $1,976.77 $1,732.97 $1,745.72 $1,431.43 65 2,020.02 $2,272.15 $1,991.92 $2,006.57 $1,645.32 1,757.41 1,976.77 1,732.97 1,745.72 1,431.43 66 2,020.02 2,272.15 1,991.92 2,006.57 1,645.32 1,833.59 2,062.12 1,807.88 1,820.84 1,492.85 67 2,107.58 2,370.25 2,078.02 2,092.92 1,715.92 1,915.35 2,153.36 1,888.07 1,901.54 1,559.44 68 2,201.55 2,475.12 2,170.18 2,185.68 1,792.46 1,999.43 2,248.07 1,971.50 1,986.04 1,628.55 69 2,298.19 2,584.00 2,266.10 2,282.81 1,871.90 2,084.98 2,344.06 2,055.26 2,070.02 1,697.47 70 2,396.53 2,694.32 2,362.37 2,379.33 1,951.11 2,169.48 2,438.88 2,138.39 2,153.77 1,766.27 71 2,493.65 2,803.31 2,457.92 2,475.61 2,030.19 2,254.07 2,534.13 2,221.95 2,237.86 1,835.06 72 2,590.89 2,912.79 2,553.96 2,572.25 2,109.27 2,339.21 2,629.27 2,305.28 2,321.83 1,904.08 73 2,688.75 3,022.15 2,649.76 2,668.77 2,188.59 2,381.36 2,677.53 2,347.64 2,364.61 1,938.94 74 2,737.19 3,077.62 2,698.44 2,717.94 2,228.68 2,424.77 2,726.21 2,390.42 2,407.49 1,974.13 75 2,787.09 3,133.57 2,747.61 2,767.23 2,269.13 2,467.64 2,774.35 2,432.56 2,449.73 2,008.59 76 2,836.37 3,188.91 2,796.05 2,815.79 2,308.73 2,510.95 2,822.40 2,474.81 2,492.72 2,044.00 77 2,886.15 3,244.13 2,844.61 2,865.20 2,349.42 2,552.88 2,870.43 2,517.27 2,535.08 2,078.76 78 2,934.35 3,299.35 2,893.42 2,913.88 2,389.39 2,600.20 2,923.33 2,563.11 2,581.65 2,117.01 79 2,988.73 3,360.15 2,946.10 2,967.41 2,433.35 2,792.27 3,139.32 2,752.76 2,772.14 2,273.05 80 and Over 3,209.50 3,608.41 3,164.09 3,186.37 2,612.70 To obtain semiannual and quarterly premiums, divide the above-quoted premiums by 2 and 4, respectively. To obtain the monthly premium for bank service plan issues, including all attached riders, divide the total annual premium by 12. M21335-1 TX 0-07 - 7 - ZIP CODES: 770-773, 775-777, 794
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 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. M221 (Plan A) M222 (Plan C) TOBACCO ANNUAL RATES FEMALE MALE M285 M223 M376 Attained M221 M222 M285 (Plan D) (Plan F) (Plan G) Age (Plan A) (Plan C) (Plan D) $3,863.70 Through 64 $4,441.04 M223 (Plan F) M376 (Plan G) 2,020.01 $2,272.15 $1,991.92 $2,006.57 $1,645.32 65 2,321.86 $2,611.67 $2,289.56 $2,306.40 $1,891.17 2,020.01 2,272.15 1,991.92 2,006.57 1,645.32 66 2,321.86 2,611.67 2,289.56 2,306.40 1,891.17 2,107.57 2,370.25 2,078.02 2,092.92 1,715.92 67 2,422.50 2,724.42 2,388.53 2,405.65 1,972.32 2,201.55 2,475.13 2,170.19 2,185.68 1,792.46 68 2,530.52 2,844.97 2,494.46 2,512.28 2,060.30 2,298.19 2,583.99 2,266.09 2,282.81 1,871.90 69 2,641.60 2,970.11 2,604.71 2,623.92 2,151.61 2,396.53 2,694.32 2,362.37 2,379.33 1,951.11 70 2,754.63 3,096.92 2,715.37 2,734.86 2,242.65 2,493.65 2,803.31 2,457.92 2,475.60 2,030.19 71 2,866.27 3,222.20 2,825.20 2,845.53 2,333.55 2,590.89 2,912.79 2,553.96 2,572.25 2,109.26 72 2,978.04 3,348.04 2,935.59 2,956.61 2,424.45 2,688.75 3,022.15 2,649.75 2,668.77 2,188.60 73 3,090.52 3,473.74 3,045.70 3,067.55 2,515.62 2,737.19 3,077.62 2,698.44 2,717.94 2,228.67 74 3,146.20 3,537.49 3,101.65 3,124.07 2,561.70 2,787.09 3,133.57 2,747.61 2,767.23 2,269.12 75 3,203.55 3,601.80 3,158.17 3,180.72 2,608.19 2,836.37 3,188.91 2,796.05 2,815.78 2,308.72 76 3,260.20 3,665.41 3,213.85 3,236.54 2,653.71 2,886.15 3,244.14 2,844.61 2,865.20 2,349.42 77 3,317.41 3,728.89 3,269.67 3,293.33 2,700.48 2,934.35 3,299.35 2,893.41 2,913.89 2,389.38 78 3,372.82 3,792.36 3,325.77 3,349.29 2,746.42 2,988.73 3,360.15 2,946.10 2,967.41 2,433.34 79 3,435.32 3,862.24 3,386.32 3,410.82 2,796.95 3,209.50 3,608.41 3,164.09 3,186.37 2,612.70 80 and Over 3,689.08 4,147.60 3,636.88 3,662.49 3,003.10 To obtain semiannual and quarterly premiums, divide the above-quoted premiums by 2 and 4, respectively. To obtain the monthly premium for bank service plan issues, including all attached riders, divide the total annual premium by 12. M21335-1 TX 0-07 - 8 - ZIP CODES: 770-773, 775-777, 794
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 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. M221 (Plan A) M222 (Plan C) NON-TOBACCO ANNUAL RATES FEMALE MALE M285 M223 M376 Attained M221 M222 M285 (Plan D) (Plan F) (Plan G) Age (Plan A) (Plan C) (Plan D) $3,187.56 Through 64 $3,663.86 M223 (Plan F) M376 (Plan G) 1,666.51 $1,874.53 $1,643.33 $1,655.42 $1,357.39 65 1,915.53 $2,154.62 $1,888.89 $1,902.79 $1,560.21 1,666.51 1,874.53 1,643.33 1,655.42 1,357.39 66 1,915.53 2,154.62 1,888.89 1,902.79 1,560.21 1,738.75 1,955.46 1,714.37 1,726.65 1,415.63 67 1,998.56 2,247.65 1,970.54 1,984.66 1,627.17 1,816.28 2,041.98 1,790.41 1,803.19 1,478.77 68 2,087.68 2,347.10 2,057.93 2,072.64 1,699.75 1,896.01 2,131.80 1,869.53 1,883.32 1,544.32 69 2,179.32 2,450.34 2,148.88 2,164.73 1,775.08 1,977.14 2,222.82 1,948.96 1,962.95 1,609.67 70 2,272.57 2,554.96 2,240.18 2,256.26 1,850.19 2,057.26 2,312.74 2,027.79 2,042.37 1,674.91 71 2,364.67 2,658.32 2,330.79 2,347.56 1,925.18 2,137.49 2,403.05 2,107.02 2,122.11 1,740.14 72 2,456.89 2,762.13 2,421.86 2,439.20 2,000.16 2,218.22 2,493.27 2,186.05 2,201.74 1,805.59 73 2,549.67 2,865.83 2,512.70 2,530.73 2,075.39 2,258.19 2,539.03 2,226.21 2,242.30 1,838.66 74 2,595.61 2,918.43 2,558.86 2,577.36 2,113.40 2,299.35 2,585.20 2,266.78 2,282.96 1,872.02 75 2,642.93 2,971.49 2,605.49 2,624.09 2,151.75 2,340.01 2,630.85 2,306.74 2,323.02 1,904.70 76 2,689.67 3,023.96 2,651.43 2,670.14 2,189.31 2,381.08 2,676.42 2,346.81 2,363.79 1,938.27 77 2,736.86 3,076.34 2,697.48 2,717.00 2,227.90 2,420.84 2,721.97 2,387.06 2,403.96 1,971.24 78 2,782.57 3,128.70 2,743.75 2,763.16 2,265.79 2,465.70 2,772.12 2,430.53 2,448.11 2,007.51 79 2,834.14 3,186.35 2,793.71 2,813.93 2,307.48 2,647.84 2,976.94 2,610.37 2,628.76 2,155.48 80 and Over 3,043.49 3,421.77 3,000.42 3,021.55 2,477.56 To obtain semiannual and quarterly premiums, divide the above-quoted premiums by 2 and 4, respectively. To obtain the monthly premium for bank service plan issues, including all attached riders, divide the total annual premium by 12. M21335-1 TX 0-07 - 9 - ZIP CODES: 752, 753, 782
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 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. M221 (Plan A) M222 (Plan C) TOBACCO ANNUAL RATES FEMALE MALE M285 M223 M376 Attained M221 M222 M285 (Plan D) (Plan F) (Plan G) Age (Plan A) (Plan C) (Plan D) $3,663.86 Through 64 $4,211.33 M223 (Plan F) M376 (Plan G) 1,915.53 $2,154.63 $1,888.89 $1,902.78 $1,560.22 65 2,201.76 $2,476.58 $2,171.14 $2,187.11 $1,793.35 1,915.53 2,154.63 1,888.89 1,902.78 1,560.22 66 2,201.76 2,476.58 2,171.14 2,187.11 1,793.35 1,998.56 2,247.65 1,970.54 1,984.66 1,627.16 67 2,297.20 2,583.50 2,264.99 2,281.22 1,870.31 2,087.68 2,347.10 2,057.94 2,072.63 1,699.74 68 2,399.63 2,697.82 2,365.44 2,382.34 1,953.73 2,179.32 2,450.34 2,148.88 2,164.73 1,775.08 69 2,504.96 2,816.48 2,469.98 2,488.20 2,040.32 2,272.57 2,554.96 2,240.18 2,256.27 1,850.19 70 2,612.15 2,936.74 2,574.92 2,593.40 2,126.65 2,364.67 2,658.32 2,330.79 2,347.55 1,925.18 71 2,718.01 3,055.54 2,679.07 2,698.34 2,212.85 2,456.88 2,762.13 2,421.86 2,439.21 2,000.16 72 2,824.01 3,174.86 2,783.75 2,803.68 2,299.04 2,549.68 2,865.83 2,512.70 2,530.73 2,075.39 73 2,930.66 3,294.06 2,888.16 2,908.88 2,385.50 2,595.62 2,918.43 2,558.86 2,577.36 2,113.40 74 2,983.46 3,354.52 2,941.22 2,962.48 2,429.20 2,642.93 2,971.49 2,605.49 2,624.09 2,151.75 75 3,037.85 3,415.50 2,994.82 3,016.20 2,473.28 2,689.67 3,023.97 2,651.43 2,670.14 2,189.31 76 3,091.57 3,475.82 3,047.62 3,069.13 2,516.45 2,736.87 3,076.34 2,697.48 2,717.00 2,227.90 77 3,145.82 3,536.02 3,100.55 3,122.99 2,560.80 2,782.57 3,128.70 2,743.75 2,763.17 2,265.79 78 3,198.36 3,596.21 3,153.74 3,176.05 2,604.36 2,834.14 3,186.35 2,793.71 2,813.92 2,307.48 79 3,257.63 3,662.47 3,211.16 3,234.40 2,652.28 3,043.49 3,421.77 3,000.43 3,021.56 2,477.56 80 and Over 3,498.26 3,933.07 3,448.76 3,473.05 2,847.77 To obtain semiannual and quarterly premiums, divide the above-quoted premiums by 2 and 4, respectively. To obtain the monthly premium for bank service plan issues, including all attached riders, divide the total annual premium by 12. M21335-1 TX 0-07 - 10 - ZIP CODES: 752, 753, 782
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 the Mutual of Omaha 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 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 or other health coverage, do NOT cancel it until you have actually received your new policy and are sure you want to keep it. EXCEPTIONS AND LIMITATIONS We will not pay for: (a) services for which a charge is normally not made when there is no insurance; (b) expense incurred before the Policy Date; or (c) expense incurred which is paid for by Medicare. REFUND OF UNEARNED PREMIUM In the event of cancellation or death, we will promptly return the unearned portion of any premium paid. Termination of coverage will not affect any claim originating while this policy is in force. 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. Review the application carefully before you sign it. Be certain that all information has been properly recorded. M21335-1 TX 0-07 - 11 -
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. In 2007 Medicare Pays Plan A Pays You Pay Plan C Pays You Pay Services HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies: First 60 days All but $992.00 $0 $992.00 (Part A Deductible) $992.00 (Part A $0** Deductible) 61 st through 90 th day All but $248.00 a day $248.00 a day $0** $248.00 a day $0** 91 st day and after: While using 60 lifetime reserve days All but $496.00 a day $496.00 a day $0** $496.00 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 $124.00 a day $0 Up to $124.00 a day Up to $124.00 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 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 $0 Balance $0 Balance **$0 indicates your liability for covered charges. You are responsible for all other noncovered charges. +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." 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. M21335-1 TX 0-07 - 12 -
PLANS A AND C MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR Once you have been billed $131.00 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. In 2007 Medicare Pays Plan A Pays You Pay Plan C Pays You Pay Services 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 $131.00 of Medicare Approved Amounts* $0 $0 $131.00 (Part B Deductible) $131.00 (Part B $0** Deductible) 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 $131.00 of Medicare Approved Amounts* $0 $0 $131.00 (Part $131.00 (Part B $0** B Deductible) Deductible) 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 $131.00 of Medicare Approved Amounts* $0 $0 $131.00(Part B $131.00 (Part B $0** Deductible.) Deductible) Remainder of Medicare Approved Amounts 80% 20% $0** 20% $0** OTHER BENEFITS - NOT COVERED BY MEDICARE FOREIGN TRAVEL NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA: First $250.00 each calendar year $0 $0 $250.00 $0 $250.00 Remainder of charges $0 $0 All costs 80% to a lifetime maximum benefit of $50,000.00 **$0 indicates your liability for covered charges. You are responsible for all other noncovered charges. M21335-1 TX 0-07 - 13-20% and amounts over the $50,000.00 lifetime maximum
PLANS D AND F MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD *A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. Services HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies: First 60 days All but $992.00 $992.00 (Part A Deductible) In 2007 Medicare Pays Plan D Pays You Pay Plan F Pays You Pay $0** $992.00 (Part A $0** Deductible) 61 st through 90 th day All but $248.00 a day $248.00 a day $0** $248.00 a day $0** 91 st day and after: While using 60 lifetime reserve days All but $496.00 a day $496.00 a day $0** $496.00 a day $0** Once lifetime reserve days are used: Additional 365 days $0 100% of Medicare Eligible Expenses $0** 100% of Medicare Eligible Expenses $0**+ 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 $124.00 a day Up to $124.00 a day $0** Up to $124.00 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 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 $0 Balance $0 Balance **$0 indicates your liability for covered charges. You are responsible for all other noncovered charges. +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." 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. M21335-1 TX 0-07 - 14 -
PLANS D AND F MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR Once you have been billed $131.00 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. Services In 2007 Medicare Pays Plan D Pays You Pay Plan F Pays You Pay MEDICAL EXPENSES IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENTS, such as physician s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment: First $131.00 of Medicare Approved Amounts* $0 $0 $131.00 (Part B $131.00 (Part B $0** Deductible) Deductible) 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 100% $0** BLOOD First 3 pints $0 All costs $0** All costs $0** Next $131.00 of Medicare Approved Amounts* $0 $0 $131.00 (Part B $131.00 (Part B $0** Deductible) Deductible) 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 $131.00 of Medicare Approved Amounts* $0 $0 $131.00 (Part B $131.00 (Part B $0** Deductible) Deductible) Remainder of Medicare Approved Amounts 80% 20% $0** 20% $0** **$0 indicates your liability for covered charges. You are responsible for all other noncovered charges. M21335-1 TX 0-07 - 15 -
PLANS D AND F PARTS A and B (continued) Services In 2007 Medicare Pays Plan D Pays You Pay Plan F Pays You Pay 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 $0 Actual charges to Balance $0 All costs Number of visits covered (must be received within 8 weeks of last Medicare approved visit) $40.00 a visit $0 Up to the number of Medicare approved visits, not to exceed 7 each week Balance $0 All costs Calendar year maximum $0 $1,600.00 Balance $0 All costs OTHER BENEFITS NOT COVERED BY MEDICARE FOREIGN TRAVEL NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA: First $250.00 each calendar year $0 $0 $250.00 $0 $250.00 Remainder of charges $0 80% to a lifetime Maximum Benefit of $50,000.00 20% and amounts over the $50,000.00 lifetime Maximum Benefit 80% to a lifetime Maximum Benefit of $50,000.00 20% and amounts over the $50,000.00 lifetime Maximum Benefit M21335-1 TX 0-07 - 16 -
PLAN G MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD *A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. In 2007 Medicare Pays Plan G Pays You Pay Services HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies: First 60 days All but $992.00 $992.00 (Part A Deductible) $0** 61 st through 90 th day All but $248.00 a day $248.00 a day $0** 91 st day and after: While using 60 lifetime reserve days All but $496.00 a day $496.00 a day $0** Once lifetime reserve days are used: Additional 365 days $0 100% of Medicare Eligible Expenses $0**+ 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 $124.00 a day Up to $124.00 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 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 $0 Balance **$0 indicates your liability for covered charges. You are responsible for all other noncovered charges. +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." 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. M21335-1 TX 0-07 - 17 -
PLAN G MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR Once you have been billed $131.00 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. Services Medicare Pays 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 $131.00 of Medicare Approved Amounts* $0 $0 $131.00 (Part B Deductible) Remainder of Medicare Approved Amounts 80% 20% $0** Part B Excess Charges (above Medicare Approved Amounts) $0 80% 20% BLOOD First 3 pints $0 All costs $0** Next $131.00 of Medicare Approved Amounts* $0 $0 $131.00 (Part B Deductible) 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 $131.00 of Medicare Approved Amounts* $0 $0 $131.00 (Part B Deductible) Remainder of Medicare Approved Amounts 80% 20% $0** 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 $0 Actual charges to $40.00 a visit Balance Number of visits covered (must be received within 8 weeks $0 Up to the number of Medicare approved Balance of last Medicare approved visit) visits, not to exceed 7 each week Calendar year maximum $0 $1,600.00 Balance OTHER BENEFITS NOT COVERED BY MEDICARE FOREIGN TRAVEL NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA: First $250.00 each calendar year $0 $0 $250.00 Remainder of charges $0 80% to a lifetime Maximum Benefit of $50,000.00 **$0 indicates your liability for covered charges. You are responsible for all other noncovered charges. M21335-1 TX 0-07 - 18-20% and amounts over the $50,000.00 lifetime Maximum Benefit