AHLMS04865AZ OUTLINE MEDSUP AZ 032021A

Outline of coverage Medicare Supplement Insurance

Benefit plans: A, B, F, G High Deductible G, N

Arizona

Underwritten by

Aetna Health and Life Insurance Company

aetnaseniorproducts.com AHLMS04865AZ ©2020 Aetna Inc. Rates effective�: 03/2021 A

http://aetnaseniorproducts.com

AETNA HEALTH AND LIFE INSURANCE COMPANY OUTLINE OF MEDICARE SUPPLEMENT COVERAGE COVER PAGE BENEFIT PLANS AVAILABLE: A, B, F, G, HIGH DEDUCTIBLE G, N

Benefit Chart of Medicare Supplement Plans Sold on or After January 1, 2020

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.

Note: A ✔ means 100% of the benefit is paid.

Benefits

Plans Available to All Applicants

A B D G1 K L M N

Medicare first eligible before

2020 only C F1

Medicare Part A coinsurance and hospital coverage (up to an additional 365 days after Medicare benefits are used up)

✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔ ✔

Medicare Part B coinsurance or copayment ✔ ✔ ✔ ✔ 50% 75% ✔

✔ copays apply3

✔ ✔

Blood (first three pints) ✔ ✔ ✔ ✔ 50% 75% ✔ ✔ ✔ ✔

Part A hospice care coinsurance or copayment ✔ ✔ ✔ ✔ 50% 75% ✔ ✔ ✔ ✔

Skilled nursing facility coinsurance ✔ ✔ 50% 75% ✔ ✔ ✔ ✔

Medicare Part A deductible ✔ ✔ ✔ 50% 75% 50% ✔ ✔ ✔

Medicare Part B deductible ✔ ✔ Medicare Part B excess charges ✔ ✔

Foreign travel emergency (up to plan limits) ✔ ✔ ✔ ✔ ✔ ✔

Out-of-pocket limit in 20212 $62202 $31102

1 Plans F and G also have a high deductible option, which require first paying a plan deductible of $2370 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.

2 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.

3 Plan N pays 100% of the Part B coinsurance, except for a copayment of up to $20 for some office visits and up to a $50 copayment for emergency room visits that do not result in an inpatient admission.

1 AHLMS04865AZ 03/2021 A

Aetna Health and Life Insurance Company Annual Premiums

For Use in ZIP Codes: 850-853 and 857Female Rates

Rates Effective 3/1/2021

Issue Age

Preferred Plan A Plan B Plan F Plan G Plan HG Plan N

65 1,339 1,528 1,696 1,434 574 1,068 66 1,348 1,540 1,708 1,444 579 1,080 67 1,369 1,563 1,735 1,467 588 1,103 68 1,396 1,595 1,770 1,497 600 1,131 69 1,429 1,633 1,812 1,531 614 1,163 70 1,463 1,671 1,854 1,567 628 1,192 71 1,497 1,709 1,898 1,604 643 1,221 72 1,531 1,749 1,941 1,642 657 1,249 73 1,565 1,789 1,984 1,678 673 1,276 74 1,602 1,830 2,031 1,718 688 1,306 75 1,638 1,870 2,076 1,756 703 1,335 76 1,675 1,913 2,123 1,795 719 1,365 77 1,716 1,959 2,175 1,839 737 1,397 78 1,754 2,003 2,224 1,880 753 1,430 79 1,793 2,047 2,272 1,922 770 1,462 80 1,834 2,094 2,325 1,965 788 1,497 81 1,877 2,144 2,379 2,011 806 1,530 82 1,916 2,190 2,430 2,056 823 1,564 83 1,961 2,240 2,486 2,102 843 1,600 84 2,003 2,289 2,540 2,147 860 1,634 85 2,061 2,354 2,613 2,209 885 1,681 86 2,105 2,403 2,667 2,256 904 1,717 87 2,148 2,455 2,724 2,303 923 1,753 88 2,193 2,505 2,781 2,351 942 1,790 89 2,238 2,557 2,838 2,400 961 1,826 90 2,284 2,608 2,896 2,447 981 1,863 91 2,329 2,661 2,954 2,497 1,001 1,900 92 2,374 2,713 3,012 2,546 1,020 1,937 93 2,420 2,764 3,067 2,594 1,040 1,974 94 2,463 2,814 3,124 2,641 1,058 2,010 95 2,506 2,863 3,177 2,687 1,077 2,045 96 2,545 2,908 3,226 2,728 1,093 2,076 97 2,579 2,946 3,270 2,765 1,107 2,105 98 2,606 2,977 3,305 2,795 1,119 2,127 99+ 2,621 2,995 3,325 2,810 1,126 2,139

Issue Age

Standard Plan A Plan B Plan F Plan G Plan HG Plan N

65 1,487 1,697 1,885 1,594 639 1,187 66 1,498 1,710 1,898 1,606 643 1,200 67 1,521 1,737 1,928 1,631 653 1,225 68 1,551 1,772 1,967 1,663 666 1,257 69 1,588 1,814 2,013 1,701 682 1,293 70 1,625 1,856 2,060 1,742 698 1,325 71 1,662 1,899 2,108 1,782 715 1,356 72 1,703 1,943 2,157 1,824 730 1,388 73 1,740 1,987 2,204 1,864 748 1,418 74 1,780 2,034 2,256 1,908 764 1,451 75 1,821 2,079 2,308 1,951 782 1,483 76 1,861 2,126 2,359 1,995 799 1,516 77 1,906 2,177 2,415 2,043 819 1,552 78 1,949 2,226 2,471 2,090 837 1,589 79 1,991 2,275 2,524 2,134 855 1,624 80 2,037 2,327 2,583 2,184 875 1,663 81 2,085 2,382 2,644 2,235 895 1,700 82 2,130 2,433 2,699 2,284 915 1,737 83 2,179 2,488 2,763 2,335 936 1,778 84 2,226 2,543 2,822 2,385 956 1,816 85 2,291 2,616 2,903 2,456 983 1,867 86 2,339 2,672 2,964 2,506 1,004 1,908 87 2,387 2,727 3,027 2,559 1,026 1,948 88 2,437 2,783 3,089 2,612 1,046 1,988 89 2,486 2,841 3,153 2,666 1,068 2,028 90 2,538 2,898 3,218 2,720 1,090 2,070 91 2,589 2,956 3,282 2,775 1,112 2,111 92 2,638 3,015 3,345 2,830 1,134 2,152 93 2,689 3,072 3,410 2,882 1,155 2,193 94 2,738 3,128 3,472 2,935 1,176 2,233 95 2,785 3,181 3,531 2,984 1,197 2,272 96 2,827 3,231 3,586 3,031 1,214 2,308 97 2,866 3,273 3,634 3,072 1,231 2,339 98 2,896 3,308 3,672 3,105 1,244 2,363 99+ 2,912 3,328 3,694 3,122 1,251 2,376

The above rates do not include the $20 one-time policy fee.

To calculate a Household discount: Annual premium x modal factor = modal premium (round to nearest whole cent)

Modal premium x .93 = discounted premium

If applying during Open Enrollment or Guaranteed Issue Period, use Preferred rates.

Modal Factors: Semi-Annual: 0.5200 Quarterly: 0.2650 Monthly: 0.0833

2AHLMS04865AZ 03/2021 A

Male Rates

Issue Age


65 1,540 1,757 1,951 1,649 661 1,228 66 1,550 1,770 1,965 1,661 666 1,243 67 1,574 1,797 1,996 1,687 676 1,269 68 1,606 1,834 2,036 1,721 690 1,301 69 1,644 1,878 2,084 1,761 705 1,337 70 1,682 1,922 2,132 1,803 722 1,371 71 1,721 1,966 2,182 1,844 740 1,404 72 1,761 2,012 2,232 1,888 755 1,437 73 1,801 2,057 2,281 1,929 774 1,468 74 1,842 2,105 2,336 1,975 791 1,502 75 1,885 2,151 2,388 2,019 809 1,536 76 1,926 2,201 2,443 2,066 827 1,570 77 1,973 2,253 2,500 2,115 847 1,607 78 2,018 2,304 2,557 2,163 867 1,645 79 2,061 2,354 2,614 2,209 885 1,681 80 2,109 2,409 2,674 2,261 906 1,721 81 2,158 2,466 2,736 2,313 927 1,760 82 2,204 2,518 2,795 2,363 946 1,799 83 2,255 2,576 2,859 2,417 969 1,840 84 2,304 2,632 2,920 2,469 989 1,879 85 2,371 2,708 3,004 2,541 1,018 1,933 86 2,420 2,764 3,067 2,595 1,039 1,974 87 2,471 2,823 3,133 2,649 1,062 2,015 88 2,521 2,881 3,197 2,703 1,083 2,058 89 2,573 2,941 3,265 2,760 1,105 2,099 90 2,626 3,000 3,330 2,814 1,128 2,142 91 2,679 3,060 3,396 2,871 1,151 2,184 92 2,732 3,121 3,463 2,928 1,173 2,228 93 2,783 3,178 3,528 2,982 1,196 2,270 94 2,834 3,237 3,593 3,038 1,218 2,312 95 2,882 3,293 3,654 3,090 1,238 2,351 96 2,927 3,344 3,710 3,138 1,257 2,388 97 2,967 3,388 3,762 3,180 1,273 2,421 98 2,998 3,424 3,800 3,213 1,287 2,446 99+ 3,015 3,444 3,824 3,232 1,295 2,459

Issue Age


65 1,709

1,952

2,167 1,833

735

1,365 66 1,722 1,967 2,182

1,845 740 1,380 67 1,749 1,998 2,218 1,875 751 1,409 68 1,784 2,039 2,263 1,912 766 1,445 69 1,826 2,086 2,315 1,957 785 1,487 70 1,869 2,135 2,370 2,005 802 1,524 71 1,912 2,183 2,425 2,049 822 1,560 72 1,958 2,236 2,481 2,097 840 1,596 73 2,001 2,285 2,534 2,144 860 1,631 74 2,047 2,339 2,595 2,193 879 1,669 75 2,094 2,390 2,653 2,243 899 1,706 76 2,140 2,445 2,713 2,294 919 1,744 77 2,192 2,503 2,778 2,349 942 1,785 78 2,241 2,560 2,842 2,402 962 1,828 79 2,291 2,616 2,903 2,455 983 1,868 80 2,344 2,677 2,970 2,512 1,006 1,913 81 2,398 2,738 3,041 2,570 1,029 1,955 82 2,448 2,798 3,104 2,626 1,052 1,998 83 2,506 2,861 3,177 2,686 1,077 2,045 84 2,560 2,924 3,246 2,744 1,100 2,088 85 2,635 3,007 3,339 2,824 1,130 2,147 86 2,690 3,072 3,410 2,883 1,154 2,194 87 2,746 3,137 3,481 2,944 1,179 2,240 88 2,802 3,201 3,552 3,004 1,203 2,287 89 2,859 3,267 3,626 3,066 1,228 2,333 90 2,918 3,332 3,699 3,127 1,254 2,381 91 2,977 3,400 3,774 3,192 1,279 2,429 92 3,033 3,467 3,847 3,254 1,304 2,474 93 3,092 3,532 3,920 3,314 1,329 2,522 94 3,149 3,597 3,992 3,375 1,353 2,568 95 3,204 3,658 4,060 3,432 1,377 2,613 96 3,251 3,715 4,123 3,486 1,396 2,654 97 3,295 3,765 4,179 3,534 1,415 2,690 98 3,330 3,805 4,223 3,571 1,430 2,717 99+ 3,350 3,827 4,249 3,590 1,439 2,733


To calculate a Household discount: Annual premium x modal factor = modal premium (round to nearest whole cent) Modal premium x .93 = discounted premium




For Use in ZIP Codes: 850-853 and 857


3AHLMS04865AZ 03/2021 A


For Use in: Rest of StateFemale Rates

Issue Age


65 1,228 1,402 1,556 1,316 527 980 66 1,237 1,413 1,567 1,325 531 991 67 1,256 1,434 1,592 1,346 539 1,012 68 1,281 1,463 1,624 1,373 550 1,038 69 1,311 1,498 1,662 1,405 563 1,067 70 1,342 1,533 1,701 1,438 576 1,094 71 1,373 1,568 1,741 1,472 590 1,120 72 1,405 1,605 1,781 1,506 603 1,146 73 1,436 1,641 1,820 1,539 617 1,171 74 1,470 1,679 1,863 1,576 631 1,198 75 1,503 1,716 1,905 1,611 645 1,225 76 1,537 1,755 1,948 1,647 660 1,252 77 1,574 1,797 1,995 1,687 676 1,282 78 1,609 1,838 2,040 1,725 691 1,312 79 1,645 1,878 2,084 1,763 706 1,341 80 1,683 1,921 2,133 1,803 723 1,373 81 1,722 1,967 2,183 1,845 739 1,404 82 1,758 2,009 2,229 1,886 755 1,435 83 1,799 2,055 2,281 1,928 773 1,468 84 1,838 2,100 2,330 1,970 789 1,499 85 1,891 2,160 2,397 2,027 812 1,542 86 1,931 2,205 2,447 2,070 829 1,575 87 1,971 2,252 2,499 2,113 847 1,608 88 2,012 2,298 2,551 2,157 864 1,642 89 2,053 2,346 2,604 2,202 882 1,675 90 2,095 2,393 2,657 2,245 900 1,709 91 2,137 2,441 2,710 2,291 918 1,743 92 2,178 2,489 2,763 2,336 936 1,777 93 2,220 2,536 2,814 2,380 954 1,811 94 2,260 2,582 2,866 2,423 971 1,844 95 2,299 2,627 2,915 2,465 988 1,876 96 2,335 2,668 2,960 2,503 1,003 1,905 97 2,366 2,703 3,000 2,537 1,016 1,931 98 2,391 2,731 3,032 2,564 1,027 1,951 99+ 2,405 2,748 3,050 2,578 1,033 1,962

Issue Age


65 1,364 1,557 1,729 1,462 586 1,089 66 1,374 1,569 1,741 1,473 590 1,101 67 1,395 1,594 1,769 1,496 599 1,124 68 1,423 1,626 1,805 1,526 611 1,153 69 1,457 1,664 1,847 1,561 626 1,186 70 1,491 1,703 1,890 1,598 640 1,216 71 1,525 1,742 1,934 1,635 656 1,244 72 1,562 1,783 1,979 1,673 670 1,273 73 1,596 1,823 2,022 1,710 686 1,301 74 1,633 1,866 2,070 1,750 701 1,331 75 1,671 1,907 2,117 1,790 717 1,361 76 1,707 1,950 2,164 1,830 733 1,391 77 1,749 1,997 2,216 1,874 751 1,424 78 1,788 2,042 2,267 1,917 768 1,458 79 1,827 2,087 2,316 1,958 784 1,490 80 1,869 2,135 2,370 2,004 803 1,526 81 1,913 2,185 2,426 2,050 821 1,560 82 1,954 2,232 2,476 2,095 839 1,594 83 1,999 2,283 2,535 2,142 859 1,631 84 2,042 2,333 2,589 2,188 877 1,666 85 2,102 2,400 2,663 2,253 902 1,713 86 2,146 2,451 2,719 2,299 921 1,750 87 2,190 2,502 2,777 2,348 941 1,787 88 2,236 2,553 2,834 2,396 960 1,824 89 2,281 2,606 2,893 2,446 980 1,861 90 2,328 2,659 2,952 2,495 1,000 1,899 91 2,375 2,712 3,011 2,546 1,020 1,937 92 2,420 2,766 3,069 2,596 1,040 1,974 93 2,467 2,818 3,128 2,644 1,060 2,012 94 2,512 2,870 3,185 2,693 1,079 2,049 95 2,555 2,918 3,239 2,738 1,098 2,084 96 2,594 2,964 3,290 2,781 1,114 2,117 97 2,629 3,003 3,334 2,818 1,129 2,146 98 2,657 3,035 3,369 2,849 1,141 2,168 99+ 2,672 3,053 3,389 2,864 1,148 2,180


To calculate a Household discount: Annual premium x modal factor = modal premium (round to nearest whole cent)

Modal premium x .93 = discounted premium



Modal Factors: Semi-Annual: 0.5200 Quarterly:

4AHLMS04865AZ 03/2021 A

Male Rates


Issue Age


65 1,413 1,612 1,790 1,513 606 1,127 66 1,422 1,624 1,803 1,524 611 1,140 67 1,444 1,649 1,831 1,548 620 1,164 68 1,473 1,683 1,868 1,579 633 1,194 69 1,508 1,723 1,912 1,616 647 1,227 70 1,543 1,763 1,956 1,654 662 1,258 71 1,579 1,804 2,002 1,692 679 1,288 72 1,616 1,846 2,048 1,732 693 1,318 73 1,652 1,887 2,093 1,770 710 1,347 74 1,690 1,931 2,143 1,812 726 1,378 75 1,729 1,973 2,191 1,852 742 1,409 76 1,767 2,019 2,241 1,895 759 1,440 77 1,810 2,067 2,294 1,940 777 1,474 78 1,851 2,114 2,346 1,984 795 1,509 79 1,891 2,160 2,398 2,027 812 1,542 80 1,935 2,210 2,453 2,074 831 1,579 81 1,980 2,262 2,510 2,122 850 1,615 82 2,022 2,310 2,564 2,168 868 1,650 83 2,069 2,363 2,623 2,217 889 1,688 84 2,114 2,415 2,679 2,265 907 1,724 85 2,175 2,484 2,756 2,331 934 1,773 86 2,220 2,536 2,814 2,381 953 1,811 87 2,267 2,590 2,874 2,430 974 1,849 88 2,313 2,643 2,933 2,480 994 1,888 89 2,361 2,698 2,995 2,532 1,014 1,926 90 2,409 2,752 3,055 2,582 1,035 1,965 91 2,458 2,807 3,116 2,634 1,056 2,004 92 2,506 2,863 3,177 2,686 1,076 2,044 93 2,553 2,916 3,237 2,736 1,097 2,083 94 2,600 2,970 3,296 2,787 1,117 2,121 95 2,644 3,021 3,352 2,835 1,136 2,157 96 2,685 3,068 3,404 2,879 1,153 2,191 97 2,722 3,108 3,451 2,917 1,168 2,221 98 2,750 3,141 3,486 2,948 1,181 2,244 99+ 2,766 3,160 3,508 2,965 1,188 2,256

Issue Age


65 1,568 1,791

1,988

1,682

674 1,252 66 1,580 1,805 2,002 1,693 679 1,266 67 1,605 1,833 2,035 1,720 689 1,293 68 1,637 1,871 2,076 1,754 703 1,326 69 1,675 1,914 2,124 1,795 720 1,364 70 1,715 1,959 2,174 1,839 736 1,398 71 1,754 2,003 2,225 1,880 754 1,431 72 1,796 2,051 2,276 1,924 771 1,464 73 1,836 2,096 2,325 1,967 789 1,496 74 1,878 2,146 2,381 2,012 806 1,531 75 1,921 2,193 2,434 2,058 825 1,565 76 1,963 2,243 2,489 2,105 843 1,600 77 2,011 2,296 2,549 2,155 864 1,638 78 2,056 2,349 2,607 2,204 883 1,677 79 2,102 2,400 2,663 2,252 902 1,714 80 2,150 2,456 2,725 2,305 923 1,755 81 2,200 2,512 2,790 2,358 944 1,794 82 2,246

2,567 2,848 2,409 965 1,833 83 2,299 2,625 2,915 2,464 988

1,876 84 2,349 2,683

2,978 2,517 1,009 1,916 85 2,417 2,759 3,063 2,591 1,037 1,970 86 2,468 2,818 3,128 2,645 1,059 2,013 87 2,519 2,878 3,194 2,701 1,082 2,055 88 2,571 2,937 3,259 2,756 1,104 2,098 89 2,623 2,997 3,327 2,813 1,127 2,140 90 2,677 3,057 3,394 2,869 1,150 2,184 91 2,731 3,119 3,462 2,928 1,173 2,228 92 2,783 3,181 3,529 2,985 1,196 2,270 93 2,837 3,240 3,596 3,040 1,219 2,314 94 2,889 3,300 3,662 3,096 1,241 2,356 95 2,939 3,356 3,725 3,149 1,263 2,397 96 2,983 3,408 3,783 3,198 1,281 2,435 97 3,023 3,454 3,834 3,242 1,298 2,468 98 3,055 3,491 3,874 3,276 1,312 2,493 99+ 3,073 3,511 3,898 3,294 1,320 2,507


For Use in: Rest of State



To calculate a Household discount: Annual premium x modal factor = modal premium (round to nearest whole cent) Modal premium x .93 = discounted premium


5AHLMS04865AZ 03/2021 A

AHLMS04865AZ 6 03/2021 A

PREMIUM INFORMATION Aetna Health and Life Insurance Company can only raise your premium if we raise the premium for all policies like yours in this state.

Premiums payable other than annually will be determined according to the following factors:

Semi-annual: 0.5200 Quarterly: 0.2650 Monthly EFT: 0.0833.

HOUSEHOLD DISCOUNT In order to be eligible for the Household discount under an Aetna Health and Life Insurance Company Medicare supplement plan, you must apply for a Medicare supplement plan at the same time as another Medicare eligible adult or the other Medicare eligible adult must currently have a Medicare supplement policy with an Aetna company. The Medicare eligible adult must be either (a) your spouse or someone with whom you are in a civil union partnership; and (b) someone with whom you have continuously resided for the past 12 months. The household discount will only be applicable if a policy for each applicant is issued. The discounted rates will be 7 percent lower than the individual rates and will apply as long as both policies remain in force.

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

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

RIGHT TO RETURN POLICY If you find that you are not satisfied with your policy, you may return it to Aetna Health and Life Insurance Company, P.O. Box 14770, Lexington, KY 40512-4770. 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 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

The policy may not cover all of your medical costs.

Neither Aetna Health and Life Insurance 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 & 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 any questions about your medical and health history. The company may cancel your policy and refuse to pay any claims if you leave out or falsify important medical information.

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

THE FOLLOWING CHARTS DESCRIBE PLANS A, B, F, G, HIGH DEDUCTIBLE G, and N OFFERED BY AETNA HEALTH AND LIFE INSURANCE COMPANY.

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 $1484 $0 $1484

(Part A Deductible) 61st thru 90th day All but $371 a day $371 a day $0 91st day and after •While using 60 lifetime reserve days All but $742 a day $742 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 $185.50 a day $0 Up to $185.50 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 copayment/ 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.

AHLMS04865AZ 7 03/2021 A

PLAN A

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

*Once you have been billed $203 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.


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 $203 of Medicare-Approved amounts*

$0 $0 $203 (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 $203 of Medicare-Approved amounts*


Remainder of Medicare-Approved amounts 80% 20% $0 CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0

PARTS A & B


PLAN PAYS

YOU PAY

HOME HEALTH CARE – MEDICARE APPROVED SERVICES •Medically necessary skilled care services and medical supplies

100% $0 $0

•Durable medical equipment

•First $203 of Medicare Approved amounts*


•Remainder of Medicare Approved amounts 80% 20% $0

8 AHLMS04865AZ 03/2021 A

PLAN B


* 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.


PLAN PAYS

YOU PAY

HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $1484 $1484

(Part A Deductible) $0

61st thru 90th day All but $371 a day $371 a day $0 91st day and after •While using 60 lifetime reserve days All but $742 a day $742 a day $0 •Once lifetime reserve days are used: •Additional 365 days $0 100% of Medicare


•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 $185.50 a day $0 Up to $185.50 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.



$0


9 AHLMS04865AZ 03/2021 A

PLAN B


* Once you have been billed $203 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.


PLAN PAYS

YOU PAY



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 $203 of Medicare-Approved amounts*



PARTS A & B


PLAN PAYS

YOU PAY


100% $0 $0

•Durable medical equipment •First $203 of Medicare Approved amounts*



10 AHLMS04865AZ 03/2021 A

PLAN F




PLAN PAYS

YOU PAY



61st thru 90th day All but $371 a day $371 a day $0 91st day and after •While using 60 lifetime reserve days All but $742 a day $742 a day $0 •Once lifetime reserve days are used:•Additional 365 days

$0 100% of Medicare


•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 da y All but $185.50 a day Up to $185.50 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


11 AHLMS04865AZ 03/2021 A

PLAN F




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 test, durable medical equipment First $203 of Medicare-Approved amounts*

$0 $203 (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 $203 of Medicare-Approved amounts*


$0


PARTS A & B


PLAN PAYS

YOU PAY


100% $0 $0

•Durable medical equipment •First $203 of Medicare Approved amounts*


$0


12 AHLMS04865AZ 03/2021 A

PLAN F

OTHER BENEFITS – NOT COVERED BY MEDICARE


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

13 AHLMS04865AZ 03/2021 A

PLAN G




PLAN PAYS

YOU PAY

HOSPITALIZATION* Semiprivate room and board, generalnursing and miscellaneous services and supplies First 60 days All but $1484 $1484


61st thru 90th day All but $371 a day $371 a day $0 91st day and after •While using 60 lifetime reserve days All but $742 a day $742 a day $0 •Once lifetime reserve days are used: •Additional 365 days $0 100% of Medicare


•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 facilitywithin 30 days after leaving the hospital First 20 days All approved amounts $0 $0 21st thru 100th da y All but $185.50 a day Up to $185.50 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 services



$0


14 AHLMS04865AZ 03/2021 A

PLAN G




PLAN PAYS

YOU PAY


$0 $0 $203 (unless the Part B Deductible has been met)

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 $203 of Medicare-Approved amounts*



PARTS A & B


PLAN PAYS

YOU PAY

HOME HEALTH CARE – MEDICARE APPROVED SERVICES • Medically necessary skilled care services and medical supplies 100% $0 $0 •Durable medical equipment • First $203 of Medicare Approved amounts*



15 AHLMS04865AZ 03/2021 A

PLAN G


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



16 AHLMS04865AZ 03/2021 A

HIGH DEDUCTIBLE PLAN G



***This high deductible plan pays the same benefits as Plan G after one has paid a calendar year $2370 deductible. Benefits from high deductible plan G will not begin until out-of-pocket expenses are $2370. 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.


AFTER YOU PAY $2370

DEDUCTIBLE*** PLAN PAYS

IN ADDITION TO $2370

DEDUCTIBLE*** YOU PAY



61st thru 90th day All but $371 a day $371 a day $0 91st day and after * While using 60 lifetime reserve days All but $742 a day $742 a day $0 * Once lifetime reserve days are used: * Additional 365 days $0 100% of Medicare


*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 da y All but $185.50 a day Up to $185.50 a day $0 101st day and after $0 $0 All costs BLOOD First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0

17 AHLMS04865AZ 03/2021 A

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



$0


18 AHLMS04865AZ 03/2021 A




***This high deductible plan pays the same benefits as Plan G after one has paid a calendar year $2370 deductible. Benefits from high deductible plan G will not begin until out-of-pocket expenses are $2370. 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.


AFTER YOU PAY $2370





$0 $0 $203 (Unless Part B Deductible has been met)

Remainder o f 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 $203 of Medicare-Approved amounts*


Remainder o f Medicare-Approved amounts 80% 20% $0 CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0

19 AHLMS04865AZ 03/2021 A


PARTS A & B


AFTER YOU PAY $2370




HOME HEALTH CARE – MEDICARE APPROVED SERVICES *Medically necessary skilled care services and medical supplies

100% $0 $0

* Durable medical equipment * First $203 of Medicare Approved amounts*


* Remainder o f Medicare Approved amounts 80% 20% $0



AFTER YOU PAY $2370 DEDUCTIBLE**

PLAN PAYS

IN ADDITION TO $2370 DEDUCTIBLE**

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



20 AHLMS04865AZ 03/2021 A

PLAN N




PLAN PAYS

YOU PAY



61st thru 90th day All but $371 a day $371 a day $0 91st day and after * While using 60 lifetime reserve days All but $742 a day $742 a day $0 * Once lifetime reserve days are used:* Additional 365 days

$0 100% of Medicare


*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 da y All but $185.50 a day Up to $185.50 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 services


Medicare co-payment/ coinsurance

$0


21 AHLMS04865AZ 03/2021 A

PLAN N




PLAN PAYS

YOU PAY



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.

Part B Excess Charges (Above Medicare-Approved amounts) $0 0% All costs BLOOD First 3 pints $0 All costs $0 Next $203 of Medicare-Approved amounts*


Remainder o f Medicare-Approved amounts 80% 20% $0 CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0

22 AHLMS04865AZ 03/2021 A

PLAN N

PARTS A & B


PLAN PAYS

YOU PAY

HOME HEALTH CARE – MEDICARE APPROVED SERVICES • Medically necessary skilled care services and medical supplies 100% $0 $0 * Durable medical equipment • First $203 of Medicare Approved amounts*


*Remainder of Medicare Approved amounts 80% 20% $0



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


23 AHLMS04865AZ 03/2021 A

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AHLMS04865AZ OUTLINE MEDSUP AZ 032021A

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