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padding-left: 5.4pt; } td.s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000126 { vertical-align: top; width: 135pt; border-top: solid #000000 1.0pt; padding-top: 0; border-right: solid #000000 1.0pt; padding-right: 5.4pt; border-bottom: solid #000000 1.0pt; padding-bottom: 0; border-left: solid #000000 1.0pt; padding-left: 5.4pt; } td.s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000127 { vertical-align: top; width: 122.05pt; border-top: solid #000000 1.0pt; padding-top: 0; border-right: solid #000000 1.0pt; padding-right: 5.4pt; border-bottom: solid #000000 1.0pt; padding-bottom: 0; border-left: solid #000000 1.0pt; padding-left: 5.4pt; } td.s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000128 { vertical-align: top; width: 108pt; border-top: solid #000000 1.0pt; padding-top: 0; border-right: solid #000000 1.0pt; padding-right: 5.4pt; border-bottom: solid #000000 1.0pt; padding-bottom: 0; border-left: solid #000000 1.0pt; padding-left: 5.4pt; } span.s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000129 { color: #000000; background: white; font-size: 9pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } </style></head><body><div><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0">DEPARTMENT OF LABOR AND REGULATION</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0">DIVISION OF INSURANCE</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0">OUTLINE OF MEDICARE SUPPLEMENT COVERAGE POLICIES</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0">PLANS A THROUGH N</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0">Chapter </span><a href="https://sdlegislature.gov/Rules?Rule=20:06:13"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000002">20:06:13</span></a></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0">APPENDIX D</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0">SEE: §</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000003"> </span><a href="https://sdlegislature.gov/Rules?Rule=20:06:13:36"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000002">20:06:13:36</span></a></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000004"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0">    </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000005">Source:</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0"> 18 SDR 225, effective July 17, 1992; 23 SDR 236, effective July 13, 1997; 25 SDR 44, effective September 30, 1998; 26 SDR 26, effective September 1, 1999; 27 SDR 53, effective December 4, 2000; 31 SDR 214, effective July 6, 2005; 35 SDR 83, effective February 2, 2009; 36 SDR 209, effective July 1, 2010; 37 SDR 241, effective July 1, 2011; 39 SDR 10, effective August 1, 2012; 41 SDR 41, effective September 17, 2014; 42 SDR 52, effective October 13, 2015</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0">; 42 SDR 177, effective June 28, 2016</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0">; 43 SDR 181, effective July 7, 2017</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0">; 44 SDR 184, effective June 25, 2018; 46 SDR 147, effective July 2, 2020; 47 SDR 137, effective June 28, 2021; 48 SDR 115, effective May 24, 2022; 49 SDR 130, effective July 4, 2023</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0">.</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000007"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000008"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000009">APPENDIX D</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000007"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">[COMPANY NAME]</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000007"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">Outline of Medicare Supplement Coverage-Cover Page:</span></p><div align="left"><table dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000011"><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000012"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000007"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">Benefit Plan(s)________[insert letter(s) of plan(s) being offered]</span></p></td></tr></table></div><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">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.</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000007"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">See Outlines of Coverage sections for details about ALL plans.</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000009">Basic Benefits:</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000013"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000014">·ð</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000009">Hospitalization</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010"> -- Part A coinsurance plus coverage for 365 additional days after Medicare benefits end.</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000013"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000014">·ð</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000009">Medical Expenses</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010"> -- Part B coinsurance (generally 20% of Medicare-approved expenses) or copayments for hospital outpatient services. Plans K, L, and N require insureds to pay a portion of Part B coinsurance or copayments.</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000013"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000014">·ð</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000009">Blood</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010"> -- First three pints of blood each year.</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000013"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000014">·ð</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000009">Hospice</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010"> -- Part A coinsurance.</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><div align="left"><table dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000015"><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000016"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000007"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000009">A</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000017"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000007"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000009">B</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000018"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000009">C</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000018"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000007"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000009">D</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000019"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000007"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000009">F</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000020"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000007"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000009">F*</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000018"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000007"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000009">G</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000021"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000022"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">Basic, including 100% Part B</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000022"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">coinsurance</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000023"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000022"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">Basic,</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000022"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">Including 100% Part </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000022"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">B coinsurance</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000024"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000022"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">Basic, including 100% Part </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000022"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">B coinsurance</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000024"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000022"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">Basic, including 100% Part</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000022"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">B coinsurance</span></p></td><td colspan="2" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000025"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000022"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">Basic, including 100% Part </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000022"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">B coinsurance*</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000026"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000022"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">Basic, including 100% Part </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000022"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">B coinsurance</span></p></td></tr></table></div><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><div align="left"><table dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000015"><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000027"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000028"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">Part A</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">Deductible</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000024"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">Skilled Nursing Facility Coinsurance Part A</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">Deductible Part B</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">Deductible</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">Foreign Travel Emergency</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000024"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">Skilled Nursing Facility Coinsurance Part A</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">Deductible</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">Foreign Travel Emergency</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000025"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">Skilled Nursing Facility Coinsurance Part A</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">Deductible Part B</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">Deductible Part B</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">Excess (100%) Foreign Travel Emergency</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000026"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">Skilled Nursing Facility Coinsurance Part A</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">Deductible</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">Part B </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">Excess (100%) Foreign Travel Emergency</span></p></td></tr></table></div><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000008"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><div align="left"><table dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000015"><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000029"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000007"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000009">K</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000030"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000007"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000009">L</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000031"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000007"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000009">M</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000032"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000007"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000009">N</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000033"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">Hospitalization and</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">preventive care paid</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">at 100%; other basic</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">benefits paid at 50%</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000034"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">Hospitalization and</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">preventive care paid at 100%; other basic benefits paid at 75%</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000035"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">Basic,</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">including</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">100% Part B</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">coinsurance</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000036"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">Basic, </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">including </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">100% Part B</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">coinsurance</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">except up to $20</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">copayment for</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">office visit, and </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">up to $50</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">copayment for </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">ER</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000033"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">50% Skilled</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">Nursing</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">Facility</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">Coinsurance</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">50% Part A</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">Deductible</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000034"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">75% Skilled</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">Nursing</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">Facility</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">Coinsurance</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">75% Part A</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">Deductible</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000035"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">Skilled</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">Nursing</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">Facility</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">Coinsurance</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">50% Part A</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">Deductible</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000036"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">Skilled</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">Nursing</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">Facility</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">Coinsurance</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">Part A</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">Deductible</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000033"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000034"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000035"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000036"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000033"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000034"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000035"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000036"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000033"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000034"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000035"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">Foreign</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">Travel</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">Emergency</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000036"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">Foreign</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">Travel</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">Emergency</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000033"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000034"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000035"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000036"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000033"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">Out-of-pocket limit</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">$[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">6,940</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">];</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">paid at 100%</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">after limit</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">reached</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000034"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">Out-of-pocket limit</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">$[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">3,470</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">]; paid at</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">100% after limit</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">reached</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000035"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000036"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p></td></tr></table></div><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">* Plan F also has an option called a high deductible Plan F. This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">,700</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010"> deductible. Benefits from high deductible Plan F will not begin until out-of-pocket expenses exceed $2</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">,700</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000010">. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan's separate foreign travel emergency deductible.</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000006"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000037"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000008"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000038">PREMIUM INFORMATION</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000039"> [Boldface Type]</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000040"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000040"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000039">We [insert issuer's name] can only raise your premium if we raise the premium for all policies like yours in this State. [If the premium is based on the increasing age of the insured, include information specifying when premiums will change.]</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000040"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000037"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000038">READ YOUR POLICY VERY CAREFULLY</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000039"> [Boldface Type]</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000037"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000040"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000039">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.</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000040"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000037"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000038">RIGHT TO RETURN POLICY</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000039"> [Boldface Type]</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000040"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000040"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000039">If you find that you are not satisfied with your policy, you may return it to [insert issuer's address]. 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.</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000040"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000037"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000038">POLICY REPLACEMENT</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000039"> [Boldface Type]</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000040"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000040"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000039">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.</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000040"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000037"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000038">NOTICE</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000039"> [Boldface Type]</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000040"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000040"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000039">This policy may not fully cover all of your medical costs.</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000040"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000040"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000039">[for agents:]</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000040"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000039">Neither [insert company's name] nor its agents are connected with Medicare.</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000040"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000040"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000039">[for direct response:]</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000040"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000039">[insert company's name] is not connected with Medicare.</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000040"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000040"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000039">This outline of coverage does not give all the details of Medicare coverage. Contact your local Social Security Office or consult "Medicare &amp; You" for more details.</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000040"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000037"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000038">COMPLETE ANSWERS ARE VERY IMPORTANT</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000039"> [Boldface Type]</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000040"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000040"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000039">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. [If the policy or certificate is guaranteed issue, this paragraph need not appear.]</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000040"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000040"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000039">Review the application carefully before you sign it. Be certain that all information has been properly recorded.</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000040"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000040"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000039">[Include for each plan prominently identified in the cover page, a chart showing the services, Medicare payments, plan payments and insured payments for each plan, using the same language, in the same order, using uniform layout and format as shown in the charts below. No more than four plans may be shown on one chart. For purposes of illustration, charts for each plan are included in this chapter. An issuer may use additional benefit plan designations on these charts pursuant to § </span><a href="https://sdlegislature.gov/Rules?Rule=20:06:13:17.05"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000041">20:06:13:17.05</span></a><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000039">.]</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000040"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000040"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000039">[Include an explanation of any innovative benefits on the cover page and in the chart, in a manner approved by the director.]</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000040"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000037"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000008"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000005">Benefit Chart of Medicare Supplement Plans Sold on or after January 1, 2020</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000004"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0">This chart shows the benefits included in each of the standard Medicare supplement plans. Some plans may not be available. Only applicants first eligible for Medicare before 2020 may purchase Plans C, F, and high deductible F.</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0">Note: A </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000042">ü</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0"> means 100% of the benefit is paid.</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><div align="left"><table dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000043"><tr><td rowspan="2" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000044"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000005">Benefits</span></p></td><td colspan="8" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000045"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000005">Plans Available to All Applicants</span></p></td><td colspan="2" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000046"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000047"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000048">Medicare</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000047"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000048">first eligible before 2020 only</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000049"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000005">A</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000050"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000005">B</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000051"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000005">D</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000052"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000005">G</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000005"><sup>1</sup></span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000053"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000005">K</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000054"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000005">L</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000055"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000005">M</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000056"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000005">N</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000057"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000005">C</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000058"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000005">F</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000005"><sup>1</sup></span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000044"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0">Medicare Part A coinsurance and hospital coverage (up to an additional 365 days after Medicare benefits are used up)</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000049"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000042">ü</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000050"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000042">ü</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000051"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000042">ü</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000052"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000042">ü</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000053"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000042">ü</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000054"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000042">ü</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000055"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000042">ü</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000056"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000042">ü</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000059"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000042">ü</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000060"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000042">ü</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000044"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0">Medicare Part B Coinsurance or Copayment</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000049"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000042">ü</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000050"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000042">ü</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000051"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000042">ü</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000052"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000042">ü</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000053"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0">50%</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000054"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0">75%</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000055"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000042">ü</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000056"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000061"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000042">ü</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0">copays apply</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000005"><sup>3</sup></span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000059"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000042">ü</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000060"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000042">ü</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000044"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0">Blood (first three pints)</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000049"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000042">ü</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000050"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000042">ü</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000051"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000042">ü</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000052"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000042">ü</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000053"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000062"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0">50%</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000054"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0">75%</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000055"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000042">ü</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000056"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000042">ü</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000059"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000042">ü</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000060"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000042">ü</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000044"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0">Part A hospice care coinsurance or copayment</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000049"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000042">ü</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000050"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000042">ü</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000051"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000042">ü</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000052"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000042">ü</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000053"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0">50%</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000054"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0">75%</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000055"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000042">ü</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000056"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000042">ü</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000059"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000042">ü</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000060"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000042">ü</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000044"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0">Skilled nursing facility coinsurance</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000049"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000050"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000051"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000042">ü</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000052"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000042">ü</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000053"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0">50%</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000054"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0">75%</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000055"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000042">ü</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000056"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000042">ü</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000059"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000042">ü</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000060"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000042">ü</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000044"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0">Medicare Part A deductible</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000049"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000050"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000042">ü</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000051"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000042">ü</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000052"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000042">ü</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000053"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0">50%</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000054"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0">75%</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000055"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0">50%</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000056"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000042">ü</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000059"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000042">ü</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000060"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000042">ü</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000044"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0">Medicare Part B deductible</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000049"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000050"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000051"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000052"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000053"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000054"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000055"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000056"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000059"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000042">ü</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000060"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000042">ü</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000044"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0">Medicare Part B excess charges</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000049"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000050"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000051"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000052"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000042">ü</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000053"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000054"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000055"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000056"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000059"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000060"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000042">ü</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000044"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0">Foreign travel emergency (up to plan limits)</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000049"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000050"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000051"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0">80%</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000052"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0">80%</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000053"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000054"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000055"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0">80%</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000056"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0">80%</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000059"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0">80%</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000060"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0">80%</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000044"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0">Out-of-pocket limit in [2022]</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000005"><sup>2</sup></span></p></td><td colspan="4" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000063"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000053"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000047"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000064">[$6,940]</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000048"><sup>2</sup></span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000054"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000047"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000048">[$3,470]</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000048"><sup>2</sup></span></p></td><td colspan="4" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000065"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000001"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p></td></tr></table></div><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000066"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000004"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000005"><sup>1</sup></span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0">Plans F and G also have a high deductible option which require first paying a plan deductible of [$2,700] before the plan begins to pay. Once the plan deductible is met, the plan pays 100% of covered services for the rest of the calendar year. High deductible plan G does not cover the Medicare Part B deductible. However, high deductible plans F and G count your payment of the Medicare part B deductible toward meeting the plan deductible.</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000004"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000004"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000005"><sup>2</sup></span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0">Plans K and L pay 100% of covered services for the rest of the calendar year once you meet the out-of-pocket yearly limit.</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000004"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000007"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000005"><sup>3</sup></span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0">Plan N pays 100% of the Part B coinsurance, except for a co-payment of up to $20 for some office visits and up to a $50 co-payment for emergency room visits that do not result in an inpatient admission.</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000008"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000067">PLAN A</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000068"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000069"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000068"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000070">MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000071"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000072"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000071"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000073">* 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.</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><div align="left"><table dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000076"><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000077"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">SERVICES </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000079"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">MEDICARE PAYS </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000080"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">PLAN PAYS </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000081"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">YOU PAY </span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000077"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000083">HOSPITALIZATION* </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">Semiprivate room and board, general nursing and miscellaneous services and supplies </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> First 60 days</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> 61</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"><sup>st</sup></span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> thru 90</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"><sup>th</sup></span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> day</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> 91</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"><sup>st</sup></span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> day and after:</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> --While using 60 lifetime reserve days</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> --Once lifetime reserve days are used:</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> --Additional 365 days</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> --Beyond the additional 365 days</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000079"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">All but $[1</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">,600</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">]</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">All but $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">400</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] a day</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">All but $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">800</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] a day</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000080"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">400</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] a day</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">800</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] a day</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">100% of Medicare eligible expenses</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000081"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$[1</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">,600</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] (Part A deductible)</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0**</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">All costs </span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000077"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000083">SKILLED NURSING FACILITY CARE*</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">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</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> First 20 days</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> 21</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"><sup>st</sup></span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> thru 100</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"><sup>th</sup></span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> day </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> 101</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"><sup>st</sup></span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> day and after</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000079"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">All approved amounts</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">All but $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">200</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] a day</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000080"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000081"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> $0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">Up to $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">200</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] a day</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">All costs </span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000077"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000086"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000083">BLOOD</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000086"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">First 3 pints</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000086"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">Additional amounts</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000086"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000087"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000079"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">100%</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000080"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">3 pints</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000081"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000077"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000083">HOSPICE CARE</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">You must meet Medicare's requirements, including a doctor's certification of terminal illness</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000079"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">All but very limited copayment/coinsurance for out-patient drugs and inpatient respite care</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000080"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">Medicare</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">copayment/coinsurance </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000081"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td></tr></table></div><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000089"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000003">**</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000067">NOTICE:</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000003"> When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's Core Benefits. During this time the hospital is prohibited from billing you for the balance on any difference between its billed charges and the amount Medicare would have paid.</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000068"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000090"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000070">PLAN A</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000068"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000069"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000068"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000070">MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000071"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000069"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000071"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000073">*Once you have been billed $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000073">226</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000073">] 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.</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000086"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><div align="left"><table dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000076"><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">SERVICES </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">MEDICARE PAYS </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">PLAN PAYS </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000094"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">YOU PAY </span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000083">MEDICAL EXPENSES -</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">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,</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> First $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">226</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] of Medicare approved amounts*</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> Remainder of Medicare approved amounts</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">Generally 80%</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">Generally 20% </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000094"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">226</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] (Part B deductible)</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000083">Part B Excess Charges</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> (Above Medicare Approved Amounts)</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000087"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000094"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">All costs</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000083">BLOOD</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">First 3 pints</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">Next $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">226</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] of Medicare approved amounts*</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">Remainder of Medicare approved amounts </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">80% </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">All costs </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">20% </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000094"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">226</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] (Part B deductible)</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000083">CLINICAL LABORATORY SERVICES </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">--TESTS FOR</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">DIAGNOSTIC SERVICES </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">100% </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000094"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p></td></tr></table></div><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000095"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000096"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000068"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000070">PARTS A &amp; B</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000086"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><div align="left"><table dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000076"><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000097"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">SERVICES</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">MEDICARE PAYS</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">PLAN PAYS</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000094"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">YOU PAY</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000083">HOME HEALTH CARE</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">MEDICARE APPROVED SERVICES </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">---Medically necessary skilled care </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">services and medical supplies</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">---Durable medical equipment</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> First $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">226</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] of Medicare approved amounts* </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> Remainder of Medicare approved amounts </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">100%</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">80%</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">20%</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000094"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">226]</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> (Part B deductible)</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p></td></tr></table></div><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000068"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000090"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000070">PLAN B</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000068"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000069"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000068"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000070">MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000071"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000072"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000071"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000073">*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.</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000086"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><div align="left"><table dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000076"><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">SERVICES </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">MEDICARE PAYS </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">PLAN PAYS </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000094"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">YOU PAY </span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000083">HOSPITALIZATION*</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">Semiprivate room and board, general nursing and miscellaneous services and supplies</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> First 60 days</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> 61</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"><sup>st</sup></span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> thru 90</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"><sup>th</sup></span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> day</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> 91</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"><sup>st</sup></span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> day and after:</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> --While using 60 lifetime reserve days</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> --Once lifetime reserve days are used:</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> --Additional 365 days</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> --Beyond the additional 365 days</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">All but $[1</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">,600</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">]</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">All but $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">400</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] a day </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">All but $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">800</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] a day </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$[1</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">,600</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">](Part A deductible) </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">400</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] a day </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">800</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] a day </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">100% of Medicare eligible expenses </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000094"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0**</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">All costs </span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000083">SKILLED NURSING FACILITY CARE*</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">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</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> First 20 days</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> 21</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"><sup>st</sup></span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> thru 100</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"><sup>th</sup></span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> day</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> 101</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"><sup>st</sup></span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> day and after</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">All approved amounts </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">All but $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">200</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] a day</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000094"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">Up to $</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">[200</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] a day</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">All costs </span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000083">BLOOD</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">First 3 pints</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">Additional amounts </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">100% </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">3 pints</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000094"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000083">HOSPICE CARE</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">You must meet Medicare's requirements including a doctor's certification of terminal illness. </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">All but very limited copayment/coinsurance for out-patient drugs and inpatient respite care</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">Medicare copayment/coinsurance </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000094"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p></td></tr></table></div><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000086"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000071"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000073">** </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000070">NOTICE:</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000073"> When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's Core Benefits. During this time the hospital is prohibited from billing you for the balance on any difference between its billed charges and the amount Medicare would have paid.</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000068"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000090"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000070">PLAN B</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000068"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000069"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000068"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000070">MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000071"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000072"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000071"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000073">*Once you have been billed $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000073">226</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000073">] 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.</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000086"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><div align="left"><table dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000076"><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">SERVICES </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">MEDICARE PAYS </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">PLAN PAYS </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000094"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">YOU PAY </span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000083">MEDICAL EXPENSES -</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">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,</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> First $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">226</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] of Medicare approved amounts*</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> Remainder of Medicare approved amounts</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">Generally 80% </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">Generally 20% </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000094"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">226</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] (Part B deductible)</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000083">Part B Excess Charges</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> (Above Medicare Approved Amounts</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000094"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">All costs</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000083">BLOOD</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">First 3 pints</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">Next $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">226</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] of Medicare approved amounts*</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">Remainder of Medicare approved amounts </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">80% </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">All costs </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">20% </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000094"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">226</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] (Part B deductible)</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000086"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000083">CLINICAL LABORATORY</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000086"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000083">SERVICES --</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">TESTS FOR</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000086"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">DIAGNOSTIC SERVICES </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000086"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">100% </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000094"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p></td></tr></table></div><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000086"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000068"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000070">PARTS A &amp; B</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000086"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><div align="left"><table dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000076"><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000097"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">SERVICES</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000098"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">MEDICARE PAYS</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">PLAN PAYS</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000099"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">YOU PAY</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000083">HOME HEALTH CARE</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">MEDICARE APPROVED SERVICES </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">---Medically necessary skilled care </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> services and medical supplies</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">---Durable medical equipment</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> First $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">226</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] of Medicare approved</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">amounts* </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> Remainder of Medicare approved</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">amounts </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000098"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">100%</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">80%</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">20%</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000099"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">226</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] (Part B deductible)</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p></td></tr></table></div><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000086"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000068"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000090"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000070">PLAN C</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000068"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000069"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000068"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000070">MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000071"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000072"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000071"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000073">*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.</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000086"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><div align="left"><table dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000076"><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">SERVICES </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">MEDICARE PAYS </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">PLAN PAYS </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000094"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">YOU PAY </span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000083">HOSPITALIZATION*</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">Semiprivate room and board, general nursing and miscellaneous services and supplies</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> First 60 days</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> 61</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"><sup>st</sup></span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> thru 90</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"><sup>th</sup></span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> day</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> 91</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"><sup>st</sup></span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> day and after:</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> --While using 60 lifetime reserve days</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> --Once lifetime reserve days are used:</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> --Additional 365 days</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> --Beyond the additional 365 days </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">All but $[1</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">,600</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">]</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">All but $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">400</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] a day </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">All but $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">800</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] a day </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$[1</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">,600</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">](Part A deductible)</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">400</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">]</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> a</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> day </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">800</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">]</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> a</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> day </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">100% of Medicare eligible expenses </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000094"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0**</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">All costs </span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000083">SKILLED NURSING FACILITY CARE*</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">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</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> First 20 days</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> 21</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"><sup>st</sup></span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> thru 100</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"><sup>th</sup></span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> day</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> 101</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"><sup>st</sup></span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> day and after </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">All approved amounts </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">All but $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">200</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] a day</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">Up to $ [</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">200</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] a day</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000094"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">All costs </span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000083">BLOOD</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">First 3 pints</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">Additional amounts </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">100% </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">3 pints</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000094"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000083">HOSPICE CARE</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">You must meet Medicare's requirements, including a doctor's certification of terminal illness </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">All but very limited copayment/coinsurance for out-patient drugs and inpatient respite care</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">Medicare copayment/coinsurance</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000094"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p></td></tr></table></div><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000100"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000101"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000003">**</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000067">NOTICE:</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000003"> When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's Core Benefits. During this time the hospital is prohibited from billing you for the balance on any difference between its billed charges and the amount Medicare would have paid.</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000101"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000072"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000068"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000090"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000070">PLAN C</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000068"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000069"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000068"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000070">MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000071"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000072"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000071"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000073">*Once you have been billed $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000073">226</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000073">] 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.</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000086"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><div align="left"><table dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000076"><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">SERVICES </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">MEDICARE PAYS </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">PLAN PAYS </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000094"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">YOU PAY </span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000083">MEDICAL EXPENSES -</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">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,</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> First $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">226</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] of Medicare approved amounts*</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> Remainder of Medicare approved amounts</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">Generally 80% </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">226</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] (Part B deductible)</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">Generally 20% </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000094"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000083">Part B Excess Charges (</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">Above Medicare Approved Amounts)</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000087"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000094"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">All costs</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000083">BLOOD</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">First 3 pints</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">Next $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">226</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] of Medicare approved amounts*</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">Remainder of Medicare approved amounts </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">80% </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">All costs </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">226</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] (Part B deductible)</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">20% </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000094"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000083">CLINICAL LABORATORY SERVICES </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">--TESTS FOR</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">DIAGNOSTIC SERVICES </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">100% </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000094"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p></td></tr></table></div><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000095"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000096"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000068"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000070">PARTS A &amp; B</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000086"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><div align="left"><table dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000076"><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000097"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">SERVICES</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000098"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">MEDICARE PAYS</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">PLAN PAYS</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000099"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">YOU PAY</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000083">HOME HEALTH CARE</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">MEDICARE APPROVED SERVICES </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">---Medically necessary skilled care services and medical supplies</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">---Durable medical equipment</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> First $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">226</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] of Medicare approved </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> amounts*</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> Remainder of Medicare approved</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> amounts </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000098"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">100%</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">80%</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">226</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] (Part B deductible)</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">20%</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000099"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p></td></tr></table></div><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000068"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000070">OTHER BENEFITS - NOT COVERED BY MEDICARE</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000071"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000072"> </span></p><div align="left"><table dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000076"><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">SERVICES </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000098"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">MEDICARE PAYS </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000102"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">PLAN PAYS </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000103"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">YOU PAY </span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000083">FOREIGN TRAVEL -</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> First $250 each calendar year </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> Remainder of charges </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000098"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000102"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">80% to a lifetime maximum benefit of $50,000 </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000103"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$250</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">20% and amounts over the $50,000 life-time maximum </span></p></td></tr></table></div><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000087"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000068"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000104"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000070">PLAN D</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000068"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000069"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000068"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000070">MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000071"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000072"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000071"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000073">*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.</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000086"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><div align="left"><table dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000076"><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">SERVICES </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">MEDICARE PAYS </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">PLAN PAYS </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000094"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">YOU PAY </span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000083">HOSPITALIZATION*</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">Semiprivate room and board, general nursing and miscellaneous services and supplies</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> First 60 days</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> 61</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"><sup>st</sup></span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> thru 90</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"><sup>th</sup></span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> day</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> 91</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"><sup>st</sup></span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> day and after:</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> --While using 60 lifetime reserve days</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> --Once lifetime reserve days are used:</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> --Additional 365 days</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> --Beyond the additional 365 days</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">All but $[1</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">,600</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">]</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">All but $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">400</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] a day </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">All but $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">800</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] a day </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$[1</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">,600</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">](Part A deductible)</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">400</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] a day </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">800</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] a day </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">100% of Medicare eligible expenses </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000094"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0**</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">All costs </span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000083">SKILLED NURSING FACILITY CARE*</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">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</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> First 20 days</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> 21</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"><sup>st</sup></span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> thru 100</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"><sup>th</sup></span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> day</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> 101</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"><sup>st</sup></span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> day and after</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">All approved amounts </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">All but $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">200</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> a day</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">Up to $ [</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">200</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] a day</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000094"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">All costs </span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000083">BLOOD</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">First 3 pints</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">Additional amounts</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">100% </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">3 pints</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000094"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000083">HOSPICE CARE</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">You must meet Medicare's requirements including a doctor's certification of terminal illness</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">All but very limited copayment/coinsurance for out-patient drugs and inpatient respite care</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">Medicare copayment/coinsurance</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000094"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p></td></tr></table></div><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000100"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000101"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000003">**</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000067">NOTICE:</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000003"> When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's Core Benefits. During this time the hospital is prohibited from billing you for the balance on any difference between its billed charges and the amount Medicare would have paid.</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000101"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000072"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000101"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000072"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000068"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000090"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000070">PLAN D</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000068"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000069"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000068"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000070">MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000071"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000072"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000071"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000073">*Once you have been billed $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000073">226</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000073">] 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.</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000086"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><div align="left"><table dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000076"><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">SERVICES </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">MEDICARE PAYS </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">PLAN PAYS </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000094"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">YOU PAY </span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000083">MEDICAL EXPENSES -</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">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,</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> First $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">226</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] of Medicare approved amounts*</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> Remainder of Medicare approved amounts</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">Generally 80% </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">Generally 20% </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000094"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">226</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] (Part B deductible)</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000083">Part B Excess Charges </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">(Above Medicare Approved Amounts)</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000087"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000094"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">All costs</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000083">BLOOD</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">First 3 pints</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">Next $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">226</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] of Medicare approved amounts*</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">Remainder of Medicare approved amounts</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">80% </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">All costs </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">20% </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000094"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">226</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] (Part B deductible)</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000083">CLINICAL LABORATORY SERVICES </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">--TESTS FOR</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">DIAGNOSTIC SERVICES</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">100% </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000094"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p></td></tr></table></div><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000068"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000070">PARTS A &amp; B</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000071"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000069"> </span></p><div align="left"><table dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000076"><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">SERVICES </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000105"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">MEDICARE PAYS </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000106"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">PLAN PAYS </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000107"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">YOU PAY </span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000083">HOME HEALTH CARE</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">MEDICARE APPROVED SERVICES</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> ---Medically necessary skilled care services and medical supplies</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> ---Durable medical equipment</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> First $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">226</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] of Medicare approved amounts*</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> Remainder of Medicare approved amounts</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000105"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">100% </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">80% </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000106"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">20%</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000107"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">226</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] (Part B deductible)</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td></tr></table></div><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000087"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000068"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000070">OTHER BENEFITS - NOT COVERED BY MEDICARE</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000086"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><div align="left"><table dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000076"><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">SERVICES</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000105"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">MEDICARE PAYS</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000106"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">PLAN PAYS</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000107"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">YOU PAY</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000083">FOREIGN TRAVEL -</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000083">NOT COVERED BY MEDICARE</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> First $250 each calendar year </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> Remainder of charges </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000105"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000106"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">80% to a lifetime maximum benefit of $50,000 </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000107"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$250</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">20% and amounts over the $50,000 life-time maximum</span></p></td></tr></table></div><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000108"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000072"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000068"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000090"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000070">PLAN F or HIGH DEDUCTIBLE PLAN F</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000068"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000069"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000068"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000070">MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000071"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000072"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000071"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000073">*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.</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000071"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000073">**This high deductible plan pays the same benefits as Plan F after </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000073">you have</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000073"> paid a calendar year $[2</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000073">,700</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000073">] deductible. Benefits from the high deductible </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000073">P</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000073">lan F will not begin until out-of-pocket expenses are $[2</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000073">,700</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000073">]. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include the plan's separate foreign travel emergency deductible.</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000071"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000072"> </span></p><div align="left"><table dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000076"><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">SERVICES </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">MEDICARE PAYS </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">[AFTER YOU PAY</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$[2</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">,700</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">]</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">DEDUCTIBLE,**</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">PLAN PAYS] </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000094"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">[IN ADDITION TO</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$[2</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">,700</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">]</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">DEDUCTIBLE,**</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">YOU PAY] </span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000083">HOSPITALIZATION*</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">Semiprivate room and board, general nursing and miscellaneous services and supplies</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> First 60 days</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> 61</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"><sup>st</sup></span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> thru 90</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"><sup>th</sup></span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> day</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> 91</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"><sup>st</sup></span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> day and after:</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> --While using 60 lifetime reserve days</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> --Once lifetime reserve days are used:</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> --Additional 365 days</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> --Beyond the additional 365 days</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">All but $[1</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">,600</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">]</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">All but $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">400</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] a day </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">All but $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">800</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] a day </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$[1</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">,600</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">](Part A deductible) $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">400</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] a day </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">800</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] a day </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">100% of Medicare eligible expenses </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000094"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0***</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">All costs </span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000083">SKILLED NURSING FACILITY CARE*</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">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</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> First 20 days</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> 21</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"><sup>st</sup></span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> thru 100</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"><sup>th</sup></span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> day</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> 101</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"><sup>st</sup></span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> day and after</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">All approved amounts </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">All but $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">200</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] a day</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">Up to $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">200</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] a day</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000094"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">All costs </span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000083">BLOOD</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">First 3 pints</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">Additional amounts</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">100% </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">3 pints</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000094"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000083">HOSPICE CARE</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">You must meet Medicare's requirements, including a doctor's certification of terminal illness</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">All but very limited copayment/coinsurance for out-patient drugs and inpatient respite care</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">Medicare copayment/coinsurance</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000094"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p></td></tr></table></div><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000100"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000101"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000003">**</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000067">NOTICE:</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000003"> When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's Core Benefits. During this time the hospital is prohibited from billing you for the balance on any difference between its billed charges and the amount Medicare would have paid.</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000101"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000072"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000068"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000090"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000070">PLAN F or HIGH DEDUCTIBLE PLAN F</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000068"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000069"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000068"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000070">MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000071"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000072"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000071"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000073">*Once you have been billed $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000073">226</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000073">] 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.</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000071"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000073">**This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $[2</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000073">,700</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000073">] deductible. Benefits from the high deductible </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000073">P</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000073">lan F will not begin until out-of-pocket expenses are $[2</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000073">,700</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000073">]. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductibles for Part A and Part B, but does not include the plan's separate foreign travel emergency deductible.</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000071"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000072"> </span></p><div align="left"><table dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000076"><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">SERVICES </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">MEDICARE PAYS </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">[AFTER YOU PAY</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$[2</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">,700</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">]</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">DEDUCTIBLE,**</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">PLAN PAYS] </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000094"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">[IN ADDITION TO</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$[2</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">,700</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">]</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">DEDUCTIBLE,**</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">YOU PAY]</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000083">MEDICAL EXPENSES -</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">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,</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> First $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">226</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] of Medicare approved amounts*</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> Remainder of Medicare approved amounts</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">Generally 80% </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">226</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] (Part B deductible) </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">Generally 20% </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000094"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000083">Part B Excess Charges</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> (Above Medicare Approved Amounts)</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">100%</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000094"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000083">BLOOD</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">First 3 pints</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">Next $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">226</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] of Medicare approved amounts*</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">Remainder of Medicare approved amounts</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">80% </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">All costs </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">226</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] (Part B deductible)</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">20% </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000094"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000083">CLINICAL LABORATORY SERVICES --</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">TESTS FOR</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">DIAGNOSTIC SERVICES</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">100% </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000094"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p></td></tr></table></div><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000095"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000096"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000068"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000070">PARTS A &amp; B</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000086"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000087"> </span></p><div align="left"><table dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000076"><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000097"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">SERVICES</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000098"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">MEDICARE PAYS</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000109"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">[AFTER YOU PAY $[2</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">,700</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] DEDUCTIBLE,**] PLAN PAYS</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000109"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">[IN ADDITION TO $[2</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">,700</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">]</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">DEDUCTIBLE,**] YOU PAY'</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000083">HOME HEALTH CARE</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">MEDICARE APPROVED SERVICES </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> --Medically necessary skilled care </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">services and medical supplies</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> ---Durable medical equipment</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> ---First $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">226</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] of Medicare approved </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">amounts* </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> Remainder of Medicare approved</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">amounts </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000098"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">100% </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">80% </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000109"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">226</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] (Part B deductible)</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">20% </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000109"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p></td></tr></table></div><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000110"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000073">(continued)</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000068"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000072"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000068"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000090"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000070">PLAN F or HIGH DEDUCTIBLE PLAN F (continued)</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000068"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000069"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000068"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000070">OTHER BENEFITS - NOT COVERED BY MEDICARE</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000071"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000072"> </span></p><div align="left"><table dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000076"><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">SERVICES </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000098"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">MEDICARE PAYS </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000102"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">[AFTER YOU PAY</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$[2</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">,700</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">]</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">DEDUCTIBLE,**]</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">PLAN PAYS </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000103"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">[IN ADDITION TO</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$[2</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">,700</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">]</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">DEDUCTIBLE,**]</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">YOU PAY </span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000083">FOREIGN TRAVEL -</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000083">NOT COVERED BY MEDICARE</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> First $250 each calendar year </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> Remainder of charges </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000098"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000102"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">80% to a lifetime maximum benefit of $50,000 </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000103"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$250</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">20% and amounts over the $50,000 life-time maximum </span></p></td></tr></table></div><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000111"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000096"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000068"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000090"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000070">PLAN G</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000070"> or HIGH DEDUCTIBLE PLAN G</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000068"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000069"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000068"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000070">MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000071"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000072"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000071"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000073">*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.</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000071"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000073">[**This high deductible plan pays the same benefits as Plan G after you have paid a calendar year [$2,700] deductible. Benefits from the high deductible Plan G will not begin until out-of-pocket expenses are [$2,700]. Out-of-pocket expenses for this deductible include expenses for the Medicare Part B deductible, and expenses that would ordinarily be paid by the policy. This does not include the plan's separate foreign travel emergency deductible.]</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000086"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><div align="left"><table dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000076"><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">SERVICES </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">MEDICARE PAYS </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">[AFTER YOU PAY $[2,700] DEDUCTIBLE,**]</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">PLAN PAYS </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000112"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">[IN ADDITION TO $[2,700]</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">DEDUCTIBLE,**]</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">YOU PAY </span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000083">HOSPITALIZATION*</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">Semiprivate room and board, general nursing and miscellaneous services and supplies</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> First 60 days</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> 61st thru 90</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"><sup>th</sup></span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> day</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> 91</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"><sup>st</sup></span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> day and after:</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> --While using 60 lifetime reserve days</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> --Once lifetime reserve days are used:</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> --Additional 365 days</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> --Beyond the additional 365 days </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">All but $[1</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">,600</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">]</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">All but $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">400</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] a day </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">All but $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">800</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] a day </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$[1</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">,600</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">](Part A deductible) $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">400</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] a day </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">800</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] a day </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">100% of Medicare eligible expenses </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000112"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0**</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">All costs </span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000083">SKILLED NURSING FACILITY CARE*</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">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</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> First 20 days</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> 21</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"><sup>st</sup></span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> thru 100</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"><sup>th</sup></span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> day</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> 101th day and after </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">All approved amounts </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">All but $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">200</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] a day</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> $0 </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">Up to $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">200</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] a day</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000112"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">All costs </span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000083">BLOOD</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">First 3 pints</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">Additional amounts </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">100% </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">3 pints</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000112"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000083">HOSPICE CARE</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">You must meet Medicare's requirements, including a doctor's certification of terminal illness </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">All but very limited copayment/coinsurance for out-patient drugs and inpatient respite care</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">Medicare copayment/coinsurance</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000112"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p></td></tr></table></div><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000100"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000101"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000003">**</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000067">NOTICE:</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000003"> When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's Core Benefits. During this time the hospital is prohibited from billing you for the balance on any difference between its billed charges and the amount Medicare would have paid.</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000101"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000072"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000068"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000090"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000070">PLAN G</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000070"> or HIGH DEDUCTIBLE PLAN G</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000068"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000069"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000068"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000070">MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000071"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000072"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000071"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000073">*Once you have been billed $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000073">226</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000073">] 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.</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000071"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000073">[**This high deductible plan pays the same benefits as Plan G after you have paid a calendar year [$2,700] deductible. Benefits from the high deductible Plan G will not begin until out-of-pocket expenses are [$2,700]. Out-of-pocket expenses for this deductible include expenses for the Medicare Part B deductible, and expenses that would ordinarily be paid by the policy. This does not include the plan's separate foreign travel emergency deductible.]</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000086"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><div align="left"><table dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000076"><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">SERVICES </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000105"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">MEDICARE PAYS </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000106"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">[AFTER YOU PAY $[2,700] DEDUCTIBLE,**]</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">PLAN PAYS </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000107"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">[IN ADDITION TO $[2,700] DEDUCTIBLE,**]</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">YOU PAY </span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000083">MEDICAL EXPENSES -</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">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,</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> First $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">226</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] of Medicare approved amounts*</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> Remainder of Medicare approved amounts</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000105"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">Generally 80% </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000106"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">Generally 20% </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000107"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">226</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] (</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">Unless </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">Part B deductible</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> has been met</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">)</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000083">Part B Excess Charges</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> (Above Medicare Approved Amounts)</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000105"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000106"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">100%</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000107"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">0%</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000083">BLOOD</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">First 3 pints</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">Next $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">226]</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> of Medicare approved amounts*</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">Remainder of Medicare approved amounts </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000082"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000105"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">80% </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000106"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">All costs </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">20% </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000107"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">226</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] (</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">Unless </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">Part B deductible</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> has been met</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">)</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000086"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000083">CLINICAL LABORATORY </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000086"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000083">SERVICES --</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">TESTS FOR</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000086"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">DIAGNOSTIC SERVICES </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000086"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000105"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">100% </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000106"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000107"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p></td></tr></table></div><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000113"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000096"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000068"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000070">PARTS A &amp; B</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000071"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000069"> </span></p><div align="left"><table dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000076"><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">SERVICES </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000105"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">MEDICARE PAYS </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000106"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">[AFTER YOU PAY $[2,700] DEDUCTIBLE,**]</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">PLAN PAYS </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000107"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">[IN ADDITION TO $[2,700] DEDUCTIBLE,**]</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">YOU PAY</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000083">HOME HEALTH CARE</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">MEDICARE APPROVED SERVICES</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> ---Medically necessary skilled care services and medical supplies</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> ---Durable medical equipment</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> First $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">226</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] of Medicare approved amounts*</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> Remainder of Medicare approved amounts </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000105"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">100% </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">80% </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000106"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">20% </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000107"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">226</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">] (</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">Unless </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">Part B deductible</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> has been met</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">)</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p></td></tr></table></div><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000068"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000104"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000069"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000068"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000070">OTHER BENEFITS - NOT COVERED BY MEDICARE</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000086"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><div align="left"><table dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000076"><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">SERVICES</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000105"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">MEDICARE PAYS</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000106"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">[AFTER YOU PAY $[2,700] DEDUCTIBLE,**] </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">PLAN PAYS</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000107"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">[IN ADDITION TO $[2,700] DEDUCTIBLE,**]</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000074"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">YOU PAY</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000091"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000083">FOREIGN TRAVEL -</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000083">NOT COVERED BY MEDICARE</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> First $250 each calendar year </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078"> Remainder of charges </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000105"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0 </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000106"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000085"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">80% to a lifetime maximum benefit of $50,000 </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000107"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">$250</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000084"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000078">20% and amounts over the $50,000 life-time maximum</span></p></td></tr></table></div><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000100"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000108"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000090"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000067">PLAN K</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000101"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000072"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000101"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000003">*You will pay half the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000003">6,940</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000003">] each calendar year. The amounts that count toward your annual limit are noted with diamonds(f&) in the chart below. Once you reach the annual limit, the plan pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year.</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000067"> However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called "Excess Charges") and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for that item or service.</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000089"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000072"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000108"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000067">MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000108"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000072"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000101"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000003">**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.</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000101"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000072"> </span></p><div align="left"><table dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000114"><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000115"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000116"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">SERVICES</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000118"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000116"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">MEDICARE PAYS</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000116"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">PLAN PAYS</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000116"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">YOU PAY*</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000115"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000119">HOSPITALIZATION</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">**</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">Semiprivate room and board, general nursing and miscellaneous services and supplies</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> First 60 days</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> 61</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"><sup>st</sup></span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> thru 90</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"><sup>th</sup></span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> day</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> 91</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"><sup>st</sup></span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> day and after:</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> --While using 60 lifetime reserve days</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> --Once lifetime reserve days are used:</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> --Additional 365 days</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> --Beyond the additional 365 days</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000118"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">All but $[1</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">,600</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">]</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">All but $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">400</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">] a day</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">All but $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">800</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">] a day</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">800</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">] (50% of Part A deductible)</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">400</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">] a day</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">800</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">] a day</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">100% of Medicare eligible expenses</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">800</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">] (50% of Part A deductible)f&</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0***</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">All costs</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000115"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000119">SKILLED NURSING FACILITY CARE**</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">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</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> First 20 days</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> 21</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"><sup>st</sup></span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> thru 100</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"><sup>th</sup></span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> day</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> 101</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"><sup>st</sup></span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> day and after</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000118"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">All approved amounts</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">All but $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">200</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">] a day</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">Up to $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">100</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">] a day (50% of Part A coinsurance)</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">Up to $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">100</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">] a day (50% of Part A coinsurance)f&</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">All costs</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000115"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000119">BLOOD</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">First 3 pint</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000119">s</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">Additional amounts</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000087"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000118"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">100%</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">50%</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">50%f&</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000115"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000119">HOSPICE CARE</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">You must meet Medicare's requirements, including a doctor's certification of terminal illness</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000087"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000118"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">50% of coinsurance/copayment</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">50% of Medicare copayment/coinsurancef&</span></p></td></tr></table></div><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000101"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000003">***</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000067">NOTICE:</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000003"> When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's Core Benefits. During this time the hospital is prohibited from billing you for the balance on any difference between its billed charges and the amount Medicare would have paid.</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000089"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000072"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000108"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000090"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000067">PLAN K</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000108"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000069"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000108"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000067">MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000089"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000072"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000101"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000003">****Once you have been billed $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000003">226</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000003">] 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.</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000089"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000072"> </span></p><div align="left"><table dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000114"><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000120"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000116"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">SERVICES</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000121"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000116"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">MEDICARE PAYS</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000030"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000116"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">PLAN PAYS</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000080"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000116"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">YOU PAY*</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000120"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000119">MEDICAL EXPENSES</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> -</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">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</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> First $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">226</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">] of Medicare approved amounts****</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> Preventative Benefits for Medicare covered services</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> Remainder of Medicare approved amounts</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000121"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">Generally 80% or more of Medicare approved amounts</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">Generally 80%</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000030"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">Remainder of Medicare approved amounts</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">Generally 10%</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000080"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">226</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">] (Part B deductible)****f&</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">All costs above Medicare approved amounts</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">Generally 10%</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000120"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000119">Part B Excess Charges</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> (Above Medicare Approved Amounts)</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000121"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000030"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">0%</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000080"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">All costs (and they do not count toward annual out-of-pocket limit of $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">6,940</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">])*</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000120"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000119">BLOOD</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">First 3 pints</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">Next $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">226</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">] of Medicare approved amounts****</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">Remainder of Medicare approved amounts</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000087"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000121"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">Generally 80%</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000030"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">50%</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">Generally 10%</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000080"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$50%f&</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">226</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">] (Part B deductible)****f&</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">Generally 10%f&</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000120"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000119">CLINICAL LABORATORY SERVICES</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">--TESTS FOR DIAGNOSTIC SERVICES</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000087"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000121"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">100%</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000030"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000080"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td></tr></table></div><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000111"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000096"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000101"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000003">*This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000003">6,940</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000003">] per year. </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000067">However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called "Excess Charges") and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000089"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000072"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000108"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000067">PARTS A &amp; B</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000089"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000072"> </span></p><div align="left"><table dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000114"><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000077"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000116"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">SERVICES</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000030"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000116"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">MEDICARE PAYS</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000122"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000116"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">PLAN PAYS</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000123"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000116"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">YOU PAY</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000077"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000119">HOME HEALTH CARE</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">MEDICARE APPROVED SERVICES</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> --Medically necessary skilled care services and medical supplies</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> --Durable medical equipment</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> First $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">226</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">] of Medicare approved amounts *****</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> Remainder of Medicare approved amounts</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000030"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">100%</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">80%</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000122"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">10%</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000123"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">226</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">] (Part B deductible)f&</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">10%f&</span></p></td></tr></table></div><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000101"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000003">*****Medicare benefits are subject to change. Please consult the latest</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000124"> Guide to Health Insurance for People with Medicare.</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000089"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000072"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000108"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000090"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000067">PLAN L</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000101"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000072"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000101"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000003">*You will pay one-fourth of the cost-sharing of some covered services until you reach the annual out-of-pocket limit of $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000003">3,470</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000003">] each calendar year. The amounts that count toward your annual limit are noted with diamonds (f&) in the chart below. Once you reach the annual limit, the plan pays 100% of your Medicare copayment and coinsurance for the rest of the calendar year. </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000067">However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called "Excess Charges") and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for that item or service.</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000101"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000072"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000108"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000067">MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000101"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000072"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000101"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000003">**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.</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000089"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000072"> </span></p><div align="left"><table dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000114"><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000115"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000116"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">SERVICES</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000125"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000116"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">MEDICARE PAYS</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000116"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">PLAN PAYS</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000115"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000116"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">YOU PAY*</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000115"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000119">HOSPITALIZATION</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">**</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">Semiprivate room and board, general nursing and miscellaneous services and supplies</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> First 60 days</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> 61</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"><sup>st</sup></span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> thru 90</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"><sup>th</sup></span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> day</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> 91</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"><sup>st</sup></span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> day and after:</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> --While using 60 lifetime reserve days</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> --Once lifetime reserve days are used:</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> --Additional 365 days</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> --Beyond the additional 365 days</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000125"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">All but $[1</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">,600</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">]</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">All but $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">400</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">] a day</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">All but $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">800</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">] a day</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">1,200</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">] (75% of Part A deductible)</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">400</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">] a day</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">800]</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> a day</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">100% of Medicare eligible expenses</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000115"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">400</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">] (25% of Part A deductible)f&</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0***</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">All costs</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000115"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000119">SKILLED NURSING FACILITY CARE**</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">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</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> First 20 days</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> 21</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"><sup>st</sup></span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> thru 100</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"><sup>th</sup></span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> day</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> 101</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"><sup>st</sup></span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> day and after</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000125"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">All approved amounts</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">All but $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">200</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">] a day</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">Up to $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">150</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">] a day (75% of Part A Coinsurance)</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000115"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">Up to $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">50</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">] a day (25% of Part A Coinsurance)f&</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">All costs</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000115"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000119">BLOOD</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">First 3 pint</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000119">s</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">Additional amounts</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000087"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000125"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">100%</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">75%</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000115"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">25%f&</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000115"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000119">HOSPICE CARE</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">You must meet Medicare's requirements including a doctor's certification of terminal illness</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000087"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000125"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">75% of copayment/coinsurance</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000115"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">25% of copayment/coinsurance f&</span></p></td></tr></table></div><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000111"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000096"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000101"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000003">***</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000067">NOTICE:</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000003"> When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's Core Benefits. During this time the hospital is prohibited from billing you for the balance on any difference between its billed charges and the amount Medicare would have paid.</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000089"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000072"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000089"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000072"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000108"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000090"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000067">PLAN L</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000108"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000069"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000108"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000067">MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000089"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000072"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000101"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000003">****Once you have been billed $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000003">226</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000003">] 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.</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000089"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000072"> </span></p><div align="left"><table dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000114"><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000120"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000116"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">SERVICES</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000116"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">MEDICARE PAYS</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000116"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">PLAN PAYS</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000030"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000116"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">YOU PAY*</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000120"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000119">MEDICAL EXPENSES</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> - 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</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> First $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">226</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">] of Medicare approved amounts****</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> Preventative Benefits for Medicare covered services</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> Remainder of Medicare approved amounts</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">Generally 80% or more of Medicare approved amounts</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">Generally 80%</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">Remainder of Medicare approved amounts</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">Generally 15%</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000030"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">226</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">] (Part B deductible)****f&</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">All costs above Medicare approved amounts</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">Generally 5%f&</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000120"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000119">Part B Excess Charges</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> (Above Medicare Approved Amounts)</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000030"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">All costs (and they do not count toward annual out-of-pocket limit of $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">3,470</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">])*</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000120"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000119">BLOOD</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">First 3 pints</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">Next $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">226</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">] of Medicare approved amounts****</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">Remainder of Medicare approved amounts</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000087"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">Generally 80%</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">75%</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">Generally 15%</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000030"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$25%</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">226</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">] (Part B deductible)****f&</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">Generally 5%f&</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000120"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000119">CLINICAL LABORATORY SERVICES</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">--TESTS FOR DIAGNOSTIC SERVICES</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000087"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">100%</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000030"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td></tr></table></div><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000101"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000003">*This plan limits your annual out-of-pocket payments for Medicare-approved amounts to $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000003">3,470</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000003">] per year. </span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000067">However, this limit does NOT include charges from your provider that exceed Medicare-approved amounts (these are called "Excess Charges") and you will be responsible for paying this difference in the amount charged by your provider and the amount paid by Medicare for the item or service.</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000089"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000072"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000108"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000067">PARTS A &amp; B</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000089"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000072"> </span></p><div align="left"><table dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000114"><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000077"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000116"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">SERVICES</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000030"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000116"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">MEDICARE PAYS</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000122"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000116"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">PLAN PAYS</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000123"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000116"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">YOU PAY</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000077"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000119">HOME HEALTH CARE</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">MEDICARE APPROVED SERVICES</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> --Medically necessary skilled care services and medical supplies</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> --Durable medical equipment</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> First $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">226</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">] of Medicare approved amounts ***** </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> Remainder of Medicare approved amounts</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000087"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000030"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">100%</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">80%</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000122"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">15%</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000123"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">226</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">] (Part B deductible)f&</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">5%f&</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td></tr></table></div><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000089"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000003">*****Medicare benefits are subject to change. Please consult the latest</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000124"> Guide to Health Insurance for People with Medicare.</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000022"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000007"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000008"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000067">PLAN M</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000101"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000072"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000108"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000067">MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000101"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000072"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000101"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000003">*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.</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000089"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000072"> </span></p><div align="left"><table dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000114"><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000126"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000116"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">SERVICES</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000125"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000116"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">MEDICARE PAYS</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000116"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">PLAN PAYS</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000116"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">YOU PAY</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000126"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000119">HOSPITALIZATION</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">*</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">Semiprivate room and board, general nursing and miscellaneous services and supplies</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> First 60 days</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> 61</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"><sup>st</sup></span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> thru 90</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"><sup>th</sup></span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> day</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> 91</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"><sup>st</sup></span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> day and after:</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> --While using 60 lifetime reserve days</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> --Once lifetime reserve days are used:</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> --Additional 365 days</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> --Beyond the additional 365 days</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000125"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">All but $[1</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">,600</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">]</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">All but $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">400</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">] a day</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">All but $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">800</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">] a day</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">800</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">] (50% of Part A deductible)</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">400</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">] a day</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">800</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">] a day</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">100% of Medicare eligible expenses</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">800</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">] (50% of Part A deductible)</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0***</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">All costs</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000126"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000119">SKILLED NURSING FACILITY CARE*</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">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</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> First 20 days</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> 21</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"><sup>st</sup></span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> thru 100</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"><sup>th</sup></span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> day</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> 101</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"><sup>st</sup></span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> day and after</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000125"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">All approved amounts</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">All but $[</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">200] </span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> a day</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">Up to $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">200</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">] a day</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">All costs</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000126"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000119">BLOOD</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">First 3 pint</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000119">s</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">Additional amounts</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000087"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000125"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">100%</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">3 pints</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000126"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000119">HOSPICE CARE</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">You must meet Medicare's requirements, including a doctor's certification of terminal illness</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000087"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000125"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">Medicare copayment/coinsurance</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p></td></tr></table></div><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000111"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000096"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000101"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000003">**</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000067">NOTICE:</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000003"> When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's Core Benefits. During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000089"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000072"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000089"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000072"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000108"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000090"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000067">PLAN M</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000108"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000069"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000108"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000067">MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000089"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000072"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000101"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000003">*Once you have been billed $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000003">226</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000003">] 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.</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000089"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000072"> </span></p><div align="left"><table dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000114"><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000120"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000116"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">SERVICES</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000116"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">MEDICARE PAYS</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000116"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">PLAN PAYS</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000030"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000116"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">YOU PAY</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000120"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000119">MEDICAL EXPENSES</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> - 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</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> First $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">226</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">] of Medicare approved amounts*</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> Remainder of Medicare approved amounts</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">Generally 80% </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">Generally 20%</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000030"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">226</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">] (Part B deductible)</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000120"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000119">Part B Excess Charges</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">(Above Medicare Approved Amounts)</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000030"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">All costs </span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000120"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000119">BLOOD</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">First 3 pints</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">Next $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">226</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">] of Medicare approved amounts*</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">Remainder of Medicare approved amounts</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000087"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">80%</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">All costs</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">20%</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000030"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0%</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">226</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">] (Part B deductible)</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">0%</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000120"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000119">CLINICAL LABORATORY SERVICES</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">--TESTS FOR DIAGNOSTIC SERVICES</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000087"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">100%</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000030"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td></tr></table></div><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000111"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000096"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000108"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000067">PARTS A &amp; B</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000089"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000072"> </span></p><div align="left"><table dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000114"><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000077"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000116"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">SERVICES</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000030"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000116"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">MEDICARE PAYS</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000122"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000116"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">PLAN PAYS</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000123"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000116"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">YOU PAY</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000077"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000119">HOME HEALTH CARE</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">MEDICARE APPROVED SERVICES</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> --Medically necessary skilled care services and medical supplies</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> --Durable medical equipment</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> First $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">226</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">] of Medicare approved amounts *</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> Remainder of Medicare approved amounts</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000087"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000030"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">100%</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">80%</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000122"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">20%</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000123"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">226</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">] (Part B deductible)</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p></td></tr></table></div><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000111"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000096"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000108"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000067">OTHER BENEFITS -- NOT COVERED BY MEDICARE</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000089"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000072"> </span></p><div align="left"><table dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000114"><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000077"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000119">FOREIGN TRAVEL</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">NOT COVERED BY MEDICARE</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> First $250 each calendar year</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> Remainder of charges</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000087"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000030"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">80% to a lifetime maximum benefit of $50,000</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000127"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$250</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">20% and amounts over the $50,000 lifetime maximum</span></p></td></tr></table></div><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000022"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000007"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000008"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000067">PLAN N</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000101"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000072"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000108"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000067">MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000101"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000072"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000101"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000003">*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.</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000089"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000072"> </span></p><div align="left"><table dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000114"><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000126"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000116"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">SERVICES</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000121"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000116"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">MEDICARE PAYS</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000128"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000116"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">PLAN PAYS</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000115"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000116"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">YOU PAY</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000126"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000119">HOSPITALIZATION</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">*</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">Semiprivate room and board, general nursing and miscellaneous services and supplies</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> First 60 days</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> 61</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"><sup>st</sup></span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> thru 90</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"><sup>th</sup></span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> day</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> 91</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"><sup>st</sup></span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> day and after:</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> --While using 60 lifetime reserve days</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> --Once lifetime reserve days are used:</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> --Additional 365 days</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> --Beyond the additional 365 days</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000121"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">All but $[1</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">,600</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">]</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">All but $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">400</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">] a day</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">All but $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">800</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">] a day</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000128"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$[1</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">,600</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">] (Part A deductible)</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">400</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">] a day</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">800</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">] a day</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">100% of Medicare eligible expenses</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000115"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0**</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">All costs</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000126"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000119">SKILLED NURSING FACILITY CARE*</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">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</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> First 20 days</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> 21</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"><sup>st</sup></span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> thru 100</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"><sup>th</sup></span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> day</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> 101</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"><sup>st</sup></span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> day and after</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000121"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">All approved amounts</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">All but $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">200</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">] a day</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000128"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">Up to $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">200</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">] a day</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000115"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">All costs</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000126"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000119">BLOOD</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">First 3 pint</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000119">s</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">Additional amounts</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000087"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000121"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">100%</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000128"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">3 pints</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000115"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000126"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000119">HOSPICE CARE</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">You must meet Medicare's requirements, including, a doctor's certification of terminal illness</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000087"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000121"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000128"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">Medicare copayment/coinsurance</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000115"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p></td></tr></table></div><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000111"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000096"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000101"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000003">**</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000067">NOTICE:</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000003"> When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy's Core Benefits. During this time the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000089"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000072"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000089"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000072"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000108"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000090"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000067">PLAN N</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000108"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000069"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000108"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000067">MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000089"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000072"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000101"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000003">*Once you have been billed $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000003">226</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000003">] 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.</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000089"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000072"> </span></p><div align="left"><table dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000114"><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000120"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000116"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">SERVICES</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000116"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">MEDICARE PAYS</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000116"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">PLAN PAYS</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000030"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000116"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">YOU PAY</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000120"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000119">MEDICAL EXPENSES</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> - 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</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> First $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">226</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">] of Medicare approved amounts*</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> Remainder of Medicare approved amounts</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">Generally 80% </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">Balance, other than up to [$20] per office visit and up to [$50] per emergency room visit. The copayment of up to [$50] is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000030"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">226</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">] (Part B deductible)</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">Up to [$20] per office visit and up to [$50] per emergency room visit. The copayment of up to [$50] is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense.</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000120"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000119">Part B Excess Charges</span><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">(Above Medicare Approved Amounts)</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000030"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">All costs </span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000120"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000119">BLOOD</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">First 3 pints</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">Next $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">226</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">] of Medicare approved amounts*</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">Remainder of Medicare approved amounts</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000087"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">80%</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">All costs</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">20%</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000030"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0%</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">226</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">] (Part B deductible)</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">0%</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000120"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000119">CLINICAL LABORATORY SERVICES</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">--TESTS FOR DIAGNOSTIC SERVICES</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000087"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000092"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">100%</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000030"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td></tr></table></div><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000111"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000096"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000108"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000067">PARTS A &amp; B</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000089"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000072"> </span></p><div align="left"><table dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000114"><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000077"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000116"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">SERVICES</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000030"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000116"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">MEDICARE PAYS</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000122"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000116"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">PLAN PAYS</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000123"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000116"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">YOU PAY</span></p></td></tr><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000077"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000119">HOME HEALTH CARE</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">MEDICARE APPROVED SERVICES</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> --Medically necessary skilled care services and medical supplies</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> --Durable medical equipment</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> First $[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">226</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">] of Medicare approved amounts*</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> Remainder of Medicare approved amounts</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000087"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000030"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">100%</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">80%</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000122"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">20%</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000123"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$[</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">226</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">] (Part B deductible)</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p></td></tr></table></div><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000111"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000096"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000108"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000129"><br />&#x200e;</span><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000067">OTHER BENEFITS -- NOT COVERED BY MEDICARE</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000089"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000072"> </span></p><div align="left"><table dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000114"><tr><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000077"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000119">FOREIGN TRAVEL</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">NOT COVERED BY MEDICARE</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> First $250 each calendar year</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117"> Remainder of charges</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000087"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000030"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000093"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$0</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">80% to a lifetime maximum benefit of $50,000</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p></td><td class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000127"><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000075"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">$250</span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000088"><span class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bC0-000117">20% and amounts over the $50,000 lifetime maximum</span></p></td></tr></table></div><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0-000022"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p><p dir="ltr" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972bP0"><span xml:space="preserve" class="s58ecec6c-cd8f-4a91-97ea-a31a3aec972b000000"> </span></p></div></body></html>