EVEREST REINSURANCE COMPANY Outline of Medicare … · EVOC2017MI Effective: 02-13-2017 Page 1 of 18 EVEREST REINSURANCE COMPANY Outline of Medicare Supplement Coverage Benefit Plans

EVOC2017MI Effective: 02-13-2017 Page 1 of 18

EVEREST REINSURANCE COMPANY

Outline of Medicare Supplement Coverage Benefit Plans A, C, D, F, G, and N

Benefit Chart of Medicare Supplement Plans Sold for Effective Dates on or After June 1, 2010

This chart shows the benefits included in each of the standard Medicare supplement plans. Every company must make Plan “A” available. Some plans may not be available in your state. Basic Benefits: • Hospitalization – Part A coinsurance plus coverage for 365 additional days after Medicare benefits end. • Medical Expenses – Part B coinsurance (generally 20% of Medicare-approved expenses) or copayments for hospital outpatient

services. Plans K, L, and N require insureds to pay a portion of Part B coinsurance or copayments. • Blood – First three pints of blood each year. • Hospice – Part A coinsurance

A B C D F F* G K L M N Basic, including 100% Part B coinsurance

Basic, including 100% Part B coinsurance



Basic, including 100% Part B coinsurance*


Hospitalization and preventive care paid at 100%; other basic benefits paid at 50%

Hospitalization and preventive care paid at 100%; other basic benefits paid at 75%


Basic, including 100 % Part B coinsurance except up to $20 copayment for office visit, and up to $50 copayment for ER

Skilled Nursing Facility Coinsurance




50% Skilled Nursing Facility Coinsurance

75% Skilled Nursing Facility Coinsurance



Part A Deductible

Part A Deductible

Part A Deductible

Part A Deductible

Part A Deductible

50% Part A Deductible



Part A Deductible

Part B Deductible

Part B Deductible

Part B Excess (100 %)

Part B Excess (100%)

Foreign Travel Emergency






Out-of-pocket limit $5120 paid at 100% after limit reached

Out-of-pocket limit $2560 paid at 100% after limit reached

*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 $2200 deductible. Benefits from high deductible plan F will not begin until out-of-pocket expenses exceed $2200. 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.

Rates Effective 02-13-2017 EVEREST REINSURANCE COMPANY One-Time Policy Fee $25

Plan C Plan C

65 1,692.37 2,093.32 1,616.91 2,114.37 1,635.45 1,404.83 65 1,878.54 2,323.60 1,794.77 2,346.95 1,815.34 1,559.3766 1,692.37 2,093.32 1,616.91 2,114.37 1,635.45 1,404.83 66 1,878.54 2,323.60 1,794.77 2,346.95 1,815.34 1,559.3767 1,692.37 2,093.32 1,616.91 2,114.37 1,635.45 1,404.83 67 1,878.54 2,323.60 1,794.77 2,346.95 1,815.34 1,559.3768 1,729.84 2,132.32 1,655.62 2,153.82 1,674.55 1,437.33 68 1,920.13 2,366.87 1,837.74 2,390.75 1,858.76 1,595.4369 1,799.26 2,214.44 1,727.86 2,236.81 1,747.55 1,497.63 69 1,997.17 2,458.03 1,917.92 2,482.85 1,939.78 1,662.3670 1,866.40 2,290.75 1,794.98 2,313.96 1,815.42 1,554.38 70 2,071.71 2,542.74 1,992.43 2,568.50 2,015.12 1,725.3571 1,922.26 2,364.78 1,860.11 2,388.73 1,881.20 1,611.36 71 2,133.70 2,624.91 2,064.72 2,651.50 2,088.13 1,788.6072 1,978.11 2,438.82 1,925.23 2,463.51 1,946.97 1,668.33 72 2,195.71 2,707.09 2,137.00 2,734.49 2,161.14 1,851.8573 2,033.97 2,512.85 1,990.36 2,538.27 2,012.75 1,725.31 73 2,257.71 2,789.26 2,209.30 2,817.49 2,234.14 1,915.0974 2,089.82 2,586.88 2,055.48 2,613.04 2,078.52 1,782.29 74 2,319.70 2,871.44 2,281.59 2,900.48 2,307.16 1,978.3475 2,147.46 2,663.13 2,122.37 2,690.05 2,146.08 1,840.80 75 2,383.69 2,956.07 2,355.84 2,985.96 2,382.15 2,043.2876 2,195.75 2,740.97 2,188.82 2,768.63 2,213.18 1,890.44 76 2,437.29 3,042.47 2,429.59 3,073.18 2,456.63 2,098.3877 2,244.76 2,820.00 2,256.31 2,848.42 2,281.33 1,941.42 77 2,491.68 3,130.20 2,504.50 3,161.74 2,532.28 2,154.9878 2,294.47 2,900.26 2,324.85 2,929.44 2,350.55 1,993.77 78 2,546.85 3,219.29 2,580.59 3,251.68 2,609.11 2,213.0979 2,346.83 2,984.21 2,396.44 3,014.19 2,422.84 2,047.54 79 2,604.99 3,312.49 2,660.05 3,345.75 2,689.35 2,272.7880 2,400.01 3,069.56 2,469.23 3,100.34 2,496.34 2,102.76 80 2,664.02 3,407.21 2,740.85 3,441.38 2,770.93 2,334.0781 2,446.88 3,158.51 2,544.97 3,189.95 2,572.66 2,159.48 81 2,716.04 3,505.94 2,824.91 3,540.83 2,855.64 2,397.0182 2,494.48 3,249.02 2,622.06 3,281.11 2,650.33 2,217.71 82 2,768.88 3,606.41 2,910.48 3,642.03 2,941.86 2,461.6683 2,542.83 3,341.12 2,700.52 3,373.89 2,729.39 2,277.52 83 2,822.55 3,708.64 2,997.58 3,745.02 3,029.62 2,528.0484 2,591.93 3,434.83 2,780.37 3,468.29 2,809.84 2,342.42 84 2,877.04 3,812.67 3,086.22 3,849.80 3,118.92 2,600.0885 2,641.79 3,530.19 2,861.64 3,564.34 2,891.72 2,409.15 85 2,932.39 3,918.51 3,176.43 3,956.41 3,209.81 2,674.1686 2,692.64 3,625.93 2,942.20 3,660.83 2,972.95 2,477.79 86 2,988.82 4,024.78 3,265.85 4,063.53 3,299.98 2,750.3587 2,744.40 3,723.74 3,024.55 3,759.43 3,055.98 2,548.39 87 3,046.29 4,133.36 3,357.24 4,172.97 3,392.13 2,828.7288 2,797.11 3,823.69 3,108.69 3,860.15 3,140.81 2,621.00 88 3,104.79 4,244.30 3,450.65 4,284.78 3,486.30 2,909.3189 2,848.45 3,922.56 3,192.06 3,959.80 3,224.86 2,695.68 89 3,161.79 4,354.04 3,543.19 4,395.38 3,579.60 2,992.2190 2,898.30 4,020.17 3,274.47 4,058.16 3,307.94 2,772.50 90 3,217.12 4,462.38 3,634.66 4,504.57 3,671.81 3,077.4791 2,932.61 4,100.36 3,342.17 4,138.79 3,376.03 2,834.33 91 3,255.20 4,551.39 3,709.82 4,594.06 3,747.39 3,146.1192 2,967.32 4,181.82 3,410.96 4,220.70 3,445.21 2,897.17 92 3,293.72 4,641.81 3,786.17 4,684.98 3,824.18 3,215.8593 3,002.43 4,264.56 3,480.84 4,303.89 3,515.49 2,961.04 93 3,332.70 4,733.65 3,863.74 4,777.32 3,902.20 3,286.7694 3,037.96 4,348.60 3,551.85 4,388.38 3,586.89 3,025.95 94 3,372.14 4,826.94 3,942.54 4,871.11 3,981.45 3,358.8095 3,073.91 4,433.96 3,623.97 4,474.21 3,659.43 3,091.92 95 3,412.04 4,921.70 4,022.60 4,966.38 4,061.96 3,432.0396 3,135.39 4,522.64 3,696.45 4,563.69 3,732.62 3,153.77 96 3,480.28 5,020.13 4,103.06 5,065.70 4,143.21 3,500.6797 3,198.09 4,613.09 3,770.38 4,654.97 3,807.27 3,216.84 97 3,549.88 5,120.53 4,185.12 5,167.02 4,226.07 3,570.7098 3,262.05 4,705.35 3,845.79 4,748.07 3,883.41 3,281.17 98 3,620.88 5,222.94 4,268.83 5,270.35 4,310.59 3,642.10

99+ 3,327.29 4,799.45 3,922.70 4,843.03 3,961.08 3,281.17 99+ 3,693.29 5,327.40 4,354.20 5,375.77 4,396.80 3,642.10

Modal Factors: Semi Annual: 0.50 Quarterly: 0.25 Monthly BSP: 0.08333Household Discount Factor: .93

Plan D Plan F Plan GPlan N Plan A

MICHIGAN Standard Plans MALE Rates - ANNUALFOR USE IN ZIP CODES: 480-485

Attained Age

Non-Tobacco Attained Age

Tobacco

Plan A Plan D Plan F Plan G Plan N

EVOC2017MI Rate Pg 1 of 6


Plan C Plan C

65 1,476.98 1,826.90 1,411.12 1,845.26 1,427.30 1,226.04 65 1,639.45 2,027.87 1,566.35 2,048.25 1,584.30 1,360.9166 1,476.98 1,826.90 1,411.12 1,845.26 1,427.30 1,226.04 66 1,639.45 2,027.87 1,566.35 2,048.25 1,584.30 1,360.9167 1,476.98 1,826.90 1,411.12 1,845.26 1,427.30 1,226.04 67 1,639.45 2,027.87 1,566.35 2,048.25 1,584.30 1,360.9168 1,509.68 1,860.93 1,444.91 1,879.70 1,461.43 1,254.39 68 1,675.75 2,065.63 1,603.84 2,086.47 1,622.19 1,392.3769 1,570.26 1,932.60 1,507.95 1,952.12 1,525.13 1,307.02 69 1,742.99 2,145.19 1,673.82 2,166.85 1,692.90 1,450.7970 1,628.86 1,999.20 1,566.53 2,019.46 1,584.36 1,356.55 70 1,808.04 2,219.12 1,738.85 2,241.60 1,758.65 1,505.7671 1,677.61 2,063.81 1,623.37 2,084.71 1,641.77 1,406.28 71 1,862.14 2,290.83 1,801.94 2,314.03 1,822.37 1,560.9672 1,726.35 2,128.43 1,680.20 2,149.97 1,699.17 1,455.99 72 1,916.26 2,362.55 1,865.02 2,386.46 1,886.08 1,616.1673 1,775.10 2,193.03 1,737.04 2,215.22 1,756.58 1,505.72 73 1,970.36 2,434.26 1,928.11 2,458.90 1,949.80 1,671.3574 1,823.85 2,257.64 1,793.88 2,280.47 1,813.98 1,555.45 74 2,024.47 2,505.98 1,991.20 2,531.33 2,013.52 1,726.5575 1,874.15 2,324.19 1,852.25 2,347.68 1,872.94 1,606.51 75 2,080.31 2,579.85 2,056.00 2,605.93 2,078.97 1,783.2376 1,916.29 2,392.12 1,910.25 2,416.26 1,931.50 1,649.84 76 2,127.09 2,655.24 2,120.37 2,682.05 2,143.97 1,831.3277 1,959.06 2,461.09 1,969.14 2,485.89 1,990.98 1,694.33 77 2,174.55 2,731.81 2,185.75 2,759.34 2,209.99 1,880.7178 2,002.44 2,531.14 2,028.96 2,556.60 2,051.39 1,740.02 78 2,222.71 2,809.56 2,252.15 2,837.83 2,277.04 1,931.4279 2,048.14 2,604.40 2,091.44 2,630.56 2,114.48 1,786.94 79 2,273.44 2,890.90 2,321.50 2,919.93 2,347.07 1,983.5180 2,094.56 2,678.89 2,154.96 2,705.75 2,178.62 1,835.14 80 2,324.97 2,973.56 2,392.01 3,003.39 2,418.27 2,037.0081 2,135.46 2,756.52 2,221.07 2,783.95 2,245.23 1,884.63 81 2,370.36 3,059.73 2,465.38 3,090.18 2,492.20 2,091.9482 2,177.00 2,835.50 2,288.34 2,863.52 2,313.01 1,935.46 82 2,416.47 3,147.41 2,540.05 3,178.50 2,567.44 2,148.3683 2,219.19 2,915.88 2,356.82 2,944.48 2,382.01 1,987.65 83 2,463.31 3,236.63 2,616.07 3,268.38 2,644.03 2,206.2984 2,262.05 2,997.67 2,426.51 3,026.87 2,452.22 2,044.29 84 2,510.87 3,327.42 2,693.42 3,359.83 2,721.96 2,269.1685 2,305.56 3,080.89 2,497.43 3,110.70 2,523.69 2,102.53 85 2,559.18 3,419.79 2,772.15 3,452.87 2,801.29 2,333.8186 2,349.94 3,164.45 2,567.74 3,194.91 2,594.57 2,162.44 86 2,608.43 3,512.53 2,850.19 3,546.36 2,879.98 2,400.3187 2,395.11 3,249.81 2,639.61 3,280.95 2,667.03 2,224.05 87 2,658.58 3,607.30 2,929.96 3,641.87 2,960.40 2,468.7088 2,441.12 3,337.04 2,713.04 3,368.86 2,741.07 2,287.42 88 2,709.64 3,704.11 3,011.47 3,739.44 3,042.59 2,539.0489 2,485.92 3,423.32 2,785.80 3,455.83 2,814.42 2,352.60 89 2,759.38 3,799.89 3,092.24 3,835.97 3,124.01 2,611.3890 2,529.43 3,508.51 2,857.72 3,541.67 2,886.93 2,419.63 90 2,807.66 3,894.44 3,172.07 3,931.26 3,204.49 2,685.7991 2,559.37 3,578.50 2,916.81 3,612.04 2,946.36 2,473.59 91 2,840.90 3,972.12 3,237.66 4,009.36 3,270.45 2,745.7092 2,589.66 3,649.58 2,976.84 3,683.52 3,006.73 2,528.44 92 2,874.52 4,051.04 3,304.29 4,088.71 3,337.47 2,806.5693 2,620.30 3,721.80 3,037.82 3,756.12 3,068.06 2,584.18 93 2,908.54 4,131.19 3,371.99 4,169.30 3,405.55 2,868.4494 2,651.31 3,795.14 3,099.79 3,829.86 3,130.38 2,640.83 94 2,942.96 4,212.60 3,440.76 4,251.15 3,474.72 2,931.3195 2,682.68 3,869.64 3,162.74 3,904.76 3,193.68 2,698.41 95 2,977.78 4,295.30 3,510.63 4,334.29 3,544.98 2,995.2396 2,736.34 3,947.03 3,225.99 3,982.86 3,257.56 2,752.38 96 3,037.33 4,381.20 3,580.85 4,420.97 3,615.89 3,055.1397 2,791.06 4,025.97 3,290.52 4,062.52 3,322.70 2,807.42 97 3,098.07 4,468.83 3,652.46 4,509.40 3,688.20 3,116.2598 2,846.88 4,106.49 3,356.32 4,143.77 3,389.16 2,863.56 98 3,160.04 4,558.20 3,725.52 4,599.58 3,761.97 3,178.56

99+ 2,903.82 4,188.61 3,423.45 4,226.64 3,456.94 2,863.56 99+ 3,223.24 4,649.37 3,800.03 4,691.58 3,837.21 3,178.56

Plan F Plan G Plan N


Plan A Plan D Plan F Plan G Plan N Plan A Plan D

MICHIGAN Standard Plans MALE Rates - ANNUALFOR USE IN ZIP CODES: 486-489, 492

Attained Age

Attained Age Attained Age

Tobacco



Plan C Plan C

65 1,353.90 1,674.66 1,293.53 1,691.49 1,308.36 1,123.87 65 1,502.83 1,858.88 1,435.82 1,877.56 1,452.27 1,247.5066 1,353.90 1,674.66 1,293.53 1,691.49 1,308.36 1,123.87 66 1,502.83 1,858.88 1,435.82 1,877.56 1,452.27 1,247.5067 1,353.90 1,674.66 1,293.53 1,691.49 1,308.36 1,123.87 67 1,502.83 1,858.88 1,435.82 1,877.56 1,452.27 1,247.5068 1,383.87 1,705.85 1,324.50 1,723.06 1,339.64 1,149.86 68 1,536.10 1,893.50 1,470.19 1,912.60 1,487.01 1,276.3469 1,439.41 1,771.55 1,382.29 1,789.44 1,398.04 1,198.10 69 1,597.74 1,966.42 1,534.33 1,986.28 1,551.83 1,329.8970 1,493.12 1,832.60 1,435.98 1,851.17 1,452.33 1,243.50 70 1,657.37 2,034.19 1,593.94 2,054.80 1,612.10 1,380.2871 1,537.81 1,891.82 1,488.09 1,910.98 1,504.96 1,289.09 71 1,706.96 2,099.93 1,651.78 2,121.20 1,670.50 1,430.8872 1,582.49 1,951.06 1,540.18 1,970.80 1,557.57 1,334.66 72 1,756.57 2,165.67 1,709.60 2,187.59 1,728.91 1,481.4873 1,627.17 2,010.28 1,592.29 2,030.62 1,610.20 1,380.24 73 1,806.16 2,231.41 1,767.44 2,253.99 1,787.32 1,532.0774 1,671.86 2,069.50 1,644.39 2,090.43 1,662.81 1,425.83 74 1,855.76 2,297.15 1,825.27 2,320.38 1,845.73 1,582.6775 1,717.97 2,130.51 1,697.90 2,152.04 1,716.86 1,472.64 75 1,906.95 2,364.86 1,884.67 2,388.77 1,905.72 1,634.6376 1,756.60 2,192.78 1,751.06 2,214.91 1,770.54 1,512.35 76 1,949.83 2,433.97 1,943.67 2,458.54 1,965.30 1,678.7177 1,795.81 2,256.00 1,805.05 2,278.73 1,825.07 1,553.14 77 1,993.34 2,504.16 2,003.60 2,529.39 2,025.82 1,723.9878 1,835.57 2,320.21 1,859.88 2,343.55 1,880.44 1,595.02 78 2,037.48 2,575.43 2,064.47 2,601.34 2,087.29 1,770.4779 1,877.46 2,387.37 1,917.15 2,411.35 1,938.27 1,638.03 79 2,083.99 2,649.99 2,128.04 2,676.60 2,151.48 1,818.2280 1,920.01 2,455.65 1,975.38 2,480.27 1,997.07 1,682.21 80 2,131.22 2,725.76 2,192.68 2,753.11 2,216.75 1,867.2581 1,957.51 2,526.81 2,035.98 2,551.96 2,058.13 1,727.58 81 2,172.83 2,804.75 2,259.93 2,832.67 2,284.52 1,917.6182 1,995.58 2,599.21 2,097.65 2,624.89 2,120.26 1,774.17 82 2,215.10 2,885.12 2,328.38 2,913.63 2,353.49 1,969.3383 2,034.26 2,672.89 2,160.42 2,699.11 2,183.51 1,822.01 83 2,258.04 2,966.91 2,398.06 2,996.01 2,423.70 2,022.4384 2,073.54 2,747.86 2,224.30 2,774.63 2,247.87 1,873.93 84 2,301.63 3,050.13 2,468.97 3,079.84 2,495.13 2,080.0685 2,113.43 2,824.15 2,289.31 2,851.47 2,313.38 1,927.32 85 2,345.91 3,134.81 2,541.14 3,165.13 2,567.85 2,139.3286 2,154.11 2,900.74 2,353.76 2,928.67 2,378.36 1,982.24 86 2,391.06 3,219.82 2,612.68 3,250.83 2,639.98 2,200.2887 2,195.52 2,978.99 2,419.64 3,007.54 2,444.78 2,038.71 87 2,437.03 3,306.69 2,685.80 3,338.38 2,713.70 2,262.9788 2,237.69 3,058.95 2,486.95 3,088.12 2,512.65 2,096.80 88 2,483.84 3,395.44 2,760.52 3,427.82 2,789.04 2,327.4589 2,278.76 3,138.04 2,553.65 3,167.84 2,579.89 2,156.55 89 2,529.43 3,483.23 2,834.55 3,516.30 2,863.68 2,393.7790 2,318.64 3,216.14 2,619.58 3,246.53 2,646.35 2,218.00 90 2,573.69 3,569.90 2,907.73 3,603.65 2,937.45 2,461.9891 2,346.09 3,280.29 2,673.74 3,311.04 2,700.83 2,267.46 91 2,604.16 3,641.11 2,967.85 3,675.25 2,997.91 2,516.8992 2,373.85 3,345.45 2,728.77 3,376.56 2,756.17 2,317.74 92 2,634.98 3,713.45 3,028.93 3,747.98 3,059.35 2,572.6893 2,401.94 3,411.65 2,784.67 3,443.11 2,812.39 2,368.83 93 2,666.16 3,786.92 3,090.99 3,821.86 3,121.76 2,629.4094 2,430.37 3,478.88 2,841.48 3,510.71 2,869.51 2,420.76 94 2,697.71 3,861.55 3,154.03 3,896.89 3,185.16 2,687.0495 2,459.12 3,547.17 2,899.18 3,579.36 2,927.54 2,473.54 95 2,729.63 3,937.36 3,218.08 3,973.10 3,249.57 2,745.6396 2,508.31 3,618.11 2,957.16 3,650.95 2,986.10 2,523.01 96 2,784.22 4,016.10 3,282.44 4,052.56 3,314.56 2,800.5497 2,558.47 3,690.47 3,016.31 3,723.98 3,045.81 2,573.47 97 2,839.90 4,096.43 3,348.09 4,133.62 3,380.85 2,856.5698 2,609.64 3,764.28 3,076.63 3,798.46 3,106.73 2,624.93 98 2,896.70 4,178.35 3,415.06 4,216.28 3,448.47 2,913.68

99+ 2,661.83 3,839.56 3,138.16 3,874.42 3,168.86 2,624.93 99+ 2,954.64 4,261.92 3,483.36 4,300.61 3,517.44 2,913.68

Plan D Plan F Plan G Plan N


Non-Tobacco Attained AgePlan A Plan D Plan F Plan G Plan N Plan A

Tobacco

MICHIGAN Standard Plans MALE Rates - ANNUALFOR USE IN ZIP CODES: 490-491,493-499

Attained Age



Plan C Plan C

65 1,484.54 1,836.25 1,418.34 1,854.71 1,434.60 1,232.31 65 1,647.83 2,038.23 1,574.36 2,058.73 1,592.40 1,367.8766 1,484.54 1,836.25 1,418.34 1,854.71 1,434.60 1,232.31 66 1,647.83 2,038.23 1,574.36 2,058.73 1,592.40 1,367.8767 1,484.54 1,836.25 1,418.34 1,854.71 1,434.60 1,232.31 67 1,647.83 2,038.23 1,574.36 2,058.73 1,592.40 1,367.8768 1,517.41 1,870.45 1,452.30 1,889.32 1,468.91 1,260.81 68 1,684.32 2,076.21 1,612.05 2,097.15 1,630.49 1,399.5069 1,578.29 1,942.49 1,515.66 1,962.11 1,532.94 1,313.71 69 1,751.90 2,156.17 1,682.38 2,177.95 1,701.57 1,458.2270 1,637.20 2,009.44 1,574.55 2,029.79 1,592.48 1,363.48 70 1,817.29 2,230.47 1,747.75 2,253.06 1,767.65 1,513.4771 1,686.19 2,074.37 1,631.67 2,095.38 1,650.18 1,413.47 71 1,871.67 2,302.55 1,811.16 2,325.87 1,831.69 1,568.9572 1,735.18 2,139.31 1,688.80 2,160.97 1,707.87 1,463.45 72 1,926.06 2,374.64 1,874.57 2,398.67 1,895.74 1,624.4373 1,784.18 2,204.26 1,745.93 2,226.55 1,765.57 1,513.42 73 1,980.44 2,446.72 1,937.98 2,471.48 1,959.78 1,679.9174 1,833.18 2,269.19 1,803.05 2,292.15 1,823.26 1,563.41 74 2,034.82 2,518.80 2,001.38 2,544.28 2,023.82 1,735.3875 1,883.74 2,336.08 1,861.73 2,359.70 1,882.53 1,614.73 75 2,090.96 2,593.05 2,066.52 2,619.27 2,089.60 1,792.3576 1,926.10 2,404.36 1,920.02 2,428.62 1,941.39 1,658.27 76 2,137.97 2,668.83 2,131.22 2,695.77 2,154.94 1,840.6977 1,969.08 2,473.69 1,979.22 2,498.62 2,001.18 1,703.00 77 2,185.68 2,745.80 2,196.93 2,773.46 2,221.30 1,890.3378 2,012.69 2,544.09 2,039.35 2,569.68 2,061.88 1,748.92 78 2,234.08 2,823.94 2,263.68 2,852.34 2,288.69 1,941.3179 2,058.63 2,617.74 2,102.14 2,644.03 2,125.30 1,796.09 79 2,285.07 2,905.68 2,333.38 2,934.87 2,359.08 1,993.6680 2,105.28 2,692.59 2,165.99 2,719.60 2,189.77 1,844.54 80 2,336.86 2,988.78 2,404.25 3,018.75 2,430.65 2,047.4381 2,146.39 2,770.61 2,232.43 2,798.19 2,256.72 1,894.28 81 2,382.49 3,075.38 2,477.99 3,105.99 2,504.95 2,102.6482 2,188.14 2,850.01 2,300.06 2,878.17 2,324.85 1,945.36 82 2,428.84 3,163.51 2,553.06 3,194.77 2,580.58 2,159.3683 2,230.55 2,930.81 2,368.87 2,959.55 2,394.19 1,997.82 83 2,475.91 3,253.20 2,629.45 3,285.11 2,657.56 2,217.5984 2,273.62 3,013.01 2,438.92 3,042.36 2,464.77 2,054.75 84 2,523.72 3,344.44 2,707.21 3,377.02 2,735.90 2,280.7785 2,317.36 3,096.65 2,510.21 3,126.61 2,536.60 2,113.29 85 2,572.27 3,437.29 2,786.33 3,470.53 2,815.63 2,345.7586 2,361.95 3,180.64 2,580.89 3,211.26 2,607.86 2,173.50 86 2,621.77 3,530.51 2,864.79 3,564.50 2,894.72 2,412.5987 2,407.37 3,266.45 2,653.11 3,297.75 2,680.68 2,235.43 87 2,672.18 3,625.75 2,944.95 3,660.49 2,975.56 2,481.3488 2,453.61 3,354.11 2,726.92 3,386.10 2,755.09 2,299.13 88 2,723.51 3,723.06 3,026.88 3,758.57 3,058.15 2,552.0389 2,498.64 3,440.84 2,800.05 3,473.51 2,828.83 2,364.64 89 2,773.50 3,819.33 3,108.05 3,855.60 3,139.99 2,624.7490 2,542.38 3,526.46 2,872.34 3,559.80 2,901.70 2,432.01 90 2,822.03 3,914.37 3,188.30 3,951.38 3,220.89 2,699.5391 2,572.46 3,596.80 2,931.73 3,630.53 2,961.43 2,486.25 91 2,855.44 3,992.45 3,254.22 4,029.88 3,287.19 2,759.7592 2,602.91 3,668.26 2,992.07 3,702.37 3,022.12 2,541.37 92 2,889.23 4,071.76 3,321.20 4,109.62 3,354.55 2,820.9393 2,633.71 3,740.84 3,053.37 3,775.34 3,083.76 2,597.40 93 2,923.42 4,152.32 3,389.24 4,190.63 3,422.98 2,883.1194 2,664.87 3,814.56 3,115.65 3,849.46 3,146.40 2,654.34 94 2,958.01 4,234.15 3,458.37 4,272.91 3,492.50 2,946.3295 2,696.41 3,889.44 3,178.92 3,924.75 3,210.02 2,712.22 95 2,993.01 4,317.27 3,528.60 4,356.47 3,563.13 3,010.5696 2,750.34 3,967.23 3,242.50 4,003.24 3,274.23 2,766.46 96 3,052.87 4,403.62 3,599.18 4,443.59 3,634.39 3,070.7797 2,805.34 4,046.57 3,307.35 4,083.31 3,339.71 2,821.79 97 3,113.94 4,491.70 3,671.16 4,532.47 3,707.08 3,132.1898 2,861.45 4,127.50 3,373.49 4,164.97 3,406.50 2,878.22 98 3,176.21 4,581.52 3,744.58 4,623.12 3,781.22 3,194.82

99+ 2,918.67 4,210.05 3,440.97 4,248.28 3,474.64 2,878.22 99+ 3,239.73 4,673.15 3,819.48 4,715.58 3,856.84 3,194.82


Plan N Plan A Plan D Plan F Plan G

Attained Age


Tobacco

Plan A Plan D Plan F Plan G Plan N

MICHIGAN Standard Plans FEMALE Rates - ANNUALFOR USE IN ZIP CODES: 480-485



Plan C Plan C

65 1,295.60 1,602.55 1,237.82 1,618.66 1,252.01 1,075.47 65 1,438.11 1,778.82 1,373.99 1,796.71 1,389.73 1,193.7866 1,295.60 1,602.55 1,237.82 1,618.66 1,252.01 1,075.47 66 1,438.11 1,778.82 1,373.99 1,796.71 1,389.73 1,193.7867 1,295.60 1,602.55 1,237.82 1,618.66 1,252.01 1,075.47 67 1,438.11 1,778.82 1,373.99 1,796.71 1,389.73 1,193.7868 1,324.28 1,632.39 1,267.46 1,648.86 1,281.96 1,100.34 68 1,469.95 1,811.96 1,406.88 1,830.24 1,422.97 1,221.3869 1,377.42 1,695.26 1,322.76 1,712.39 1,337.84 1,146.51 69 1,528.93 1,881.74 1,468.26 1,900.75 1,485.00 1,272.6270 1,428.83 1,753.69 1,374.15 1,771.45 1,389.80 1,189.95 70 1,586.00 1,946.59 1,525.31 1,966.31 1,542.67 1,320.8471 1,471.58 1,810.36 1,424.01 1,828.69 1,440.15 1,233.57 71 1,633.46 2,009.50 1,580.65 2,029.85 1,598.56 1,369.2772 1,514.34 1,867.04 1,473.86 1,885.94 1,490.51 1,277.19 72 1,680.92 2,072.41 1,635.98 2,093.39 1,654.46 1,417.6873 1,557.10 1,923.72 1,523.72 1,943.17 1,540.86 1,320.81 73 1,728.38 2,135.32 1,691.33 2,156.93 1,710.36 1,466.1074 1,599.87 1,980.38 1,573.57 2,000.42 1,591.21 1,364.43 74 1,775.85 2,198.23 1,746.66 2,220.46 1,766.25 1,514.5275 1,643.99 2,038.76 1,624.78 2,059.37 1,642.93 1,409.22 75 1,824.84 2,263.03 1,803.50 2,285.90 1,823.65 1,564.2376 1,680.96 2,098.35 1,675.65 2,119.53 1,694.30 1,447.22 76 1,865.87 2,329.16 1,859.97 2,352.67 1,880.68 1,606.4277 1,718.47 2,158.86 1,727.32 2,180.61 1,746.48 1,486.25 77 1,907.50 2,396.33 1,917.32 2,420.48 1,938.59 1,649.7478 1,756.53 2,220.30 1,779.79 2,242.63 1,799.46 1,526.33 78 1,949.74 2,464.53 1,975.57 2,489.32 1,997.40 1,694.2479 1,796.62 2,284.57 1,834.60 2,307.51 1,854.81 1,567.50 79 1,994.25 2,535.87 2,036.40 2,561.34 2,058.84 1,739.9280 1,837.33 2,349.90 1,890.32 2,373.47 1,911.07 1,609.78 80 2,039.44 2,608.39 2,098.25 2,634.55 2,121.29 1,786.8581 1,873.21 2,417.99 1,948.30 2,442.06 1,969.50 1,653.19 81 2,079.26 2,683.97 2,162.61 2,710.68 2,186.14 1,835.0382 1,909.65 2,487.28 2,007.32 2,511.86 2,028.96 1,697.77 82 2,119.72 2,760.88 2,228.12 2,788.17 2,252.14 1,884.5383 1,946.66 2,557.80 2,067.38 2,582.88 2,089.48 1,743.55 83 2,160.80 2,839.15 2,294.79 2,867.00 2,319.32 1,935.3584 1,984.25 2,629.54 2,128.51 2,655.15 2,151.07 1,793.23 84 2,202.52 2,918.78 2,362.66 2,947.22 2,387.69 1,990.4985 2,022.42 2,702.53 2,190.73 2,728.68 2,213.76 1,844.32 85 2,244.89 2,999.82 2,431.71 3,028.83 2,457.27 2,047.2086 2,061.34 2,775.83 2,252.41 2,802.56 2,275.95 1,896.87 86 2,288.09 3,081.17 2,500.18 3,110.83 2,526.30 2,105.5387 2,100.98 2,850.72 2,315.44 2,878.03 2,339.50 1,950.92 87 2,332.08 3,164.29 2,570.14 3,194.61 2,596.85 2,165.5388 2,141.33 2,927.22 2,379.86 2,955.14 2,404.44 2,006.52 88 2,376.88 3,249.22 2,641.64 3,280.20 2,668.93 2,227.2389 2,180.63 3,002.92 2,443.68 3,031.43 2,468.79 2,063.68 89 2,420.51 3,333.24 2,712.48 3,364.89 2,740.36 2,290.6890 2,218.80 3,077.64 2,506.77 3,106.73 2,532.39 2,122.48 90 2,462.86 3,416.18 2,782.51 3,448.47 2,810.96 2,355.9691 2,245.06 3,139.03 2,558.60 3,168.46 2,584.52 2,169.82 91 2,492.02 3,484.32 2,840.04 3,516.99 2,868.82 2,408.5192 2,271.63 3,201.39 2,611.26 3,231.16 2,637.48 2,217.93 92 2,521.51 3,553.54 2,898.50 3,586.58 2,927.61 2,461.9093 2,298.51 3,264.73 2,664.76 3,294.84 2,691.28 2,266.82 93 2,551.34 3,623.85 2,957.88 3,657.27 2,987.33 2,516.1794 2,325.71 3,329.07 2,719.11 3,359.53 2,745.95 2,316.52 94 2,581.54 3,695.26 3,018.21 3,729.08 3,048.00 2,571.3395 2,353.23 3,394.42 2,774.33 3,425.23 2,801.47 2,367.02 95 2,612.08 3,767.80 3,079.51 3,802.01 3,109.64 2,627.4096 2,400.30 3,462.31 2,829.82 3,493.74 2,857.51 2,414.36 96 2,664.33 3,843.16 3,141.10 3,878.04 3,171.83 2,679.9597 2,448.30 3,531.55 2,886.41 3,563.62 2,914.66 2,462.65 97 2,717.62 3,920.03 3,203.92 3,955.61 3,235.27 2,733.5498 2,497.27 3,602.18 2,944.14 3,634.89 2,972.95 2,511.90 98 2,771.96 3,998.42 3,267.99 4,034.73 3,299.97 2,788.20

99+ 2,547.21 3,674.23 3,003.02 3,707.59 3,032.41 2,511.90 99+ 2,827.40 4,078.39 3,333.36 4,115.41 3,365.97 2,788.20


Plan A Plan D Plan F Plan G Plan N Plan A

Attained Age

Tobacco


Attained Age

Attained Age

MICHIGAN Standard Plans FEMALE Rates - ANNUALFOR USE IN ZIP CODES: 486-489, 492



Plan C Plan C

65 1,187.63 1,469.00 1,134.67 1,483.77 1,147.68 985.85 65 1,318.27 1,630.59 1,259.49 1,646.98 1,273.92 1,094.3066 1,187.63 1,469.00 1,134.67 1,483.77 1,147.68 985.85 66 1,318.27 1,630.59 1,259.49 1,646.98 1,273.92 1,094.3067 1,187.63 1,469.00 1,134.67 1,483.77 1,147.68 985.85 67 1,318.27 1,630.59 1,259.49 1,646.98 1,273.92 1,094.3068 1,213.92 1,496.36 1,161.84 1,511.45 1,175.13 1,008.65 68 1,347.46 1,660.96 1,289.64 1,677.72 1,304.39 1,119.6069 1,262.63 1,553.99 1,212.53 1,569.69 1,226.35 1,050.97 69 1,401.52 1,724.93 1,345.91 1,742.36 1,361.25 1,166.5770 1,309.76 1,607.55 1,259.64 1,623.83 1,273.98 1,090.79 70 1,453.83 1,784.38 1,398.20 1,802.45 1,414.12 1,210.7771 1,348.95 1,659.50 1,305.34 1,676.30 1,320.14 1,130.77 71 1,497.34 1,842.04 1,448.93 1,860.70 1,465.35 1,255.1672 1,388.15 1,711.45 1,351.04 1,728.78 1,366.30 1,170.76 72 1,540.84 1,899.71 1,499.65 1,918.94 1,516.59 1,299.5473 1,427.34 1,763.41 1,396.74 1,781.24 1,412.45 1,210.74 73 1,584.35 1,957.38 1,550.38 1,977.18 1,567.83 1,343.9374 1,466.55 1,815.35 1,442.44 1,833.72 1,458.61 1,250.73 74 1,627.86 2,015.04 1,601.11 2,035.42 1,619.06 1,388.3175 1,506.99 1,868.86 1,489.38 1,887.76 1,506.02 1,291.79 75 1,672.77 2,074.44 1,653.21 2,095.41 1,671.68 1,433.8876 1,540.88 1,923.49 1,536.01 1,942.90 1,553.11 1,326.62 76 1,710.38 2,135.06 1,704.97 2,156.62 1,723.96 1,472.5577 1,575.26 1,978.95 1,583.38 1,998.89 1,600.94 1,362.40 77 1,748.54 2,196.64 1,757.54 2,218.77 1,777.04 1,512.2678 1,610.15 2,035.27 1,631.48 2,055.74 1,649.51 1,399.14 78 1,787.26 2,259.15 1,810.94 2,281.88 1,830.95 1,553.0579 1,646.90 2,094.19 1,681.72 2,115.22 1,700.24 1,436.87 79 1,828.06 2,324.55 1,866.70 2,347.89 1,887.27 1,594.9380 1,684.22 2,154.07 1,732.79 2,175.68 1,751.82 1,475.63 80 1,869.49 2,391.02 1,923.40 2,415.00 1,944.52 1,637.9481 1,717.11 2,216.49 1,785.94 2,238.55 1,805.37 1,515.42 81 1,905.99 2,460.30 1,982.39 2,484.79 2,003.96 1,682.1182 1,750.51 2,280.01 1,840.04 2,302.54 1,859.88 1,556.29 82 1,943.08 2,530.81 2,042.44 2,555.82 2,064.46 1,727.4883 1,784.44 2,344.65 1,895.10 2,367.64 1,915.36 1,598.26 83 1,980.73 2,602.56 2,103.56 2,628.08 2,126.04 1,774.0784 1,818.90 2,410.41 1,951.14 2,433.89 1,971.82 1,643.80 84 2,018.98 2,675.55 2,165.77 2,701.62 2,188.72 1,824.6285 1,853.89 2,477.32 2,008.17 2,501.29 2,029.28 1,690.63 85 2,057.82 2,749.83 2,229.07 2,776.43 2,252.50 1,876.6086 1,889.56 2,544.51 2,064.71 2,569.01 2,086.29 1,738.80 86 2,097.42 2,824.40 2,291.83 2,851.60 2,315.77 1,930.0787 1,925.90 2,613.16 2,122.49 2,638.20 2,144.54 1,788.34 87 2,137.74 2,900.60 2,355.96 2,928.39 2,380.44 1,985.0788 1,962.88 2,683.29 2,181.54 2,708.88 2,204.07 1,839.31 88 2,178.81 2,978.45 2,421.50 3,006.85 2,446.52 2,041.6389 1,998.91 2,752.68 2,240.04 2,778.81 2,263.06 1,891.71 89 2,218.80 3,055.47 2,486.44 3,084.48 2,512.00 2,099.7990 2,033.90 2,821.17 2,297.87 2,847.84 2,321.36 1,945.61 90 2,257.62 3,131.50 2,550.64 3,161.10 2,576.71 2,159.6391 2,057.97 2,877.44 2,345.38 2,904.42 2,369.14 1,989.00 91 2,284.35 3,193.96 2,603.37 3,223.91 2,629.75 2,207.8092 2,082.33 2,934.61 2,393.65 2,961.90 2,417.69 2,033.10 92 2,311.38 3,257.41 2,656.96 3,287.70 2,683.64 2,256.7493 2,106.97 2,992.67 2,442.70 3,020.27 2,467.01 2,077.92 93 2,338.73 3,321.86 2,711.39 3,352.50 2,738.38 2,306.4994 2,131.90 3,051.65 2,492.52 3,079.57 2,517.12 2,123.48 94 2,366.41 3,387.32 2,766.69 3,418.32 2,794.00 2,357.0595 2,157.13 3,111.55 2,543.14 3,139.80 2,568.02 2,169.77 95 2,394.41 3,453.82 2,822.88 3,485.18 2,850.50 2,408.4596 2,200.27 3,173.78 2,594.00 3,202.59 2,619.38 2,213.16 96 2,442.30 3,522.90 2,879.34 3,554.87 2,907.51 2,456.6297 2,244.27 3,237.26 2,645.88 3,266.65 2,671.77 2,257.43 97 2,491.15 3,593.36 2,936.93 3,625.98 2,965.66 2,505.7598 2,289.16 3,302.00 2,698.79 3,331.98 2,725.20 2,302.57 98 2,540.96 3,665.22 2,995.66 3,698.50 3,024.97 2,555.85

99+ 2,334.94 3,368.04 2,752.77 3,398.62 2,779.71 2,302.57 99+ 2,591.78 3,738.52 3,055.58 3,772.46 3,085.47 2,555.85


Plan A Plan D Plan F Plan G Plan N Plan A

Attained Age


Tobacco


MICHIGAN Standard Plans FEMALE Rates - ANNUALFOR USE IN ZIP CODES: 490-491,493-499



PREMIUM INFORMATION Everest Reinsurance Company may change your premium on any premium due date if a new table of rates is applicable to the policy. The change in the table of rates will apply to all covered persons in the same class. Class is determined by attained age, gender, underwriting class, state, and zip code of your primary residence.

Premiums are based on your attained age and will change on your policy anniversary date.

DISCLOSURES Use this outline to compare benefits and premiums among policies.

READ YOUR POLICY VERY CAREFULLY This is only an outline describing your policy’s most important features. The policy is your insurance contract. You must read the Policy itself to understand all of the rights and duties of both you and Everest Reinsurance Company.

RIGHT TO RETURN POLICY If you find that you are not satisfied with your policy, you may return it to: Everest Reinsurance Company, Medicare Supplement Administration, P.O. Box 10879, Clearwater, Florida 33757-8879. If you send the Policy back to us within 30 days after you receive it, we will treat the Policy as if it had never been issued and return all of your payments.

POLICY REPLACEMENT If you are replacing another health insurance policy, do NOT cancel it until you have actually received your new policy and are sure you want to keep it.

NOTICE This policy may not fully cover all of your medical costs. Neither Everest Reinsurance Company nor its agents are connected with Medicare. This outline of coverage does not give all the details of Medicare coverage. Contact your local Social Security Office or consult Medicare and You for more details.

COMPLETE ANSWERS ARE VERY IMPORTANT When you fill out the application for the new Policy, be sure to answer truthfully and completely all questions about your medical and health history. Everest Reinsurance Company may cancel your Policy and refuse to pay any claims if you leave out or falsify important medical information.

Review the application carefully before you sign it. Be certain that all information has been properly recorded.

Please refer to your Policy for details.


PLAN A

MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD *A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.

SERVICES MEDICARE PAYS PLAN PAYS YOU PAY

HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies

First 60 days All but $1316 $0 $1316 (Part A deductible)

61st thru 90th day All but $329 a day $329 a day $0 91st day and after: — While using 60 lifetime

reserve days All but $658 a day $658 a day $0 — Once lifetime reserve days

are used:

— Additional 365 days $0 100% of Medicare eligible expenses

$0**

— Beyond the additional 365 days $0 $0 All costs

SKILLED NURSING FACILITY CARE*

You must meet Medicare’s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital

First 20 days All approved amounts $0 $0 21st thru 100th day All but $164.50 a day $0 Up to $164.50 a day 101st day and after $0 $0 All costs

BLOOD

First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0

HOSPICE CARE

You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.

All but very limited co-payment/ coinsurance for outpatient drugs and inpatient respite care

Medicare copayment/coinsurance

$0

**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core 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.


PLAN A MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR

*Once you have been billed $183 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.


MEDICAL EXPENSES – IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as Physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment

First $183 of Medicare Approved Amounts* $0 $0 $183 (Part B deductible) Remainder of Medicare Approved Amounts Generally 80% Generally 20% $0

PART B EXCESS CHARGES (Above Medicare Approved Amounts) $0 $0 All costs BLOOD First 3 pints $0 All costs $0 Next $183 of Medicare Approved Amounts* $0 $0 $183 (Part B deductible) Remainder of Medicare Approved Amounts 80% 20% $0 CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0

PARTS A & B


HOME HEALTH CARE MEDICARE APPROVED SERVICES

— Medically necessary skilled care services and medical supplies 100% $0 $0

— Durable medical equipment First $183 of Medicare Approved Amounts* $0 $0 $183 (Part B deductible) Remainder of Medicare Approved Amounts 80% 20% $0


PLAN C




First 60 days All but $1316 $1316 (Part A deductible) $0 61st thru 90th day All but $329 a day $329 a day $0 91st day and after: — While using 60 lifetime


are used:


$0**




First 20 days All approved amounts $0 $0 21st thru 100th day All but $164.50 a day Up to $164.50 a day $0 101st day and after $0 $0 All costs

BLOOD


HOSPICE CARE



Medicare co-payment/coinsurance

$0



PLAN C MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR


SERVICES MEDICARE PAYS PLAN PAYS YOU PAY MEDICAL EXPENSES – IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as Physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment

First $183 of Medicare Approved Amounts* $0 $183 (Part B deductible) $0 Remainder of Medicare Approved Amounts Generally 80% Generally 20% $0

PART B EXCESS CHARGES (Above Medicare Approved Amounts) $0 $0 All costs BLOOD First 3 pints $0 All costs $0 Next $183 of Medicare Approved Amounts* $0 $183 (Part B deductible) $0 Remainder of Medicare Approved Amounts 80% 20% $0 CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0

PARTS A & B HOME HEALTH CARE MEDICARE APPROVED SERVICES


— Durable medical equipment First $183 of Medicare Approved Amounts* $0 $183(Part B deductible) $0 Remainder of Medicare Approved Amounts 80% 20% $0

OTHER BENEFITS – NOT COVERED BY MEDICARE FOREIGN TRAVEL – NOT COVERED BY MEDICARE

Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA

First $250 each calendar year $0 $0 $250 Remainder of charges $0 80% to a lifetime

maximum benefit of $50,000.

20% and amounts over the $50,000 lifetime maximum.


PLAN D



HOSPITALIZATION*

Semiprivate room and board, general nursing and miscellaneous services and supplies


reserve days All but $658 a day $658 a day $0 — Once lifetime reserve

days are used:


$0**





BLOOD


HOSPICE CARE




$0



PLAN D

MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR






PLAN D PARTS A & B

SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOME HEALTH CARE MEDICARE APPROVED SERVICES



OTHER BENEFITS – NOT COVERED BY MEDICARE

SERVICES MEDICARE PAYS PLAN PAYS YOU PAY FOREIGN TRAVEL – NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA





PLAN F

MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD

*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.

SERVICES MEDICARE PAYS PLAN PAYS YOU PAY HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies



days are used:


$0**




First 20 days All approved amounts $0 $0 21st thru 100th day All but $164.50 a day Up to $164.50 a day $0 101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.



$0



PLAN F




First $183 of Medicare Approved Amounts* $0 $183 (Part B deductible) $0 Remainder of Medicare Approved Amounts Generally 80% Generally 20% $0

PART B EXCESS CHARGES (Above Medicare Approved Amounts) $0 100% $0 BLOOD First 3 pints $0 All costs $0 Next $183 of Medicare Approved amounts* $0 $183 (Part B deductible) $0 Remainder of Medicare Approved amounts 80% 20% $0 CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0


PLAN F

PARTS A & B



— Durable medical equipment First $183 of Medicare Approved Amounts* $0 $183 (Part B deductible) $0 Remainder of Medicare Approved Amounts 80% 20% $0

OTHER SERVICES – NOT COVERED BY MEDICARE


First $250 each calendar year $0 $0 $250

Remainder of charges $0 80% to a lifetime maximum benefit of $50,000

20% and amounts over the $50,000 lifetime maximum


PLAN G

MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD

*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row.





are used:


$0**





BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0

HOSPICE CARE




$0



PLAN G

MEDICARE (PART B) – MEDICAL SERVICES-PER – CALENDAR YEAR




PART B EXCESS CHARGES (Above Medicare Approved Amounts) $0 100% $0 BLOOD First 3 pints $0 All costs $0 Next $183 of Medicare Approved Amounts* $0 $0 $183 (Part B deductible) Remainder of Medicare Approved Amounts 80% 20% $0 CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0


PLAN G

PARTS A & B





SERVICES MEDICARE PAYS PLAN PAYS YOU PAY FOREIGN TRAVEL – NOT COVERED BY MEDICARE

Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA

First $250 each calendar year $0 $0 $250

Remainder of Charges $0 80% to a lifetime maximum benefit of $50,000.

20% and amounts over the $50,000 lifetime maximum


PLAN N



HOSPITALIZATION*

Semiprivate room and board, general nursing and miscellaneous services and supplies



days are used:


$0**





BLOOD


HOSPICE CARE




$0



PLAN N




First $183of Medicare Approved Amounts*

$0 $0 $183 (Part B deductible)

Remainder of Medicare Approved Amounts

Generally 80% Balance, other than up to $20 per office visit and up to $50 per emergency room visit. The co-payment 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.

Up to $20 per office visit and up to $50 per emergency room visit. The co-payment 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.



PLAN N PARTS A & B









Documents

EVEREST REINSURANCE COMPANY Outline of Medicare … · EVOC2017MI Effective: 02-13-2017 Page 1 of 18 EVEREST REINSURANCE COMPANY Outline of Medicare Supplement Coverage Benefit Plans