SENIOR CHOICE Medicare Supplement Outline of Coverage

SENIOR CHOICE Medicare Supplement Outline of Coverage from Gundersen Health Plan The Wisconsin Insurance Commissioner has set standards for Medicare supplement insurance. This policy meets these standards. It, along with Medicare, may not cover all of your medical costs. You should review carefully all policy limitations. For an explanation of these standards and other important information, see Wisconsin Guide to Health Insurance for People with Medicare, given to you when you applied for this policy. Do not buy this policy if you did not get this guide. CONTACT US If you have questions or require language assistance, please call Customer Service at (608) 775-8081 or (888) 761-2557. For people who are deaf, hard of hearing or speech impaired please call (800) 877-8973 or TTY 711. You may also call through a video relay service company of your choice. Interpreter services are provided free of charge to you. We can also give you information in Braille, in large print, or other alternate formats. A customer service representative is available to assist you Monday through Friday from 8:00 a.m. to 5:00 p.m. You can also visit our website at www.myseniorchoice.org. Outline of Coverage - Revised 12/03/2015 OCI Approval: 12/15/2015

TABLE OF CONTENTS Why buy Medicare supplement insurance... 3 Enrollment information... 3 Service locations... 4 Premium information... 4 Disclosures: Use this outline to compare benefits and premiums among policies.... 4 Right to return policy... 4 Policy replacement... 5 Notice... 5 Renewal terms... 5 Payment options... 5 Premium rates... 7 Premium calculation... 15 Benefit table... 16 Limitations and exclusions... 22 Grievance and external review... 23 General information... 24 2

WHY BUY MEDICARE SUPPLEMENT INSURANCE If you currently have Medicare alone, you know it does not always pay 100% of the bills. With supplemental insurance, the burden is much less because more costs and benefits are covered with supplemental insurance. This leaves you with fewer medical out-of-pocket medical expenses. It gives you peace of mind that when you have a medical expense, Senior Choice covers you. With multiple options to choose from, we can build a plan that is just right for you. ENROLLMENT INFORMATION To enroll in, you need to meet the following requirements. a) You must be at least 65 years of age or under 65 with certain disabilities, or end-stage renal disease. b) You must reside in Wisconsin on effective date of policy. c) You must have been enrolled in Medicare Part A and by the date starts. d) You must not be covered by Medicaid (BadgerCare) or a Medicare Advantage plan. To apply you must meet all eligibility requirements, fill out an application, and return it to your insurance agent. If you join a Medicare Advantage Plan, you cannot use Medicare Supplement Insurance (Medigap) to pay for out-of-pocket costs you have in a Medicare Advantage Plan. If you already have a Medicare Advantage Plan, you cannot enroll in a Medigap policy. You can only use a Medigap policy if you disenroll from your Medicare Advantage Plan and return to Original Medicare. Open enrollment period The open enrollment period is the: Three calendar months before you enroll in Medicare, Calendar month in which you enroll in Medicare, Six calendar months immediately following the month you enroll in Medicare. Coverage begins the first of the month after we accept your application and premium. It could also begin on the effective date you requested on your application. (This date is up to three months from when you completed your application.) Enrollments made during the open enrollment period are guarantee issue. Special enrollment period If you lost or are losing other health insurance coverage and received a notice from your prior insurer saying you were eligible for guaranteed issue or a Medicare supplement insurance policy, or that you had certain rights to buy such a policy, you may be guaranteed acceptance in our Medicare supplement plan. You must submit a copy of the notice from 3

your prior insurer with your application. You must submit your application and notice to us no later than 63 days after your other coverage ends. Coverage begins the first of the month after we accept your application and premium. It could also begin on the effective date you requested on your application. (This date is within the 63 days from the termination of your previous policy.) Enrollments made during the special enrollment period are guarantee issue. Other enrollment period Enrollments made outside of the open enrollment period are subject to medical underwriting. SERVICE LOCATIONS Unlike an HMO, with you have the option to keep the same doctor you have been seeing for years. You can also change doctors at any time. As long as you are a Wisconsin resident at the time your policy takes effect, you have complete freedom to see any Medicare payable healthcare provider, anywhere in the U.S. If you move, your coverage can move with you. It s that easy. PREMIUM INFORMATION We can only raise your premium if we raise the premium for all policies like yours in this state. Premiums may change annually on your renewal date. They also may change if you move into a new rating area. The first month s premium must be received to activate your coverage. 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 Gundersen Health Plan, Inc., NCA2-01, 1900 South Avenue, La Crosse, WI 54601. 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. We will return all your payments directly to you. 4

POLICY REPLACEMENT If you are replacing another health insurance policy, do NOT cancel that policy 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. RENEWAL TERMS As a member of, you will never be cancelled because of your health. As long as you continue to make your premium payments on time, you are guaranteed renewable for life. For your coverage to continue, we must receive your premium as required by the policy. Your grace period for paying premium is one calendar month after the premium due date. PAYMENT OPTIONS Each month you will receive a billing statement. There are several ways you can pay your plan premium: Option 1 You can pay by check or money order (cash not accepted) If you choose to pay your monthly premium payment by check or money order, you must submit the tear off portion of your billing statement each month with your premium payment. Premium payments should be sent to: Gundersen Health Plan, PO Box 856565, Minneapolis, MN 55485-6565. Option 2 Online Payment To pay your premium using an online payment process, please visit our website www.gundersenhealthplan.org and click on Premium Payment. You can elect to make onetime payments from your bank accounts or credit/debit cards, or you can elect to set up and automatic recurring payment. You will continue to receive a monthly statement if you elect the automatic recurring payment, this statement is sent as a courtesy reminder of your monthly payment. Option 3 Phone Payment To pay your premium via telephone, call 844-327-3352. This is an automated payment process. You may provide your banking information or credit/debit account information when making your payment through this option. 5

Option 4 Mail Payment If you choose to mail your payment, tear off the bottom portion of your billing statement and mail it in with your payment in the envelope provided. Neither nor its agents are connected with Medicare. 6

Current Age Base Part A 50% Part A 100% Copay/ Coinsurance Excess Charge Home Health Foreign Travel Emergency PREMIUM RATES We can only raise your premium if we raise the premium for all policies like yours in this state. Premiums may change annually on your renewal date. They also may change if you move into a new rating area. AREA A Non-tobacco user rates Counties: Buffalo, Crawford, Grant, Jackson, Juneau, La Crosse, Monroe, Richland, Sauk, Trempealeau, Vernon Under 65 277.74 17.01 34.50 11.50-37.53 12.39 15.51 11.97 65 92.58 5.67 11.50 11.50-12.51 4.13 5.17 3.99 66 96.67 6.03 12.22 11.50-13.04 4.31 5.40 4.16 67 100.95 6.41 12.98 11.50-13.59 4.51 5.64 4.34 68 105.42 6.81 13.78 11.50-14.17 4.70 5.88 4.53 69 110.09 7.22 14.63 11.50-14.78 4.90 6.14 4.74 70 114.97 7.67 15.53 11.50-15.40 5.13 6.42 4.94 71 120.25 8.18 16.54 11.50-16.03 5.37 6.72 5.17 72 125.90 8.71 17.62 11.50-16.72 5.61 7.03 5.41 73 131.72 9.28 18.77 11.50-17.40 5.86 7.36 5.65 74 137.54 9.88 19.98 11.50-18.06 6.12 7.68 5.91 75 143.18 10.50 21.23 11.50-18.66 6.37 7.99 6.14 76 148.60 11.15 22.53 11.50-19.21 6.61 8.30 6.37 77 153.91 11.82 23.88 11.50-19.73 6.83 8.59 6.60 78 159.18 12.52 25.29 11.50-20.20 7.07 8.88 6.82 79 164.47 13.27 26.78 11.50-20.63 7.29 9.18 7.05 80 169.84 14.06 28.38 11.50-21.00 7.52 9.49 7.27 81 175.42 14.94 30.12 11.50-21.28 7.75 9.79 7.51 82 181.17 15.87 32.00 11.50-21.51 7.99 10.12 7.75 83 186.91 16.84 33.94 11.50-21.69 8.21 10.43 7.98 84 192.42 17.83 35.92 11.50-21.84 8.45 10.75 8.22 85+ 197.54 18.79 37.85 11.50-22.00 8.65 11.03 8.43 7

Current Age Base Part A 50% Part A 100% Copay/ Coinsurance Excess Charge Home Health Foreign Travel Emergency AREA A Tobacco user rates Counties: Buffalo, Crawford, Grant, Jackson, Juneau, La Crosse, Monroe, Richland, Sauk, Trempealeau, Vernon Under 65 305.51 18.71 37.95 11.50-41.28 13.63 17.06 13.17 65 101.84 6.24 12.65 11.50-13.76 4.54 5.69 4.39 66 106.34 6.63 13.44 11.50-14.34 4.74 5.94 4.58 67 111.05 7.05 14.28 11.50-14.95 4.96 6.20 4.77 68 115.96 7.49 15.16 11.50-15.59 5.17 6.47 4.98 69 121.10 7.94 16.09 11.50-16.26 5.39 6.75 5.21 70 126.47 8.44 17.08 11.50-16.94 5.64 7.06 5.43 71 132.28 9.00 18.19 11.50-17.63 5.91 7.39 5.69 72 138.49 9.58 19.38 11.50-18.39 6.17 7.73 5.95 73 144.89 10.21 20.65 11.50-19.14 6.45 8.10 6.22 74 151.29 10.87 21.98 11.50-19.87 6.73 8.45 6.50 75 157.50 11.55 23.35 11.50-20.53 7.01 8.79 6.75 76 163.46 12.27 24.78 11.50-21.13 7.27 9.13 7.01 77 169.30 13.00 26.27 11.50-21.70 7.51 9.45 7.26 78 175.10 13.77 27.82 11.50-22.22 7.78 9.77 7.50 79 180.92 14.60 29.46 11.50-22.69 8.02 10.10 7.76 80 186.82 15.47 31.22 11.50-23.10 8.27 10.44 8.00 81 192.96 16.43 33.13 11.50-23.41 8.53 10.77 8.26 82 199.29 17.46 35.20 11.50-23.66 8.79 11.13 8.53 83 205.60 18.52 37.33 11.50-23.86 9.03 11.47 8.78 84 211.66 19.61 39.51 11.50-24.02 9.30 11.83 9.04 85+ 217.29 20.67 41.64 11.50-24.20 9.52 12.13 9.27 8

Current Age Base Part A 50% Part A 100% Copay/ Coinsurance Excess Charge Home Health Foreign Travel Emergency AREA B Non-tobacco user rates Counties: Milwaukee, Ozaukee, Washington, Waukesha, Racine, Kenosha Under 65 333.29 20.41 41.40 11.50-45.04 14.87 18.61 14.36 65 111.10 6.80 13.80 11.50-15.01 4.96 6.20 4.79 66 116.00 7.24 14.66 11.50-15.65 5.17 6.48 4.99 67 121.14 7.69 15.58 11.50-16.31 5.41 6.77 5.21 68 126.50 8.17 16.54 11.50-17.00 5.64 7.06 5.44 69 132.11 8.66 17.56 11.50-17.74 5.88 7.37 5.69 70 137.96 9.20 18.64 11.50-18.48 6.16 7.70 5.93 71 144.30 9.82 19.85 11.50-19.24 6.44 8.06 6.20 72 151.08 10.45 21.14 11.50-20.06 6.73 8.44 6.49 73 158.06 11.14 22.52 11.50-20.88 7.03 8.83 6.78 74 165.05 11.86 23.98 11.50-21.67 7.34 9.22 7.09 75 171.82 12.60 25.48 11.50-22.39 7.64 9.59 7.37 76 178.32 13.38 27.04 11.50-23.05 7.93 9.96 7.64 77 184.69 14.18 28.66 11.50-23.68 8.20 10.31 7.92 78 191.02 15.02 30.35 11.50-24.24 8.48 10.66 8.18 79 197.36 15.92 32.14 11.50-24.76 8.75 11.02 8.46 80 203.81 16.87 34.06 11.50-25.20 9.02 11.39 8.72 81 210.50 17.93 36.14 11.50-25.54 9.30 11.75 9.01 82 217.40 19.04 38.40 11.50-25.81 9.59 12.14 9.30 83 224.29 20.21 40.73 11.50-26.03 9.85 12.52 9.58 84 230.90 21.40 43.10 11.50-26.21 10.14 12.90 9.86 85+ 237.05 22.55 45.42 11.50-26.40 10.38 13.24 10.12 9

Current Age Base Part A 50% Part A 100% Copay/ Coinsurance Excess Charge Home Health Foreign Travel Emergency AREA B Tobacco user rates Counties: Milwaukee, Ozaukee, Washington, Waukesha, Racine, Kenosha Under 65 366.62 22.45 45.54 11.50-49.54 16.36 20.47 15.80 65 122.21 7.48 15.18 11.50-16.51 5.46 6.82 5.27 66 127.60 7.96 16.13 11.50-17.22 5.69 7.13 5.49 67 133.25 8.46 17.14 11.50-17.94 5.95 7.45 5.73 68 139.15 8.99 18.19 11.50-18.70 6.20 7.77 5.98 69 145.32 9.53 19.32 11.50-19.51 6.47 8.11 6.26 70 151.76 10.12 20.50 11.50-20.33 6.78 8.47 6.52 71 158.73 10.80 21.84 11.50-21.16 7.08 8.87 6.82 72 166.19 11.50 23.25 11.50-22.07 7.40 9.28 7.14 73 173.87 12.25 24.77 11.50-22.97 7.73 9.71 7.46 74 181.56 13.05 26.38 11.50-23.84 8.07 10.14 7.80 75 189.00 13.86 28.03 11.50-24.63 8.40 10.55 8.11 76 196.15 14.72 29.74 11.50-25.36 8.72 10.96 8.40 77 203.16 15.60 31.53 11.50-26.05 9.02 11.34 8.71 78 210.12 16.52 33.39 11.50-26.66 9.33 11.73 9.00 79 217.10 17.51 35.35 11.50-27.24 9.63 12.12 9.31 80 224.19 18.56 37.47 11.50-27.72 9.92 12.53 9.59 81 231.55 19.72 39.75 11.50-28.09 10.23 12.93 9.91 82 239.14 20.94 42.24 11.50-28.39 10.55 13.35 10.23 83 246.72 22.23 44.80 11.50-28.63 10.84 13.77 10.54 84 253.99 23.54 47.41 11.50-28.83 11.15 14.19 10.85 85+ 260.76 24.81 49.96 11.50-29.04 11.42 14.56 11.13 10

Current Age Base Part A 50% Part A 100% Copay/ Coinsurance Excess Charge Home Health Foreign Travel Emergency AREA C Non-tobacco user rates All Other WI Counties Under 65 294.40 18.03 36.57 11.50-39.78 13.13 16.44 12.69 65 98.13 6.01 12.19 11.50-13.26 4.38 5.48 4.23 66 102.47 6.39 12.95 11.50-13.82 4.57 5.72 4.41 67 107.01 6.79 13.76 11.50-14.41 4.78 5.98 4.60 68 111.75 7.22 14.61 11.50-15.02 4.98 6.23 4.80 69 116.70 7.65 15.51 11.50-15.67 5.19 6.51 5.02 70 121.87 8.13 16.46 11.50-16.32 5.44 6.81 5.24 71 127.47 8.67 17.53 11.50-16.99 5.69 7.12 5.48 72 133.45 9.23 18.68 11.50-17.72 5.95 7.45 5.73 73 139.62 9.84 19.90 11.50-18.44 6.21 7.80 5.99 74 145.79 10.47 21.18 11.50-19.14 6.49 8.14 6.26 75 151.77 11.13 22.50 11.50-19.78 6.75 8.47 6.51 76 157.52 11.82 23.88 11.50-20.36 7.01 8.80 6.75 77 163.14 12.53 25.31 11.50-20.91 7.24 9.11 7.00 78 168.73 13.27 26.81 11.50-21.41 7.49 9.41 7.23 79 174.34 14.07 28.39 11.50-21.87 7.73 9.73 7.47 80 180.03 14.90 30.08 11.50-22.26 7.97 10.06 7.71 81 185.95 15.84 31.93 11.50-22.56 8.22 10.38 7.96 82 192.04 16.82 33.92 11.50-22.80 8.47 10.73 8.22 83 198.12 17.85 35.98 11.50-22.99 8.70 11.06 8.46 84 203.97 18.90 38.08 11.50-23.15 8.96 11.40 8.71 85+ 209.39 19.92 40.12 11.50-23.32 9.17 11.69 8.94 11

Current Age Base Part A 50% Part A 100% Copay/ Coinsurance Excess Charge Home Health Foreign Travel Emergency AREA C Tobacco user rates All Other WI Counties Under 65 323.84 19.83 40.23 11.50-43.76 14.44 18.08 13.96 65 107.94 6.61 13.41 11.50-14.59 4.82 6.03 4.65 66 112.72 7.03 14.25 11.50-15.20 5.03 6.29 4.85 67 117.71 7.47 15.14 11.50-15.85 5.26 6.58 5.06 68 122.93 7.94 16.07 11.50-16.52 5.48 6.85 5.28 69 128.37 8.42 17.06 11.50-17.24 5.71 7.16 5.52 70 134.06 8.94 18.11 11.50-17.95 5.98 7.49 5.76 71 140.22 9.54 19.28 11.50-18.69 6.26 7.83 6.03 72 146.80 10.15 20.55 11.50-19.49 6.55 8.20 6.30 73 153.58 10.82 21.89 11.50-20.28 6.83 8.58 6.59 74 160.37 11.52 23.30 11.50-21.05 7.14 8.95 6.89 75 166.95 12.24 24.75 11.50-21.76 7.43 9.32 7.16 76 173.27 13.00 26.27 11.50-22.40 7.71 9.68 7.43 77 179.45 13.78 27.84 11.50-23.00 7.96 10.02 7.70 78 185.60 14.60 29.49 11.50-23.55 8.24 10.35 7.95 79 191.77 15.48 31.23 11.50-24.06 8.50 10.70 8.22 80 198.03 16.39 33.09 11.50-24.49 8.77 11.07 8.48 81 204.55 17.42 35.12 11.50-24.82 9.04 11.42 8.76 82 211.24 18.50 37.31 11.50-25.08 9.32 11.80 9.04 83 217.93 19.64 39.58 11.50-25.29 9.57 12.17 9.31 84 224.37 20.79 41.89 11.50-25.47 9.86 12.54 9.58 85+ 230.33 21.91 44.13 11.50-25.65 10.09 12.86 9.83 12

Current Age Base Part A 50% Part A 100% Copay/ Coinsurance Excess Charge Home Health Foreign Travel Emergency AREA D Non-tobacco user rates Policyholders who relocate out of state Under 65 388.84 23.81 48.30 11.50-52.54 17.35 21.71 16.76 65 129.61 7.94 16.10 11.50-17.51 5.78 7.24 5.59 66 135.34 8.44 17.11 11.50-18.26 6.03 7.56 5.82 67 141.33 8.97 18.17 11.50-19.03 6.31 7.90 6.08 68 147.59 9.53 19.29 11.50-19.84 6.58 8.23 6.34 69 154.13 10.11 20.48 11.50-20.69 6.86 8.60 6.64 70 160.96 10.74 21.74 11.50-21.56 7.18 8.99 6.92 71 168.35 11.45 23.16 11.50-22.44 7.52 9.41 7.24 72 176.26 12.19 24.67 11.50-23.41 7.85 9.84 7.57 73 184.41 12.99 26.28 11.50-24.36 8.20 10.30 7.91 74 192.56 13.83 27.97 11.50-25.28 8.57 10.75 8.27 75 200.45 14.70 29.72 11.50-26.12 8.92 11.19 8.60 76 208.04 15.61 31.54 11.50-26.89 9.25 11.62 8.92 77 215.47 16.55 33.43 11.50-27.62 9.56 12.03 9.24 78 222.85 17.53 35.41 11.50-28.28 9.90 12.43 9.55 79 230.26 18.58 37.49 11.50-28.88 10.21 12.85 9.87 80 237.78 19.68 39.73 11.50-29.40 10.53 13.29 10.18 81 245.59 20.92 42.17 11.50-29.79 10.85 13.71 10.51 82 253.64 22.22 44.80 11.50-30.11 11.19 14.17 10.85 83 261.67 23.58 47.52 11.50-30.37 11.49 14.60 11.17 84 269.39 24.96 50.29 11.50-30.58 11.83 15.05 11.51 85+ 276.56 26.31 52.99 11.50-30.80 12.11 15.44 11.80 13

Current Age Base Part A 50% Part A 100% Copay/ Coinsurance Excess Charge Home Health Foreign Travel Emergency AREA D Tobacco user rates Policyholders who relocate out of state Under 65 427.72 26.19 53.13 11.50-57.79 19.09 23.88 18.44 65 142.57 8.73 17.71 11.50-19.26 6.36 7.96 6.15 66 148.87 9.28 18.82 11.50-20.09 6.63 8.32 6.40 67 155.46 9.87 19.99 11.50-20.93 6.94 8.69 6.69 68 162.35 10.48 21.22 11.50-21.82 7.24 9.05 6.97 69 169.54 11.12 22.53 11.50-22.76 7.55 9.46 7.30 70 177.06 11.81 23.91 11.50-23.72 7.90 9.89 7.61 71 185.19 12.60 25.48 11.50-24.68 8.27 10.35 7.96 72 193.89 13.41 27.14 11.50-25.75 8.64 10.82 8.33 73 202.85 14.29 28.91 11.50-26.80 9.02 11.33 8.70 74 211.82 15.21 30.77 11.50-27.81 9.43 11.83 9.10 75 220.50 16.17 32.69 11.50-28.73 9.81 12.31 9.46 76 228.84 17.17 34.69 11.50-29.58 10.18 12.78 9.81 77 237.02 18.21 36.77 11.50-30.38 10.52 13.23 10.16 78 245.14 19.28 38.95 11.50-31.11 10.89 13.67 10.51 79 253.29 20.44 41.24 11.50-31.77 11.23 14.14 10.86 80 261.56 21.65 43.70 11.50-32.34 11.58 14.62 11.20 81 270.15 23.01 46.39 11.50-32.77 11.94 15.08 11.56 82 279.00 24.44 49.28 11.50-33.12 12.31 15.59 11.94 83 287.84 25.94 52.27 11.50-33.41 12.64 16.06 12.29 84 296.33 27.46 55.32 11.50-33.64 13.01 16.56 12.66 85+ 304.22 28.94 58.29 11.50-33.88 13.32 16.98 12.98 14

PREMIUM CALCULATION Base Plan $ Base Plan Optional Enhancements Each of these riders may be purchased separately. Choose one type of coverage: Part A 100% Rider $ We ll pay 100% of your Medicare Part A deductible of $1,288 during 1 st 60 days of a confinement. OR Part A 50% Rider $ We ll pay 50% of your Medicare Part A deductible of $1,288 during 1 st 60 days of a confinement. Choose one type of coverage: Rider $ We ll pay your Medicare deductible of $166 each calendar year. OR Copay/Coinsurance Rider $ Your copayment or coinsurance will be the lesser of $20 per office visit, or $50 per emergency room visit, or the Medicare coinsurance. The Medicare medical deductible will apply. Excess Charges Rider $ We ll pay the difference between what Medicare approves for payment and the amount charged by the provider, if your provider does not accept Medicare assignment. The difference shall be no more than the actual charge or the limiting charge allowed by Medicare, whichever is less. Home Health Rider $ We ll pay benefits for an additional 325 home health care visits each calendar year, up to a total of 365 visits per year, in addition to those covered by Medicare. Foreign Travel Emergency Rider $ We ll pay 80% of expenses associated with emergency medical care you receive outside the U.S. that begins in the first 60 days of a trip, after you satisfy a deductible of $250, up to a lifetime maximum benefit of $50,000. BASE POLICY and SELECTED OPTIONAL RIDERS $ TOTAL MONTHLY PREMIUM 15

BENEFIT TABLE The amounts listed in the benefit table are based on 2016 Medicare deductible and coinsurance amounts. They are subject to change. These benefits apply only to Medicareapproved services unless otherwise noted. NOTE: A benefit period begins on the first day you receive services as an inpatient in a hospital. It 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. MEDICARE SENIOR CHOICE OPTIONAL YOU SERVICES BENEFITS BASE PLAN BENEFITS PAY PART A BENEFITS Hospitalization per benefit period: inpatient services such as semi-private room and board, general nursing, and miscellaneous hospital services and supplies Days 1-60: Medicare pays all but the $1,288 Part A deductible Days 1-60: Medicare pays all but the $1,288 Part A deductible Days 1-60: Senior Choice pays $0 Base Plan Part A 100% Rider Days 1-60: Medicare Part A 100% Rider* with pays the $1,288 deductible Days 1-60: You pay $1,288 Part A deductible with Senior Choice Days 1-60: You pay $0 Part A deductible with and the optional benefit Days 1-60: Medicare pays all but the $1,288 Part A deductible Days 61-90: Medicare pays all but $322 per day Part A 50% Rider Days 61-90: pays $322 per day Days 1-60: Medicare Part A 50% Rider*** with pays $644 of the deductible Days 1-60: You pay $644 Part A deductible with and the optional benefit Days 61-90: You pay $0 with 16

MEDICARE SENIOR CHOICE OPTIONAL YOU SERVICES BENEFITS BASE PLAN BENEFITS PAY 60 lifetime reserve days: Medicare pays all but $644 per day 60 lifetime reserve days: pays $644 per 60 lifetime reserve days: You pay $0 with Inpatient Psychiatric Care: in a participating psychiatric hospital per benefit period. Medicare limits the number of inpatient psychiatric benefit days to a lifetime limit of 190 days. Senior Choice covers an additional 175 days for a combined lifetime limit of 365 days. Days beyond the lifetime reserve days: Medicare does not cover any expenses Days 1-60: Medicare pays all but the $1,288 Part A deductible Days 1-60: Medicare pays all but the $1,288 Part A deductible Days 1-60: Medicare pays all but the $1,288 Part A deductible day Days beyond the lifetime reserve days: Senior Choice pays 100% of Part A Medicare-eligible expenses for an additional 365 days** Days 1-60: Senior Choice pays $0 Base Plan Part A 100% Rider Days 1-60: Medicare Part A 100% Rider* with pays the $1,288 deductible Part A 50% Rider Days 1-60: Medicare Part A 50% Rider*** with pays $644 of the deductible Days beyond the lifetime reserve days: You pay $0 of Part A Medicare-eligible expenses for an additional 365 days** with Days 1-60: You pay $1,288 Part A deductible with Senior Choice Days 1-60: You pay $0 Part A deductible with and the optional benefit Days 1-60: You pay $644 Part A deductible with and the optional benefit Days 61-90: Medicare pays all but $322 per day Days 61-90: pays $322 per day Days 61-90: You pay $0 with 17

MEDICARE SENIOR CHOICE OPTIONAL YOU SERVICES BENEFITS BASE PLAN BENEFITS PAY 60 lifetime reserve days: Medicare pays all but $644 per day 60 lifetime reserve days: pays $644 per day 60 lifetime reserve days: You pay $0 with Skilled Nursing Facility Care per benefit period: you must have been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital Days beyond the lifetime reserve days: Medicare does not cover any expenses Days 1-20: Medicare pays 100% Days 21-100: Medicare pays all but $161.00 per day Days over 100: Medicare does not cover any expenses Days beyond the lifetime reserve days: Senior Choice pays 100% of all Part A Medicareeligible expenses up to a lifetime limit of 365 days** Days 1-20: Senior Choice pays $0 Days 21-100: pays $161.00 per day Days over 100: does not cover any expenses Blood, first 3 pints Medicare pays $0 pays 100% Days beyond the lifetime reserve days: You pay $0 of Part A Medicare-eligible expenses up to a lifetime limit of 365 days** with Days 1-20: You pay $0 with Part A Medicare Days 21-100: You pay $0 with Days over 100: You pay 100% of all expenses You pay $0 with Hospice Care: your doctor must certify that you are terminally ill Medicare pays all but limited copayments and coinsurance for outpatient drugs and inpatient respite care pays 100% of any copayment or coinsurance amount You pay $0 with *These are optional riders. You may purchase these benefits if you pay an additional premium. 18

**NOTICE: When your Medicare Part A hospital benefits are exhausted, the issuer stands in the place of Medicare and will pay whatever amount Medicare would have paid as provided in the policy's "Core Benefits." ***This optional rider may reduce your premium when you pay 50% of Medicare Part A deductible. 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. SERVICES PART B BENEFITS Medical Expenses: includes Medicareeligible expenses for physician services; inpatient and outpatient medical services and supplies; physical, occupational and speech therapy; diagnostic tests; durable medical equipment MEDICARE BENEFITS Medicare, in general, pays 80% after deductible* Medicare, in general, pays 80% after deductible* Medicare, in general, pays 80% after deductible* SENIOR CHOICE BASE PLAN, in general, pays 20% after deductible* Base Plan OPTIONAL BENEFITS Rider, in general, pays 20% after deductible* Medicare Rider** with pays $166 deductible Copay/Coinsurance Rider Medicare Copayment or Coinsurance Rider*** with pays amounts exceeding $20 for an office visit or over $50 for an emergency room visit after deductible* YOU PAY You pay $166 deductible* You pay $0 Part B deductible* with Senior Choice and the optional benefit You pay no more than $20 for an office visit or $50 for an emergency room visit after deductible* with and the optional benefit 19

SERVICES Excess charges: expenses charged to you by a non-participating Medicare provider in excess of the Medicare-approved amount MEDICARE BENEFITS Medicare does not cover excess charges SENIOR CHOICE BASE PLAN OPTIONAL BENEFITS Excess Charges Rider without the optional benefit does not cover excess charges Medicare Excess Charges Rider** with pays 100% of the excess charges up to the Medicare limiting charge YOU PAY You pay $0 of the excess expenses up to the Medicare limiting charge with Senior Choice and the optional benefit Blood, first 3 pints Medicare pays $0 pays 100% Chiropractic Services Clinical Laboratory Services: tests for diagnostic services Home Health Care: your doctor must certify that you would need to be in the hospital or skilled nursing home if the home care was not available to you Medicare pays 80% of charges for chiropractic manipulation only after deductible* Medicare pays 100% of approved services Medicare pays 100% for medically necessary visits when you meet certain criteria pays 20% of Medicarecovered charges and the full usual, customary and reasonable charges for medically necessary chiropractic charges after deductible* pays $0 pays for up to 40 visits in addition to the visits provided by Medicare in a 12- month period Base Plan You pay $0 with You pay for charges in excess of the full usual, customary and reasonable charge for medically necessary chiropractic services after deductible* with You pay $0 for Medicareapproved services You pay $0 for up to 40 visits in a 12-month period with Senior Choice 20

SERVICES Preventive Services not covered by Medicare: includes routine eye and routine hearing exams Emergency Medical Services Incurred While Traveling Outside of the United States MEDICARE BENEFITS Medicare pays 100% for medically necessary visits when you meet certain criteria Medicare does not cover any expenses Medicare does not cover most emergency medical services outside of the United States SENIOR CHOICE BASE PLAN OPTIONAL BENEFITS Home Health Rider pays 100% of preventive services not covered by Medicare up to $1,000 per calendar year does not cover most emergency medical services outside of the United States Base Plan Additional Home Health Care Rider** with pays for up to a total of 365 visits in addition to the visits provided by Medicare in a 12-month period YOU PAY You pay $0 for up to a total of 365 visits per year with Senior Choice and the optional benefit You pay any amount exceeding $1,000 per calendar year for preventive services not covered by Medicare with You pay 100% of all medical expenses while traveling outside of the United States 21

SERVICES MEDICARE BENEFITS Medicare does not cover most emergency medical services outside of the United States SENIOR CHOICE BASE PLAN OPTIONAL BENEFITS Foreign Travel Emergency Rider Foreign Travel Emergency Rider** with pays 80% after $250 deductible of all eligible emergency medical expenses incurred within the first 60 days of your trip up to a lifetime maximum benefit of $50,000 YOU PAY You pay $250 deductible and 20% coinsurance for emergency medical expenses up to a lifetime maximum benefit of $50,000 with and the optional benefit *Once you have been billed $166 of Medicare-approved amounts for covered services (that are noted with an asterisk), your Medicare deductible will have been met for the calendar year. **These are optional riders. You may purchase these benefits if you pay an additional premium. ***This is an optional rider that may decrease your premium when you pay copayments for medical and emergency room visits. LIMITATIONS AND EXCLUSIONS Excluded means that the plan does not cover these services. The list below describes some services and items that are not covered under any conditions. It also describes some that are excluded only under specific conditions. Personal comfort items Routine physical exams and any related diagnostic, x-ray, and laboratory tests covered by Medicare Eye exams and hearing exams, except as stated in the policy Orthopedic and/or therapeutic shoes or other supporting devices for the feet Routine foot care not covered by Medicare Custodial care, including maintenance care or supportive care Cosmetic surgery, except as stated in the policy 22

Outpatient prescription drugs Professional services not provided by a payable provider, except as required by law Chiropractic care unless covered by Medicare or required by Wisconsin law Routine immunizations, except as eligible under Medicare and except as stated in the policy Preparation, fitting, or purchase of eyeglasses or hearing aids, unless covered by Medicare Dental care, dentures, treatment, filling, removal or replacement of teeth; dental x- rays, root canals, surgery for impacted teeth, or other surgical procedures to the teeth or supporting structures Nursing home care costs beyond what is covered by Medicare and the additional 30 day skilled nursing mandated by s. 632.895 (3), Wis. Stats. If you terminate your Medicare coverage, expenses, which would have been covered by Medicare Your Medicare Part A, unless you purchase the Medicare 100% Part A Rider or the Medicare 50% Part A Rider Your Medicare, unless you purchase the Medicare Rider Physician charges above Medicare s approved charge, unless you purchase the Medicare Excess Charges Rider Home health care beyond 40 visits, unless you purchase the Home Health Care Rider Most healthcare services received outside the U.S., unless you purchase the Foreign Travel Emergency Rider GRIEVANCE AND EXTERNAL REVIEW If you are unhappy with the providing of services, our claim practices, or administration, you have the right to file a written grievance. Your grievance must be in writing, and it should be called a grievance. We will let you know we received your grievance within 5 calendar days. Our Grievance and Appeals Committee will conduct a complete review of your grievance case. You will have a chance to come before the committee to present written or oral information and ask questions. We will inform you of the date and place of the committee meeting at least 7 calendar days in advance. In general, the resolution of your grievance will occur within 30 calendar days after receiving your grievance. However, we may extend this period by 30 more calendar days. If an extension is required, we must get your written or verbal permission prior to taking an extension. We will let you know in writing prior to the expiration of the first 30-day period. You must complete this grievance process before you start any legal action against us or before requesting external review (except in limited circumstances explained in the policy). 23

External Review If you are not happy with the decision of the Grievance and Appeals Committee and your grievance qualifies, you may request an external review. A neutral third party then reviews your case and makes a decision. We will inform you if your grievance qualifies for external review. GENERAL INFORMATION This outline of coverage provides only a general description of benefits, limitations, and exclusions. You can find a more detailed description of coverage in the policy. The policy will be issued to you upon approval for coverage under Gundersen Health Plan. Coverage is subject to all terms and conditions of the policy and all riders. 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. To receive a copy of this handbook, call (800) 633-4227. IMPORTANT: If there s ever a discrepancy between the policy and this outline of coverage, the policy has final authority. 24