Outline of Coverage for Standardized
Medicare Supplement Insurance Plan G

Part A Details
Services Medicare Pays Plan Pays You Pay
Part A Deductible $0 $1484 $0
First 60 days All but $1484 (Part A deductible) $1484 (Part A deductible) $0
61st through 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 Balance 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 All costs $0
21st through 100th day All but $185.5 a day Coinsurance amount of Medicare eligible expenses. $0
101st day and after $0 $0 All costs

BLOOD

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

HOSPICE CARE

Details All but very limited coinsurance for outpatient drugs and inpatient respite care $0 A coinsurance or copayment, up to $5 for inpatient drugs and 5% of the Medicare-approved amount for inpatient respite care.
Part B Details
Services Medicare Pays Plan Pays You Pay
Part B Deductible $0 $0 $203 (Part B deductible)
Remainder of Medicare approved amounts 80% Coinsurance amount of Medicare eligible expenses. $0
Part B excess charges (above Medicare approved amounts) $0 All costs $0

BLOOD

First three pints $0 All costs $0
Next $203 of Medicare approved amounts $0 $0 $203 (Part B deductible)
Remainder of Medicare approved amounts 80% Coinsurance amount of Medicare eligible expenses. $0

DURABLE MEDICAL EQUIPMENT

First $203 of Medicare approved amounts $0 $0 $203 (Part B deductible)
Remainder of Medicare approved amounts 80% Coinsurance amount of Medicare eligible expenses. $0

FOREIGN TRAVEL EMERGENCY

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

AT HOME RECOVERY

At home recovery All approved amounts $0 $0

PREVENTIVE CARE

Details 80% Coinsurance amount of Medicare eligible expenses $0
Preventive Care not covered by Medicare $0 $0 All costs

OTHER

Deductible -------- -------- N/A
Network -------- -------- No network
Maximum yearly copayment -------- -------- N/A

* This information is for general plan comparison only. While we strive to be accurate, we cannot guarantee the above information to be a perfect representation of benefits, nor can we guarantee the accuracy of the premium amount shown. Licensed Medicare Supplement Insurance Specialists should be consulted for a detailed description of benefits and limitations.