Summary of Basic Option Benefits

Medicare Supplement Part A Benefits - Basic Option Monthly Premium $116.84

Benefit Amount Payable

Hospital Confinement

Day of Confinement

1^st to 60^th day Medicare Part A Deductible

61^st to 90^th day Daily Coinsurance Charge (25% of Part A Deductible per day)

Lifetime Reserve Period Daily Coinsurance Charge (50% of Part A Deductible per day)

After Lifetime Reserve Period 100% of Hospital Expenses for an additional 365 days per

Person per lifetime

Skilled Nursing Facility

Day of Confinement

1^st to 20^th Day Nothing

21^st to 100^th Day Daily Coinsurance Charge (12 ½ % of Part A Deductible per day)

101^st to 365^th Day Nothing

Medicare Supplement Part B Benefits – Basic Option

Benefit Amount Payable

Medical Care 20% of Medicare Eligible Expenses after the Medicare Part B Deductible

Additional Medicare Supplement Benefits – Basic Option

Benefit Amount Payable

Hospice Care Medicare Coinsurance Charges for prescription drugs and inpatient respite care

Blood Deductible First 3 pints of blood under Medicare Part A and Medicare Part B

Foreign Medical Treatment 100% of Foreign Medical Treatment expenses up to 90 days; first

expense must be Incurred within first 180 days of Covered Person’s

travel Outside the United States per Calendar Year

In-Hospital Private Duty Nursing Maximum Benefit Amount: Costs up to $30 per 8-hour shift

Maximum Number of Shifts: 60 Shifts per Calendar Year