Americo Medicare Supplement...If, after purchasing this policy, you become eligible for Medicaid, the benefits and premiums under your Medicare Supplement policy can be suspended,

Home Office: Dallas, Texas • Medicare Supplement Administrative Office: PO BOX 10812, Clearwater, FL 33757-8812 • https://service.iasadmin.com/acFor Use in Pennsylvania15-138-8-PA (01/19)

Agents: When filling out applications, be sure to include your client’s email address. This will allow us to better service your clients’ policies.

Included in this packet: Application for Medicare Supplement Insurance Health Information Authorization Medicare Supplement Replacement Notice Bank Draft Authorization for Medicare Supplement Important Consumer Notices Guaranteed Issue Eligibility Disclosure Producer Statement Medicare Supplement Premium Worksheet Outline of Coverage Rate Guide Fax Transmittal

Additional forms that may be required: Choosing a MediGap Policy: A Guide to Health Insurance for People with Medicare – Must be left with

applicant at the point of sale for all states.

MedicareApplication Packet

Americo

Supplement

Home Office: Dallas, Texas • Medicare Supplement Administrative Office: PO Box 10812, Clearwater, FL 33757-8812 • https://service.iasadmin.com/ac 15-138-11 (08/15)

Fax applications and New Business documents ONLY to: 855.864.8526

Important:

• Only applications paying the initial premium by bank draft are eligible to be faxed. • DO NOT collect premium with an application that is being faxed. • All applications submitted with this form must be written by the same agent. • Please use one transmittal per application unless submitting companions. Companions should be faxed in together. • Do not mail in applications/forms once you have faxed them, original copies should be maintained in case of fax transmission problems. • It is important to include phone/fax number below. • DO NOT submit Pre-Underwriting Issues through the fax number above (2nd applications, replacement forms, or other additional documents).

Forms Sequence:

1. Application (include Application Addendum, if applicable) 2. Producer Statement 3. Health Information Authorization 4. Replacement Notice (if applicable) 5. Other state-specific required forms (if applicable) 6. Guaranteed Issue documentation (if applicable) 7. Signed Bank Draft Authorization

PLEASE PRINT LEGIBLY

Agent Name Agent Code

Agent Phone Number Agent Fax Number Total No. of Pages Faxed (including this cover sheet):

Applicant Name Plan Applied For

Initial Premium Amount to be drafted or charged

(include policy fee)

All application questions should be directed to the Underwriting Department at 877.212.2346.

Medicare Supplement Application Transmittal Form 15-138-11 (08/15)

Home Office: Dallas, Texas • Medicare Supplement Administrative Office: PO Box 10812, Clearwater, FL 33757-8812 • https://service.iasadmin.com/ac

APA5510 Page 1 of 5 For Use in Pennsylvania (10/18)

Americo Financial Life and Annuity Insurance Company

Medicare Supplement Administrative Office: PO Box 10812, Clearwater, FL 33757-8812

New Business Coverage Change Reinstatement

Part I – Personal Information

Title: Mr. Mrs. Miss Ms. Other______________

Last Name First Name MI Gender

Male Female

Street Address

City State ZIP

Birthdate (mm/dd/yyyy) Age Social Security Number Height

______ft. ______in.

Weight

_______________lbs.

Medicare ID Number Requested Start Date (if other than the Application Date)

____________________________ (mm/dd/yyyy)

Daytime Phone Evening Phone Mobile Phone

Email Address

Part II – Plan Selection

A B F F - High Deductible G N

Part III – Eligibility

State law allows a 6-month open enrollment period beginning with the first day of the first month in which you are both: (1) age 65

or older or (2) eligible for Medicare due to Disability and (3) enrolled in Medicare Part B. If you are a qualified open enrollee, you

may apply for and receive any Medicare Supplement Plan available from us.

1. Are you covered under Medicare Part A? ........................................................................................................................... Yes No

a. If Yes, what is your Part A start date? _______/_______/_______

b. If No, what is your eligibility date? _______/_______/_______ 2. Did you enroll in Medicare Part B in the last 6 months? ................................................................................................. Yes No

a. If Yes, what is your Part B start date? _______/_______/_______

b. If No, what is your eligibility date? _______/_______/_______ 3. Have you enrolled in Medicare Part B more than once? ................................................................................................ Yes No 4. Did you turn 65 in the last 6 months? ................................................................................................................................... Yes No 5. Are you are applying to have coverage effective under age 65 due to Disability? ................................................. Yes No

Application for

Medicare Supplement Insurance APA5510



APA5510

Part IV – Medicare & Insurance Information

If you lost or are losing other health insurance coverage and received a notice from your prior insurer saying you are eligible for guaranteed issue of a Medicare Supplement insurance policy or certificate, or that you had certain rights to buy such a policy or certificate, you may be guaranteed acceptance in one or more of our Medicare Supplement plans. Please include a copy of the notice from your prior insurer with this Application. Please mark Yes or No below with an “X”, to the best of your knowledge.

PLEASE ANSWER ALL QUESTIONS

1. Are you applying during a guaranteed issue period? (If Yes, please attach proof of eligibility.) ....................... Yes No

2. Are you covered for Medical Assistance through the state Medicaid program? ..................................................... Yes No NOTE TO APPLICANT: If you are participating in a “Spend Down Program” and have not met your

“Share of the Cost”, please answer No to this question.

a. Will Medicaid pay your premiums for this Medicare Supplement policy? ......................................................... Yes No

b. Do you receive any benefits from Medicaid, OTHER THAN payments toward your Part B premium? ........ Yes No

3. a. If you had coverage from any Medicare Plan other than Original Medicare within the past 63 days (for example, a Medicare Advantage plan, or a Medicare HMO or PPO), fill in your “Start” and “Paid-to” dates below.

If you are still covered under this plan, leave “End Date” blank.

Start Date _______/_______/_______ End Date_______/_______/_______ (mm/dd/yyyy)

b. If you are still covered under the Medicare plan, do you intend to replace your current coverage with this new Medicare Supplement policy? (If Yes, complete Replacement Notice.) .................................. Yes No

If so, with what company? _______________________________________________________________________________________

Policy Number: _________________________________________________________________________________________________

Telephone Number: _________________________ What plan do you have? ___________________________________________

(i) Was this your first time in this type of Medicare Plan? .................................................................................... Yes No

(ii) Did you drop a Medicare Supplement policy or certificate to enroll in the Medicare Plan? .................. Yes No

4. Do you have another Medicare Supplement policy or certificate in force? ............................................................... Yes No

a. If so, with what company? _______________________________________________________________________________________

Policy or Certificate Number: ____________________________________________________________________________________

Telephone Number: ______________________ What plan do you have? ______________________________________________

b. If so, do you intend to replace your current Medicare Supplement policy or certificate with this policy? (If Yes, complete Replacement Notice.) ................................................................................................ Yes No

5. Have you had coverage under any other health insurance within the past 63 days? (For example, an employer, union, or individual plan.) ............................................................................................................................... Yes No

a. If so, with what company? _______________________________________________________________________________________

(i) What kind of policy and plan number? _______________________________________________________________________

(ii) What are your dates of coverage under the policy?

Start Date _______/_______/_______ End Date_______/_______/_______ (mm/dd/yyyy)



APA5510

Part V – General Information

1. You do not need more than one Medicare Supplement policy or certificate.

2. If you purchase this policy, you may want to evaluate your existing health coverage and decide if you need multiple coverages.

3. You may be eligible for benefits under Medicaid and may not need a Medicare Supplement policy or certificate.

4. If, after purchasing this policy, you become eligible for Medicaid, the benefits and premiums under your Medicare Supplement policy can be suspended, if requested, during your entitlement to benefits under Medicaid for 24 months. You must request this suspension within 90 days of becoming eligible for Medicaid. Upon receipt of your request, we will return to you that portion of the premium attributable to the period of your Medicaid eligibility, subject to an adjustment for paid claims. If you are no longer entitled to Medicaid, your suspended Medicare Supplement policy or, if that is no longer available, a substantially equivalent policy will be reinstituted, effective as of the date of termination of Medicaid, if requested within 90 days of losing your Medicaid eligibility. If the Medicare Supplement policy provided coverage for outpatient prescription drugs and you enrolled in Medicare Part D while your policy was suspended, the reinstituted policy will not have outpatient prescription drug coverage, but will otherwise be substantially equivalent to your coverage before the date of suspension.

5. If you are eligible for, and have enrolled in a Medicare Supplement policy or certificate by reason of disability and you later become covered by an employer or union based group health plan, the benefits and premiums under your Medicare Supplement policy or certificate can be suspended, if requested, while you are covered under the employer or union based group health plan. If you suspend your Medicare Supplement policy or certificate under these circumstances, and later lose your employer or union based group health plan, your suspended Medicare Supplement policy or certificate or, if that is no longer available, a substantially equivalent policy or certificate, will be reinstituted if requested within 90 days of losing your employer or union based group health plan. If the Medicare Supplement policy or certificate provided coverage for outpatient prescription drugs and you enrolled in Medicare Part D while your policy or certificate was suspended, the reinstituted policy or certificate will not have outpatient prescription drug coverage, but will otherwise be substantially equivalent to your coverage before the date of suspension.

6. Counseling services may be available in your state to provide advice concerning your purchase of Medicare Supplement insurance and concerning medical assistance through the state Medicaid Program, including benefits as a Qualified Medicare Beneficiary (QMB) and a Specified Low Income Medicare Beneficiary (SLMB).

Part VI – Household Premium Discount Information

You may be eligible for a policy with a lower premium rate based on your answers to the question in this section.

1. Do you have a household resident that you have continuously resided with for the last 12 months with whom you are in a legal relationship? ........................................................................................................................ Yes No

Part VII – Premium Payment & Administration

Initial Premium:_______________________________ Premium Mode/Method: Monthly Bank Draft Annual Direct Bill

Part VIII – Medical Questions

Do not answer any health questions if you are in an open enrollment or guaranteed issue period. Please see Part III and Part IV for an explanation of open enrollment/guaranteed issue period information.

NOTICE TO APPLICANT: Please answer all of the following questions to the best of your knowledge and belief. Please verify the accuracy and completeness of the medical information on this application. Incomplete or false information on this application could jeopardize future claims. If you answer YES to any of the following questions 2-14, you are not eligible for coverage.

1. Within the past 12 months, have you used nicotine products in any form? .................................................... Yes No

2. Are you currently or within the past 6 months been: a. Hospitalized, bedridden, confined to a wheelchair, or require the use of a motorized mobility aid? ........ Yes No b. Residing in a nursing home or assisted living facility, or other professional care facility? ........................... Yes No c. Receiving home health care?......................................................................................................................................... Yes No d. Receiving assistance with Activities of Daily Living including eating, bathing, toileting, or dressing? ..... Yes No e. Diagnosed with a Terminal Illness? .............................................................................................................................. Yes No



APA5510

Part VIII – Medical Questions (continued)

3. Do you currently receive care or treatment that requires administration of medications or physical therapy in a medical facility or by a licensed member of the medical profession, including but not limited to: joint injections to alleviate pain, infusions or for pain to joints, spine or other areas of the body, biologics, infusions, or treatments for chronic illness that must be administered by a licensed practitioner (excluding b12 injections)? ...................................................................................................................................................... Yes No

4. Do you currently have an implanted cardiac defibrillator?.............................................................................................. Yes No

5. Have you ever been diagnosed with, advised, or treated by a member of the medical profession for: a. Pulmonary Hypertension (excluding common high blood pressure), Emphysema, chronic obstructive

pulmonary disease (COPD), or other chronic respiratory disorders (excluding seasonal asthma), or do you require the use of supplemental oxygen at any time of the day or night (excluding CPAP and BiPAP for sleep apnea)? .......................................................................................................................................... Yes No

b. Parkinson’s disease, systemic lupus, myasthenia gravis, muscular dystrophy, or amyotrophic lateral sclerosis (ALS), Multiple Sclerosis, osteoporosis with fractures, cirrhosis, or chronic hepatitis or liver failure? .................................................................................................................................................... Yes No

c. Alzheimer’s disease, senile dementia, or any other cognitive or memory disorder? ...................................... Yes No d. Chronic kidney disease, kidney failure, renal insufficiency, or kidney disease requiring dialysis? ............ Yes No

6. Have you ever been advised by a licensed member of the medical profession: a. that surgery, including cataract surgery, may be required within the next 12 months? ................................. Yes No b. to have surgery, medical tests, treatment, or therapy (including physical therapy) that has not

yet been performed, or are you currently receiving therapy or treatment or awaiting test results? ........... Yes No c. to have an organ transplant or have you ever had an organ transplant? .......................................................... Yes No

7. Have you ever been diagnosed with, advised, or treated by a licensed member of the medical profession for Acquired Immune Deficiency Syndrome (AIDS), AIDS-related complex (ARC) or Human Immunodeficiency Syndrome (HIV)? .................................................................................................................................... Yes No

8. Have you ever had an amputation Not caused by an injury or accident? ................................................................. Yes No

9. Have you ever been diagnosed with, received care or treatment for, or been advised by a licensed member of the medical profession to seek treatment for Diabetes in any form or been advised to take medication of any kind to reduce or control your blood sugar in addition to:

a. Requiring more than 50 units of insulin daily? ........................................................................................................... Yes No b. Ever being diagnosed by a licensed member of the medical profession with Coronary Artery Disease,

Neuropathy, amputation, peripheral artery disease, heart disorder or disease, Stroke, Transient Ischemic Attack (TIA), kidney disease or insufficiency, CHF, Vascular Disease, Heart Valve Disease,

Heart Rhythm Disturbances, or Retinopathy? ........................................................................................................... Yes No c. Ever being diagnosed by a licensed member of the medical profession with Hypertension (High Blood Pressure) which has required hospitalization; or has, within the past 12 months, required you to take more than three (3) medications for hypertension or been diagnosed as not well controlled by a licensed member of the medical profession? ....................................................................... Yes No

10. Within the past 2 years, have you been diagnosed with, advised, or treated by a licensed member of the medical profession for Cancer, metastasis, brain tumor, Lymphoma, Melanoma (including Merkel Cell, Melanoma, and Squamous Cell, but not including basal cell cancer of the skin), Alcoholism, Drug Abuse, or been advised by a licensed member of the medical profession to reduce alcohol intake? ............................. Yes No

11. In the past 2 years, have you been diagnosed with, advised, or treated by a licensed member of the medical profession for any mental or nervous disorder requiring hospitalization? ................................................. Yes No

12. Within the past 2 years, have you: a. been advised by a licensed member of the medical profession to have a joint replacement not

yet completed? .................................................................................................................................................................... Yes No b. had a joint replacement from which you are not completely recovered? ........................................................... Yes No c. been treated by a licensed member of the medical profession for rheumatoid arthritis or crippling or

disabling arthritis? ............................................................................................................................................................... Yes No



APA5510

Part VIII – Medical Questions (continued)

13. Within the past 2 years, have you been diagnosed with, advised, or treated by a licensed member of the medical profession for:

a. Heart attack? ........................................................................................................................................................................ Yes No b. Stroke or TIA (Transient Ischemic Attack or “Mini Stroke”)? ................................................................................. Yes No c. Bypass or Stent placement in any artery? .................................................................................................................. Yes No d. Initial installation of a Pacemaker? ................................................................................................................................ Yes No e. Initial diagnosis of Atrial Fibrillation or undergone Ablation procedure? ............................................................ Yes No f. Heart Valve Surgery for repair or replacement? ........................................................................................................ Yes No g. Pulmonary Embolism? ...................................................................................................................................................... Yes No h. Congestive Heart Failure, enlarged heart, or Cardiomyopathy? .......................................................................... Yes No

14. Within the past 2 years, have you received an initial diagnosis by a licensed member of the medical profession, or begun treatment for Coronary Artery Disease (CAD), Cerebrovascular Disease (CVD), or Peripheral Vascular Disease (PVD)? (Answer “No” if treatment began prior to the last 2 years and for which you remain on medication prescribed by a licensed member of the medical profession and/or you have been told by a licensed member of the medical profession that you maintain good control.) ................... Yes No

Part IX – Other Health Insurance Policies or Certificates

Listed below are all other health insurance policies or certificates I, the Producer, have (a) sold to the Applicant which are still in force; (b) sold to the Applicant in the last 5 years which are no longer in force.

Company Type of Policy Effective Date In Force

Yes No

Yes No

Yes No

Part X – Agreement & Acknowledgment

I wish to apply for Medicare supplement insurance coverage. I acknowledge that I have received or been given access to review: (a) an Outline of Coverage for the coverage applied for, and (b) a “Guide to Health Insurance for People with Medicare.”

I AUTHORIZE Americo to act on electronic and/or telephonic information from all parties specified in this application. This authorization may be revoked by sending written notice to Americo at its Medicare Supplement Administrative Office address. The absence of this authorization constitutes a rejection of this authorization.

I FULLY UNDERSTAND the questions contained in this Application. To the best of my knowledge and belief, the answers I provided are true and complete. I understand the Company may conduct a telephone interview with me regarding the answers. I understand and agree the coverage applied for will not take effect until issued by the Company, and that the agent is not authorized to extend, waive or change any terms, conditions or provisions of the coverage.

Caution: If your answers on this Application are incorrect or untrue, the Company has the right to deny benefits or rescind your coverage.

Fraud Warning: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

_________________________________________________________ Send policy to: Applicant Producer Signed at (City and State)

_________________________________________________________ _____________________________________ Applicant’s Signature Application Date

_________________________________________________________ _____________________________________ Producer’s Signature Producer Number

_________________________________________________________ Producer’s Phone


ABB8555 (01/18)

Health Information

Authorization ABB8555 (01/18)


This Authorization complies with the HIPAA Privacy Rule

Information regarding your insurability will be treated as confidential. Americo Financial Life and Annuity Insurance Company (Americo), is a member of MIB, Inc. (MIB). Americo, or its reinsurers, may make a brief report to MIB, which operates an information exchange on behalf of its members. If you apply to another member company for life or health insurance coverage, or a claim for benefits is submitted to such a company, MIB may supply such company with the information in its file. Americo or its reinsurers may also release information to other insurance companies to whom you may apply for life or health insurance, or to whom a claim for benefits may be submitted. It is Americo’s practice to prohibit third parties who lawfully receive nonpublic health information from redisclosing or reusing the disclosed information. You may request to see the information kept in your MIB file. You may also contact MIB and seek correction of any errors in your file.

Your authorization permits any insurance or reinsurance company, health plan, licensed medical physician, health care professional, hospital, clinic, laboratory, pharmacy, pharmacy benefit manager, records custodians, other medical or medical related facility, other health care provider that has provided services, treatment or payment to you or on your behalf, within the past 10 years (“Your Providers”), or clearing house, consumer reporting agency, or MIB , to disclose your entire medical record and any other protected health information, concerning you to Americo Financial Life and Annuity Insurance Company (“Americo”) or its reinsurers employees and representatives. This includes information on the diagnosis or treatment of Human Immunodeficiency Virus (HIV) infection and sexually transmitted diseases. This includes information on the diagnosis and treatment of mental illness and the use of alcohol, drugs, and nicotine products, but excludes psychotherapy notes and excludes information related to genetic tests or genetic services (except to pay a claim related to such tests or services).

By your signature below, you acknowledge that any agreements you have made to restrict your protected health information does not apply to this Authorization and you instruct any physician, health care professional, hospital, clinic, medical facility, or other health care provider to release and disclose your entire medial record without restriction.

Your protected health information is to be disclosed under this Authorization so that Americo may: (1) underwrite your application for coverage, make eligibility, risk rating, policy issuance and enrollment determinations; (2) obtain reinsurance; (3) administer claims and determine or fulfill their responsibility for coverage and provision for benefits; (4) administer coverage; and (5) conduct other legally permissible activities that relate to any coverage you have applied for with Americo.

This Authorization shall remain in force for 24 months following the date of your signature below, and a copy of this Authorization is as valid as the original. This Authorization may be revoked by sending a written request for revocation to Americo at PO Box 410288, Kansas City, MO 64141-0288, Attention: Legal Department; however, a revocation is not effective to the extent that any of Your Providers has relied on this Authorization or to the extent that Americo has a legal right to contest a claim under an insurance policy or to contest the policy itself. Any information that is disclosed pursuant to this Authorization may be redisclosed and no longer covered by federal rules governing privacy and confidentiality of health information.

Your Providers may not refuse to provide treatment or payment for health care services if you refuse to sign this Authorization. If you refuse to sign this Authorization to release your complete medical record, Americo may not be able to process your application, or if coverage has been issued may not be able to make any benefit payments.

_______________________________________________________________ ___________________________________

Name of Applicant (please print) Applicant’s Date of Birth

_______________________________________________________________ ___________________________________

Signature of Applicant or Personal Representative Date

______________________________________________________________________________________________________________________

Description of Personal Representative’s Authority or Relationship to Applicant (if applicable)

Home Office: Dallas, Texas • Medicare Supplement Administrative Office: PO Box 10812, Clearwater, FL 33757-8812 • https://service.iasadmin.com/ac AAA8550 Submit with Application (04/15)

Medicare Supplement

Replacement Notice AAA8550


SAVE THIS NOTICE! IT MAY BE IMPORTANT TO YOU IN THE FUTURE. According to your application, you intend to terminate existing Medicare supplement or Medicare Advantage insurance and replace it with the enclosed Medicare Supplement coverage issued by Americo Financial Life and Annuity Insurance Company. Your new policy will provide thirty (30) days within which you may decide, without cost, whether you desire to keep the policy. You should review this new coverage carefully. Compare it with all accident and sickness coverage you now have. If, after due consideration, you find that purchase of this Medicare supplement coverage is a wise decision, you should terminate your present Medicare supplement or Medicare Advantage coverage. You should evaluate the need for other accident and sickness coverage you have that may duplicate this policy. Statement to Applicant by Issuer - ______________________________________________________________________________________ Agent, Broker, or other Representative I have reviewed your current medical or health insurance coverage. To the best of my knowledge, this Medicare supplement policy will not duplicate your existing Medicare supplement or, if applicable, Medicare Advantage coverage because you intend to terminate your existing Medicare supplement coverage or leave your Medicare Advantage plan. The replacement policy is being purchased for the following reason(s) (check one):

Additional benefits.

No change in benefits, but lower premiums.

Fewer benefits and lower premiums. My plan has outpatient prescription drug coverage and I am enrolling in Part D.

Disenrollment from a Medicare Advantage plan. Please explain reason for disenrollment Other (please specify): _______________________________________________________________________________________________

1. Health conditions which you may presently have may not be immediately or fully covered under the new Medicare

Supplement coverage. This could result in denial or delay of a claim for benefits under the new policy, whereas a similar claim might have been payable under your present coverage.

2. State law provides that your replacement coverage may not contain new waiting periods, elimination periods or probationary periods. We will waive any time periods applicable to waiting periods, elimination periods or probationary periods in your new coverage for similar benefits to the extent such time was spent under your original coverage.

3. If you still wish to terminate your present policy and replace it with new coverage, be certain to truthfully and completely answer all questions on the application concerning your medical and health history, if any. Failure to include all material medical information on an application may provide a basis for the company to deny any future claims and to refund your premium as though your policy had never been in force. After the application has been completed and before you sign it, review it carefully to be certain that all information has been properly recorded.

Do not cancel your present policy until you have received your new policy and are sure you want to keep it.

_______________________________________________________________ ____________________________ Signature of Agent, Broker, or Other Representative Date

_______________________________________________________________ Applicant’s Signature

Home Office: Dallas, Texas • Medicare Supplement Administrative Office: PO Box 10812, Clearwater, FL 33757-8812 • https://service.iasadmin.com/ac AAA8550 Leave with Applicant (04/15)

Medicare Supplement

Replacement Notice AAA8550


SAVE THIS NOTICE! IT MAY BE IMPORTANT TO YOU IN THE FUTURE. According to your application, you intend to terminate existing Medicare supplement or Medicare Advantage insurance and replace it with the enclosed Medicare Supplement coverage issued by Americo Financial Life and Annuity Insurance Company. Your new policy will provide thirty (30) days within which you may decide, without cost, whether you desire to keep the policy. You should review this new coverage carefully. Compare it with all accident and sickness coverage you now have. If, after due consideration, you find that purchase of this Medicare supplement coverage is a wise decision, you should terminate your present Medicare supplement or Medicare Advantage coverage. You should evaluate the need for other accident and sickness coverage you have that may duplicate this policy. Statement to Applicant by Issuer - ______________________________________________________________________________________ Agent, Broker, or other Representative I have reviewed your current medical or health insurance coverage. To the best of my knowledge, this Medicare supplement policy will not duplicate your existing Medicare supplement or, if applicable, Medicare Advantage coverage because you intend to terminate your existing Medicare supplement coverage or leave your Medicare Advantage plan. The replacement policy is being purchased for the following reason(s) (check one):

Additional benefits.

No change in benefits, but lower premiums.

Fewer benefits and lower premiums. My plan has outpatient prescription drug coverage and I am enrolling in Part D.

Disenrollment from a Medicare Advantage plan. Please explain reason for disenrollment Other (please specify): _______________________________________________________________________________________________

4. Health conditions which you may presently have may not be immediately or fully covered under the new Medicare

Supplement coverage. This could result in denial or delay of a claim for benefits under the new policy, whereas a similar claim might have been payable under your present coverage.

5. State law provides that your replacement coverage may not contain new waiting periods, elimination periods or probationary periods. We will waive any time periods applicable to waiting periods, elimination periods or probationary periods in your new coverage for similar benefits to the extent such time was spent under your original coverage.

6. If you still wish to terminate your present policy and replace it with new coverage, be certain to truthfully and completely answer all questions on the application concerning your medical and health history, if any. Failure to include all material medical information on an application may provide a basis for the company to deny any future claims and to refund your premium as though your policy had never been in force. After the application has been completed and before you sign it, review it carefully to be certain that all information has been properly recorded.

Do not cancel your present policy until you have received your new policy and are sure you want to keep it.

_______________________________________________________________ ____________________________ Signature of Agent, Broker, or Other Representative Date

_______________________________________________________________ Applicant’s Signature

Home Office: Dallas, Texas • Medicare Supplement Administrative Office: PO Box 10812, Clearwater, FL 33757-8812 • https://service.iasadmin.com/ac 15-138-10 (03/16)



Policy Number (if known): Insured: Please indicate below when you would like your account drafted. Many of our customers have requested the option to pay their premiums on the same day they receive Social Security or SSI payments. The options below allow you to select the date that best fits your needs. You may select any option regardless of whether or not you receive Social Security or SSI payments.

Part I – Select one of the following date options

Initial Premium Payment (choose one)

Same as subsequent payment date selected below, on or after the requested Effective Date On the Policy Issue Date Paid by enclosed check

Subsequent Premium Payments (choose one)

1st day of the Month 2nd Wednesday of the Month 3rd day of the Month 3rd Wednesday of the Month

4th Wednesday of the Month

Note: If one of the dates above falls on a weekend or holiday, deduction will be on prior business day.

Other, please specify a day of the month from 1 to 28 ___________ (Note: if this date falls on a weekend or holiday, deduction will be on next business day that falls between the 1st and 28th)

Part II – Select one of the following payment options

Checking Savings Branch/Bank Name: ____________________________________________________________

Routing Number

Account Number

Check here if this is a business account To ensure accuracy, please include a voided check or deposit slip.

Part III – Complete name and address as shown on account

Accountholder Name: __________________________________________________________________________________

Address (include City, State, and ZIP): ____________________________________________________________________

Part IV – Sign and Date

As a convenience to me, I hereby request and authorize the banking institution below (the “Bank”) to pay and charge to my account drafts on my account by and payable to the order of the company who issued or assumed the policy listed below (the “Company”) administering my insurance policy provided there are sufficient collected funds in said account to pay the same upon presentation. I agree that the Bank’s rights in respect to such draft shall be the same as if it were a check drawn on the bank and signed personally by me. This authorization will remain in effect until revoked by me or the Company. Notifications should be sent to PO BOX 10812, Clearwater, FL 33757-8812. The toll-free number is 877.212.2346 and the customer service fax number is 816.701.2534. I agree that the Bank shall be fully protected in honoring any such draft. I further agree that if any such draft be dishonored, whether with or without cause and whether intentionally or inadvertently, the Bank shall be under no liability whatsoever. Should any draft not be honored by the Bank upon presentation, I understand that this method of payment may be terminated. I understand that Americo requires a 5 business day advance notice to set up, change, or discontinue my bank draft information. I also understand that my insurance policy may lapse if said draft is returned unpaid by my Bank, or if I discontinue payments, prior to receiving confirmation of draft processing from the Company. Please keep a copy of this authorization with your banking records.

____________________________________________________ ______________________ Signature Date

Bank Draft Authorization for

Medicare Supplement 15-138-10 (03/16)


AAA8394-MS (01/17) Leave with Applicant



INFORMATION PRACTICES NOTICE THIS NOTIFICATION MUST BE DELIVERED TO THE PROPOSED INSURED WHEN THE APPLICATION IS COMPLETED.

Thank you for your application. This notice is given to you at the time you apply for insurance to tell you about the kinds of information we may obtain in connection with your application. We rely primarily on information provided by you. We may also collect information from others, such as medical professionals who have treated you, hospitals, other insurance companies, and consumer reporting agencies. In certain limited situations, we are allowed by law to disclose necessary items of personal information to third parties without your specific authorization. You have a right of access and correction with respect to this information. You have the right to receive, in writing, the specific reason for an adverse underwriting decision. If you wish a more detailed explanation of our information practices, please write us at: Americo Financial Life and Annuity Insurance Company, PO BOX 410288, Kansas City, MO 64141-0288, Attention: Underwriting/New Business Department. Any requests to correct, amend or alter will be responded to within 30 days. Within a seven year timeframe, information that is corrected will be provided to any person who is designated by the requesting party and who may have received the information in the prior two years. Any statement of disagreement made by a requesting party will be filed and made available to those reviewing it in the future.

MIB, INC. PRE-NOTICE Information regarding your insurability will be treated as confidential. However, Americo Financial Life and Annuity Insurance Company or its reinsurers may make a brief report to the MIB, Inc. formerly known as Medical Information Bureau, a nonprofit membership organization of life insurance companies operating as an information exchange for its members. If you apply to another MIB member company for life or health insurance or a claim is submitted to such a company, upon request the MIB will supply the company with the information it has in its file. Upon receipt of a request from you, the MIB, Inc., will arrange disclosure of any information it has in your file. Please contact MIB at 866.692.6901 (TTY 866.346.3642). If you question the accuracy of information in the file, you may contact the MIB and seek a correction in accordance with the procedures in the Fair Credit Reporting Act. The MIB’s information office address is 50 Braintree Hill Park, Suite 400, Braintree, MA 02184-8734. The Company or its reinsurers may release information in its file to its reinsurers and to other life and health insurance companies to whom you apply for insurance or to whom a claim is submitted. Information for consumers about MIB may be obtained on its website at www.mib.com.

Important

Consumer Notices AAA8394-MS (01/17)

Home Office: Dallas, Texas • Medicare Supplement Administrative Office: PO Box 10812, Clearwater, FL 33757-8812 • https://service.iasadmin.com/ac APA8564 Leave with Applicant For Use in Pennsylvania

Disclosure Guaranteed Issue Eligibility APA8564


The following are definitions of the categories of individuals who are eligible for Guaranteed Issue under the Balanced Budget Act of 1997:

Enrolled under an employee welfare benefit plan that provides health benefits that supplement the benefits under Medicare; and

the plan terminates, or the plan ceases to provide all such supplemental health benefits to the individual, or the individual is enrolled under an employee welfare benefit plan that is primary to Medicare and the plan terminates, or the plan ceases to provide health benefits to the individual because the individual leaves the plan (eligible for Plans A, B, or F); or

Enrolled in a Medicare Advantage plan or Program of All-Inclusive Care for the Elderly (PACE) and the organization’s certification or plan is terminated or specific circumstances permit discontinuance including, but not limited to, a change in residence of the individual, the plan is terminated within a residence area, the organization substantially violated a material policy provision, including the failure to provide an enrollee on a timely basis medically necessary care for which benefits are available under the plan or the failure to provide the covered care in accordance with applicable quality standards; or a material misrepresentation was made to the individual, or the person meets any other exceptional conditions as the secretary may provide (eligible for Plans A, B, or F); or

Enrolled in a Medicare risk contract, health care prepayment plan, cost contract or Medicare Select plan, or similar organization, and the organization’s certification or plan is terminated or specific circumstances permit discontinuance including, but not limited to, a change in residence of the individual, the plan is terminated within a residence area, the organization substantially violated a material policy provision, or a material misrepresentation was made to the individual (eligible for Plans A, B, or F); or

Enrolled in a Medicare Supplement policy and coverage discontinues due to insolvency, substantial violation of a material policy provision, or material misrepresentation (eligible for Plans A, B, or F); or

Enrolled under a Medicare Supplement policy, terminates and enrolls for the first time in a Medicare Advantage, a risk or cost contract, or a Medicare Select plan, a PACE provider, and then terminates coverage within 12 months of enrollment (eligible for the same Plan you terminated with us, or, if that Plan is no longer available, Plans A, B, or F); or Upon first becoming eligible for benefits under Part A at age 65, enrolls in a Medicare Advantage or PACE provider and then disenrolls within 12 months (eligible for all plans available from us); or

Enrolled in a Medicare Part D Plan during the initial Part D enrollment period while enrolled under a Medicare Supplement policy that covers outpatient prescription drugs and terminate the Medicare Supplement policy (eligible for Plans A, B, or F).

Documentation of these events must be submitted with the Application.

You must apply within 63 days of the date of termination of previous coverage in order to qualify as an eligible person.

Home Office: Dallas, Texas • Medicare Supplement Administrative Office: PO Box 10812, Clearwater, FL 33757-8812 • https://service.iasadmin.com/ac AAA5510-AS

Producer

Statement AAA5510-AS



All questions must be completed

1. Did you meet with the Applicant in person? ....................................................................................................................... Yes No

2. Did you complete this Application over the phone? ......................................................................................................... Yes No

3. State the name and relationship of any other person present when this Application was taken:

Name:________________________________________________ Relationship to Applicant:___________________________________

4. Did you review the Application for correctness and any omissions? .......................................................................... Yes No

5. Did the Applicant review the Application for correctness and any omissions? ........................................................ Yes No

6. Are you related to the Proposed Insured? .......................................................................................................................... Yes No

If Yes, provide relationship:____________________________________________________ Replacement Information

7. Does the applicant have any existing Medicare Supplement coverage? .................................................................. Yes No (If Yes, complete the replacement notice and submit with the application. Application and replacement notice must be dated the same day.)

I hereby certify that I have personally asked each question on this application to the applicant, that I have truly and accurately recorded on the application the information supplied by him/her, and that I have no reason to believe that the information provided is inaccurate or incomplete.

Print Producer’s Name Producer’s Signature Americo

Agent Number

% Commission

Split

X

X

Home Office: Dallas, Texas • Medicare Supplement Administrative Office: PO Box 10812, Clearwater, FL 33757-8812 • https://service.iasadmin.com/ac 15-138-9 For Agent Use Only (10/15)

Medicare Supplement Premium Worksheet 15-138-9


Before you begin, please go to the height and weight chart on the reverse side of this page to determine eligibility for coverage, unless the applicant is in an open enrollment or guaranteed issue period.

Applicant 1 Applicant 2

Premium Calculation ExampleInformation shown below

is for calculation purposes only.

1. Medicare Supplement Insurance Plan Plan F

2. Applicant’s Age at Effective Date of Coverage 67

3. Applicant’s ZIP Code 30301

4. Premium Write in the Medicare Supplement plan’s premium from the Outline of Coverage provided, based on age and ZIP Code.

$183.83

5. Household Premium Discount

The applicant is eligible for a Household Premium Discount if, in the past year: a) The applicant resided with at least one, but no more than three, other adults who are age 60 and older; or b) The applicant lived with another adult who is their legal spouse. If yes, multiply the amount from Step 4 by .9. If no, enter the amount from Step 4.

$183.83 X .9 = $165.45

In this example, the applicant qualifies for the household

premium discount.

6. Rate Adjustment If the applicant is in open enrollment or guaranteed issue period, skip to Step 7.

Locate height and weight on the next page.

If weight is in the Standard column, enter the amount from Step 5.

If weight is in the Class I column, multiply the amount from Step 5 by: 1.15.

$165.45 X 1.15 = $190.27

In this example, the applicant’s weight is in the Class I column.

7. Payment Options The monthly payment is the last premium entered (Step 5 or 6).

To determine annual premium, multiply by 12.

$190.27 monthly payment

$2,283.24 annual payment

Home Office: Dallas, Texas • Medicare Supplement Administrative Office: PO Box 10812, Clearwater, FL 33757-8812 • https://service.iasadmin.com/ac 15-138-9 For Agent Use Only (10/15)

Medicare Supplement Premium Worksheet 15-138-9


Eligibility: Find the applicant’s height in the left-hand column and look across the row to find the applicant’s weight. If the weight is in the Decline column, the applicant is not eligible for coverage at this time.

Rate Adjustment: The column heading above the applicant’s weight will indicate your appropriate rate adjustment, if any (risk class).

Decline Class I Standard Class I Decline

Height Weight Weight Weight Weight Weight

4' 6'' < 63 63 – 70 71 – 128 129 – 170 171 +

4' 7'' < 65 65 – 73 74 – 133 134 – 176 177 +

4' 8'' < 67 67 – 75 76 – 138 139 – 182 183 +

4' 9'' < 70 70 – 78 79 – 143 144 – 189 190 +

4' 10'' < 72 72 – 81 82 – 148 149 – 196 197 +

4' 11'' < 75 75 – 84 85 – 153 154 – 202 203 +

5' 0'' < 77 77 – 87 88 – 158 159 – 209 210 +

5' 1'' < 80 80 – 89 90 – 164 165 – 216 217 +

5' 2'' < 83 83 – 92 93 – 169 170 – 224 225 +

5' 3'' < 85 85 – 95 96 – 175 176 – 231 232 +

5' 4'' < 88 88 – 99 100 – 180 181 – 238 239 +

5' 5'' < 91 91 – 102 103 – 186 187 – 246 247 +

5' 6'' < 93 93 – 105 106 – 192 193 – 254 255 +

5' 7'' < 96 96 – 108 109 – 197 198 – 261 262 +

5' 8'' < 99 99 – 111 112 – 203 204 – 269 270 +

5' 9'' < 102 102 – 115 116 – 209 210 – 277 278 +

5' 10'' < 105 105 – 118 119 – 216 217 – 285 286 +

5' 11'' < 108 108 – 121 122 – 222 223 – 293 294 +

6' 0'' < 111 111 – 125 126 – 228 229 – 302 303 +

6' 1'' < 114 114 – 128 129 – 234 235 – 310 311 +

6' 2'' < 117 117 – 132 133 – 241 242 – 319 320 +

6' 3'' < 121 121 – 136 137 – 248 249 – 328 329 +

6' 4'' < 124 124 – 139 140 – 254 255 – 336 337 +

6' 5'' < 127 127 – 143 144 – 261 262 – 345 346 +

6' 6'' < 130 130 – 147 148 – 268 269 – 354 355 +

6' 7'' < 134 134 – 150 151 – 275 276 – 363 364 +

6' 8'' < 137 137 – 154 155 – 282 283 – 373 374 +

6' 9'' < 140 140 – 158 159 – 289 290 – 382 383 +

6' 10'' < 144 144 – 162 163 – 296 297 – 392 393 +

6' 11'' < 147 147 – 166 167 – 303 304 – 401 402 +

7' 0'' < 151 151 – 170 171 – 311 312 – 411 412 +

7' 1'' < 155 155 – 174 175 – 318 319 – 421 422 +

7' 2'' < 158 158 – 178 179 – 326 327 – 431 432 +

7' 3'' < 162 162 – 183 184 – 333 334 – 441 442 +

7' 4'' < 166 166 – 187 188 – 341 342 – 451 452 +

AMER

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This

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263.

9130

3.50

346.

7939

8.81

111.

9512

8.75

297.

3634

1.97

252.

4229

0.28

9324

8.77

286.

0926

6.10

306.

0135

1.73

404.

4911

4.01

131.

1130

1.77

347.

0325

6.63

295.

1294

250.

3828

7.94

268.

3030

8.54

356.

7141

0.21

116.

0913

3.50

306.

2135

2.14

260.

8730

0.01

9525

2.01

289.

8127

0.52

311.

0936

1.73

415.

9911

8.19

135.

9231

0.70

357.

3026

5.16

304.

9396

254.

5329

2.71

273.

2231

4.20

365.

3542

0.15

119.

0213

6.87

313.

8036

0.87

267.

8130

7.98

9725

7.07

295.

6327

5.95

317.

3536

9.00

424.

3511

9.85

137.

8331

6.94

364.

4827

0.49

311.

0698

259.

6429

8.59

278.

7132

0.52

372.

6942

8.60

120.

6913

8.79

320.

1136

8.13

273.

1931

4.17

9926

2.24

301.

5728

1.50

323.

7237

6.42

432.

8812

1.53

139.

7632

3.31

371.

8127

5.93

317.

32

For

Ann

ual P

rem

ium

mod

e, m

ultip

ly m

onth

ly r

ates

by

12.

For

Cla

ss 1

rat

es m

ultip

ly b

y 1.

15.

Mo

nth

ly R

ates

by

Pla

n -

Pen

nsy

lvan

ia

Pla

n F

Hig

h D

edu

ctib

leP

lan

FP

lan

GP

lan

N

Zip

Co

des

: A

ll Z

ip C

od

es t

hat

sta

rt w

ith

189

-194

Pla

n A

Pla

n B

To

bac

co R

ates

AP

A50

0-O

C R

AT

ES

Ho

use

ho

ld P

rem

ium

Dis

cou

nt

of

10%

may

ap

ply

. S

ee H

ou

seh

old

Dis

cou

nt

Pre

miu

m d

escr

ipti

on

.E

ffect

ive:

10/

01/2

018

7 of 2

2

AMER

ICO

FINA

NCIA

L LI

FE A

ND A

NNUI

TY IN

SURA

NCE

COMP

ANY

Outli

ne o

f Cov

erag

e Me

dica

re S

uppl

emen

t Ben

efit

Plan

s A, B

, F, H

igh

Dedu

ctib

le F,

G, a

nd N

.

APA5

00-O

C (0

9/18

)

Effe

ctiv

e: 0

1/01

/201

9

Disc

losu

res.

Use

this

outlin

e to c

ompa

re be

nefits

and p

remi

ums a

mong

polic

ies.

Prem

ium

Info

rmat

ion.

Ame

rico F

inanc

ial Li

fe an

d Ann

uity I

nsur

ance

Com

pany

can o

nly ra

ise yo

ur pr

emium

if we

raise

the p

remi

um fo

r all p

olicie

s like

your

s in t

he sa

me

geog

raph

ic ar

ea of

the s

tate w

here

you l

ive. U

ntil y

ou ar

e age

99, y

our p

remi

um m

ay ch

ange

each

year

. This

chan

ge w

ill on

ly be

mad

e on t

he fir

st re

newa

l date

that

coinc

ides w

ith or

follo

ws ea

ch an

niver

sary

of the

effec

tive d

ate. S

ched

ules o

f rate

s may

vary

depe

nding

upon

your

effec

tive d

ate.

Hous

ehol

d Pr

emiu

m D

iscou

nt. Y

ou ar

e elig

ible f

or a

hous

ehold

prem

ium di

scou

nt if 1

) for

the p

ast y

ear Y

ou ha

ve re

sided

with

anoth

er ad

ult an

d 2) Y

ou ar

e in a

lega

l re

lation

ship

with

this a

dult.

This

adult

is no

t req

uired

to ha

ve an

insu

ranc

e poli

cy w

ith U

s. Th

e disc

ounte

d pre

mium

will

be pr

iced 1

0% lo

wer t

han t

he ra

tes ill

ustra

ted. Y

our

polic

y's ho

useh

old pr

emium

disc

ount

will b

e rem

oved

if the

othe

r adu

lt no l

onge

r res

ides w

ith yo

u (oth

er th

an in

the c

ase o

f his

or he

r dea

th).

Read

You

r Pol

icy V

ery C

aref

ully.

Thi

s is o

nly a

n ou

tline

des

crib

ing

your

pol

icy’s

mos

t im

porta

nt fe

atur

es. T

he p

olicy

is yo

ur in

sura

nce c

ontra

ct. Y

ou m

ust

read

the p

olicy

itse

lf to

und

erst

and

all o

f the

righ

ts an

d du

ties o

f bot

h yo

u an

d us

. Ri

ght t

o Re

turn

Pol

icy. I

f you

find t

hat y

ou ar

e not

satis

fied w

ith yo

ur po

licy,

you m

ay re

turn i

t to us

at: A

meric

o Fina

ncial

Life

and A

nnuit

y Ins

uran

ce C

ompa

ny

Admi

nistra

tive O

ffices

: PO

Box 1

0812

, Clea

rwate

r, FL

3325

7-88

12. If

you s

end t

he po

licy b

ack t

o us w

ithin

30 da

ys af

ter yo

u rec

eive i

t, we w

ill tre

at the

polic

y as i

f it ha

d ne

ver b

een i

ssue

d and

retur

n all o

f you

r pay

ments

. Po

licy R

eplac

emen

t. If

you a

re re

placin

g ano

ther h

ealth

insu

ranc

e poli

cy, d

o NOT

canc

el it u

ntil y

ou ha

ve ac

tually

rece

ived y

our n

ew po

licy a

nd ar

e sur

e you

wan

t to

keep

it.

Notic

e. T

he po

licy m

ay no

t fully

cove

r all o

f you

r med

ical c

osts.

Neit

her w

e nor

our a

gents

are c

onne

cted w

ith M

edica

re. T

his ou

tline d

oes n

ot giv

e all t

he de

tails

of Me

dicar

e cov

erag

e. Co

ntact

your

loca

l Soc

ial S

ecur

ity of

fice o

r con

sult “

Medic

are &

You

” for

mor

e deta

ils.

Com

plet

e Ans

wers

Are

Ver

y Im

porta

nt. W

hen y

ou fil

l out

the ap

plica

tion f

or th

e new

polic

y, be

sure

to an

swer

truth

fully

and c

omple

tely a

ll que

stion

s abo

ut yo

ur m

edica

l an

d hea

lth hi

story.

We m

ay ca

ncel

your

polic

y and

refus

e to p

ay an

y clai

ms if

you l

eave

out o

r fals

ify im

porta

nt me

dical

infor

matio

n. Re

view

the a

pplic

atio

n ca

refu

lly

befo

re yo

u sig

n it.

Be c

erta

in th

at al

l info

rmat

ion

has b

een

prop

erly

reco

rded

. No

Hea

lth R

eview

. No h

ealth

revie

w is

requ

ired i

f you

enro

ll with

in the

first

six m

onths

after

you r

each

age 6

5 and

enro

ll in M

edica

re P

art B

, or in

othe

r situ

ation

s as

requ

ired b

y law

.

PLEA

SE R

EFER

TO

YOUR

POL

ICY

FOR

DETA

ILS.

8 of 2

2

AMER

ICO

FINA

NCIA

L LI

FE A

ND A

NNUI

TY IN

SURA

NCE

COMP

ANY

Outli

ne o

f Cov

erag

e Me

dica

re S

uppl

emen

t Ben

efit

Plan

s A, B

, F, H

igh

Dedu

ctib

le F,

G, a

nd N

.

APA5

00-O

C (0

9/18

)

Effe

ctiv

e: 0

1/01

/201

9 Pl

an A

Plan

A

Medi

care

Par

t A –

Hosp

ital S

ervic

es P

er B

enef

it Pe

riod

*A be

nefit

perio

d beg

ins on

the f

irst d

ay yo

u rec

eive s

ervic

e as a

n inp

atien

t in a

hosp

ital a

nd en

ds af

ter yo

u hav

e bee

n out

of the

hosp

ital a

nd ha

ve no

t rec

eived

skille

d ca

re in

any o

ther f

acilit

y for

60 da

ys in

a ro

w.

Serv

ices

Medi

care

Pay

s Pl

an A

Pay

s Yo

u Pa

y Ho

spita

lizat

ion*

Se

mipr

ivate

room

and b

oard

, gen

eral

nursi

ng an

d misc

ellan

eous

se

rvice

s and

supp

lies.

First

60 da

ys

All b

ut $1

,364

$0

$1,36

4 Par

t A D

educ

tible

61st t

hru 9

0th day

Al

l but

$341

a da

y $3

41 a

day

$0

91st d

ay an

d afte

r -

Whil

e usin

g 60 l

ifetim

e res

erve

days

-

Once

lifeti

me re

serve

days

are u

sed

Ad

dition

al 36

5 day

s

Beyo

nd th

e add

itiona

l 365

days

All b

ut $6

82 a

day

$0

$0

$682

a da

y 10

0% of

Med

icare

Elig

ible E

xpen

ses

$0

$0

$0**

All C

osts

Skille

d Nu

rsin

g Fa

cility

Car

e*

You m

ust m

eet M

edica

re’s

requ

ireme

nts, in

cludin

g hav

ing be

en in

a ho

spita

l for a

t leas

t 3 da

ys an

d ente

red a

Med

icare

appr

oved

facil

ity

withi

n 30 d

ays a

fter le

aving

the h

ospit

al.

First

20 da

ys

21st t

hru 1

00th d

ays

101st d

ay an

d afte

r

All a

ppro

ved a

moun

ts Al

l but

$170

.50 a

day

$0

$0

$0

$0

$0

Up to

$170

.50 a

day

All C

osts

Bloo

d Fir

st 3 p

ints

Addit

ional

amou

nts

$0

100%

3 pint

s $0

$0

$0

Hosp

ice C

are

You m

ust m

eet M

edica

re’s

requ

ireme

nts, in

cludin

g a do

ctor’s

ce

rtifica

tion o

f term

inal il

lness

.

All b

ut ve

ry lim

ited

copa

ymen

t/coin

sura

nce

for ou

tpatie

nt dr

ugs a

nd

inpati

ent r

espit

e car

e.

Medic

are c

opay

ment/

coins

uran

ce

$0

**Whe

n you

r Med

icare

Par

t A ho

spita

l ben

efits

are e

xhau

sted,

the in

sure

r stan

ds in

the p

lace o

f Med

icare

and w

ill pa

y wha

tever

amou

nt Me

dicar

e wou

ld ha

ve pa

id for

up

to an

addit

ional

365 d

ays a

s pro

vided

in th

e poli

cy’s

“Cor

e Ben

efits.

” Dur

ing th

is tim

e, the

hosp

ital is

proh

ibited

from

billin

g you

for t

he ba

lance

base

d on a

ny di

ffere

nce

betw

een i

ts bil

led ch

arge

s and

the a

moun

t Med

icare

wou

ld ha

ve pa

id.

9 of 2

2

AMER

ICO

FINA

NCIA

L LI

FE A

ND A

NNUI

TY IN

SURA

NCE

COMP

ANY

Outli

ne o

f Cov

erag

e Me

dica

re S

uppl

emen

t Ben

efit

Plan

s A, B

, F, H

igh

Dedu

ctib

le F,

G, a

nd N

.

APA5

00-O

C (0

9/18

)

Effe

ctiv

e: 0

1/01

/201

9 Pl

an A

Plan

A

Medi

care

Par

t B –

Medi

cal S

ervic

es p

er C

alend

ar Y

ear

*Onc

e you

have

been

bille

d $18

5 of M

edica

re E

ligibl

e Exp

ense

s for

cove

red s

ervic

es, y

our M

edica

re P

art B

Ded

uctib

le wi

ll hav

e bee

n met

for th

e cale

ndar

year

. Se

rvice

s Me

dica

re P

ays

Plan

A P

ays

You

Pay

Medi

cal E

xpen

ses

In or

out o

f the h

ospit

al an

d outp

atien

t hos

pital

treatm

ent, s

uch a

s Ph

ysici

an’s

servi

ces,

inpati

ent a

nd ou

tpatie

nt me

dical

and s

urgic

al se

rvice

s an

d sup

plies

, phy

sical

and s

peec

h the

rapy

, diag

nosti

c tes

ts, du

rable

med

ical

equip

ment

First

$185

of M

edica

re ap

prov

ed am

ounts

* Re

maind

er of

Med

icare

appr

oved

amou

nts

$0

Gene

rally

80%

$0

Ge

nera

lly 20

%

$185

Par

t B D

educ

tible

$0

Part

B Ex

cess

Cha

rges

(abo

ve M

edica

re ap

prov

ed am

ounts

) $0

$0

Al

l cos

ts Bl

ood

First

3 pint

s Ne

xt $1

85 of

Med

icare

appr

oved

amou

nts*

Rema

inder

of M

edica

re ap

prov

ed am

ounts

$0

$0

80%

All c

osts

$0

20%

$0

$185

Par

t B D

educ

tible

$0

Clin

ical L

abor

ator

y Ser

vices

– Te

sts fo

r diag

nosti

c ser

vices

10

0%

$0

$0

Parts

A &

B

Serv

ices

Medi

care

Pay

s Pl

an A

Pay

s Yo

u Pa

y Ho

me H

ealth

Car

e Me

dicar

e Elig

ible S

ervic

es

- Me

dicall

y nec

essa

ry sk

illed c

are s

ervic

es an

d med

ical s

uppli

es

- Du

rable

med

ical e

quipm

ent. F

irst $

185 o

f Med

icare

appr

oved

amou

nts*

- Re

maind

er of

Med

icare

appr

oved

amou

nts

100%

$0

80

%

$0

$0

20%

$0

$185

Par

t B D

educ

tible

$0

10 of

22

AMER

ICO

FINA

NCIA

L LI

FE A

ND A

NNUI

TY IN

SURA

NCE

COMP

ANY

Outli

ne o

f Cov

erag

e Me

dica

re S

uppl

emen

t Ben

efit

Plan

s A, B

, F, H

igh

Dedu

ctib

le F,

G, a

nd N

.

APA5

00-O

C (0

9/18

)

Effe

ctiv

e: 0

1/01

/201

9 Pl

an B

Plan

B

Medi

care

Par

t A –

Hosp

ital S

ervic

es P

er B

enef

it Pe

riod

*A be

nefit

perio

d beg

ins on

the f

irst d

ay yo

u rec

eive s

ervic

e as a

n inp

atien

t in a

hosp

ital a

nd en

ds af

ter yo

u hav

e bee

n out

of the

hosp

ital a

nd ha

ve no

t rec

eived

skille

d ca

re in

any o

ther f

acilit

y for

60 da

ys in

a ro

w.

Serv

ices

Medi

care

Pay

s Pl

an B

Pay

s Yo

u Pa

y Ho

spita

lizat

ion*

Se

mipr

ivate

room

and b

oard

, gen

eral

nursi

ng an

d misc

ellan

eous

se

rvice

s and

supp

lies.

First

60 da

ys

All b

ut $1

,364

$1,36

4 Par

t A D

educ

tible

$0

61st t

hru 9

0th day

Al

l but

$341

a da

y $3

41 a

day

$0

91st d

ay an

d afte

r -

Whil

e usin

g 60 l

ifetim

e res

erve

days

-

Once

lifeti

me re

serve

days

are u

sed

Ad

dition

al 36

5 day

s

Beyo

nd th

e add

itiona

l 365

days

All b

ut $6

82 a

day

$0

$0

$682

a da

y 10

0% of

Med

icare

Elig

ible E

xpen

ses

$0

$0

$0**

All C

osts

Skille

d Nu

rsin

g Fa

cility

Car

e*

You m

ust m

eet M

edica

re’s

requ

ireme

nts, in

cludin

g hav

ing be

en in

a ho

spita

l for a

t leas

t 3 da

ys an

d ente

red a

Med

icare

appr

oved

facil

ity

withi

n 30 d

ays a

fter le

aving

the h

ospit

al.

First

20 da

ys

21st t

hru 1

00th d

ays

101st d

ay an

d afte

r

All a

ppro

ved a

moun

ts Al

l but

$170

.50 a

day

$0

$0

$0

$0

$0

Up to

$170

.50 a

day

All C

osts

Bloo

d Fir

st 3 p

ints

Addit

ional

amou

nts

$0

100%

3 pint

s $0

$0

$0

Hosp

ice C

are

You m

ust m

eet M

edica

re’s

requ

ireme

nts, in

cludin

g a do

ctor’s

ce

rtifica

tion o

f term

inal il

lness

.

All b

ut ve

ry lim

ited

copa

ymen

t/coin

sura

nce

for ou

tpatie

nt dr

ugs a

nd

inpati

ent r

espit

e car

e.

Medic

are c

opay

ment/

coins

uran

ce

$0

*Whe

n you

r Med

icare

Par

t A ho

spita

l ben

efits

are e

xhau

sted,

the in

sure

r stan

ds in

the p

lace o

f Med

icare

and w

ill pa

y wha

tever

amou

nt Me

dicar

e wou

ld ha

ve pa

id for

up

to an

addit

ional

365 d

ays a

s pro

vided

in th

e poli

cy’s

“Cor

e Ben

efits.

” Dur

ing th

is tim

e, the

hosp

ital is

proh

ibited

from

billin

g you

for t

he ba

lance

base

d on a

ny di

ffere

nce

betw

een i

ts bil

led ch

arge

s and

the a

moun

t Med

icare

wou

ld ha

ve pa

id.

11 of

22

AMER

ICO

FINA

NCIA

L LI

FE A

ND A

NNUI

TY IN

SURA

NCE

COMP

ANY

Outli

ne o

f Cov

erag

e Me

dica

re S

uppl

emen

t Ben

efit

Plan

s A, B

, F, H

igh

Dedu

ctib

le F,

G, a

nd N

.

APA5

00-O

C (0

9/18

)

Effe

ctiv

e: 0

1/01

/201

9 Pl

an B

Plan

B

Medi

care

Par

t B –

Medi

cal S

ervic

es p

er C

alend

ar Y

ear

*Onc

e you

have

been

bille

d $18

5 of M

edica

re E

ligibl

e Exp

ense

s for

cove

red s

ervic

es, y

our M

edica

re P

art B

Ded

uctib

le wi

ll hav

e bee

n met

for th

e cale

ndar

year

. Se

rvice

s Me

dica

re P

ays

Plan

B P

ays

You

Pay

Medi

cal E

xpen

ses

In or

out o

f the h

ospit

al an

d outp

atien

t hos

pital

treatm

ent, s

uch a

s Phy

sician

’s se

rvice

s, inp

atien

t and

outpa

tient

medic

al an

d sur

gical

servi

ces a

nd su

pplie

s, ph

ysica

l and

spee

ch th

erap

y, dia

gnos

tic te

sts, d

urab

le me

dical

equip

ment

First

$185

of M

edica

re ap

prov

ed am

ounts

* Re

maind

er of

Med

icare

appr

oved

amou

nts

$0

Gene

rally

80%

$0

Ge

nera

lly 20

%

$185

Par

t B D

educ

tible

$0

Part

B Ex

cess

Cha

rges

(abo

ve M

edica

re ap

prov

ed am

ounts

) $0

$0

Al

l cos

ts Bl

ood

First

3 pint

s Ne

xt $1

85 of

Med

icare

appr

oved

amou

nts*

Rema

inder

of M

edica

re ap

prov

ed am

ounts

$0

$0

80%

All c

osts

$0

20%

$0

$185

Par

t B D

educ

tible

$0

Clin

ical L

abor

ator

y Ser

vices

– Te

sts fo

r diag

nosti

c ser

vices

10

0%

$0

$0

Parts

A &

B

Serv

ices

Medi

care

Pay

s Pl

an B

Pay

s Yo

u Pa

y Ho

me H

ealth

Car

e Me

dicar

e Elig

ible S

ervic

es

- Me

dicall

y nec

essa

ry sk

illed c

are s

ervic

es an

d med

ical s

uppli

es

- Du

rable

med

ical e

quipm

ent. F

irst $

185 o

f Med

icare

appr

oved

amou

nts*

- Re

maind

er of

Med

icare

appr

oved

amou

nts

100%

$0

80

%

$0

$0

20%

$0

$185

Par

t B D

educ

tible

$0

12 of

22

AMER

ICO

FINA

NCIA

L LI

FE A

ND A

NNUI

TY IN

SURA

NCE

COMP

ANY

Outli

ne o

f Cov

erag

e Me

dica

re S

uppl

emen

t Ben

efit

Plan

s A, B

, F, H

igh

Dedu

ctib

le F,

G, a

nd N

.

APA5

00-O

C (0

9/18

)

Effe

ctiv

e: 0

1/01

/201

9 Pl

an F

and

Hig

h D

educ

tible

Pla

n F

Plan

F an

d Hi

gh D

educ

tible

Plan

F

Medi

care

Par

t A –

Hosp

ital S

ervic

es P

er B

enef

it Pe

riod

*A be

nefit

perio

d beg

ins on

the f

irst d

ay yo

u rec

eive s

ervic

e as a

n inp

atien

t in a

hosp

ital a

nd en

ds af

ter yo

u hav

e bee

n out

of the

hosp

ital a

nd ha

ve no

t rec

eived

skille

d ca

re in

any o

ther f

acilit

y for

60 da

ys in

a ro

w.

Serv

ices

Medi

care

Pay

s Pl

an F

Pay

s Yo

u Pa

y

High

Ded

uctib

le Pl

an F

Pa

ys (a

fter y

ou p

ay

$2,30

0 Ded

uctib

le***

You

Pay

(In ad

ditio

n to

$2,30

0 De

duct

ible*

**)

Hosp

italiz

atio

n Se

mipr

ivate

room

and b

oard

, gen

eral

nursi

ng

and m

iscell

aneo

us se

rvice

s and

supp

lies.

First

60 da

ys

All b

ut $1

,364

$1,36

4 Par

t A

Dedu

ctible

$0

$1

,364 P

art A

Ded

uctib

le $0

61st t

hru 9

0th day

Al

l but

$341

a da

y $3

41 a

day

$0

$341

a da

y $0

91st d

ay an

d afte

r -

Whil

e usin

g 60 l

ifetim

e res

erve

days

-

Once

lifeti

me re

serve

days

are u

sed

Ad

dition

al 36

5 day

s

Be

yond

the a

dditio

nal 3

65 da

ys

All b

ut $6

82 a

day

$0

$0

$682

a da

y 10

0% of

Med

icare

El

igible

Exp

ense

s $0

$0

$0**

All C

osts

$682

a da

y 10

0% of

Med

icare

El

igible

Exp

ense

s $0

$0

$0**

All C

osts

Skille

d Nu

rsin

g Fa

cility

Car

e Yo

u mus

t mee

t Med

icare

’s re

quire

ments

, inc

luding

havin

g bee

n in a

hosp

ital fo

r at le

ast 3

da

ys an

d ente

red a

Med

icare

appr

oved

facil

ity

withi

n 30 d

ays a

fter le

aving

the h

ospit

al.

First

20 da

ys

21st t

hru 1

00th d

ays

101st d

ay an

d afte

r

All a

ppro

ved

amou

nts

All b

ut $1

70.50

a da

y $0

$0

Up to

$170

.50 a

day

$0

$0

$0

All C

osts

$0

Up to

$170

.50 a

day

$0

$0

$0

All C

osts

13 of

22

AMER

ICO

FINA

NCIA

L LI

FE A

ND A

NNUI

TY IN

SURA

NCE

COMP

ANY

Outli

ne o

f Cov

erag

e Me

dica

re S

uppl

emen

t Ben

efit

Plan

s A, B

, F, H

igh

Dedu

ctib

le F,

G, a

nd N

.

APA5

00-O

C (0

9/18

)

Effe

ctiv

e: 0

1/01

/201

9 Pl

an F

and

Hig

h D

educ

tible

Pla

n F

Plan

F an

d Hi

gh D

educ

tible

Plan

F

Medi

care

Par

t A –

Hosp

ital S

ervic

es P

er B

enef

it Pe

riod

(Con

tinue

d)

Serv

ices

Medi

care

Pay

s Pl

an F

Pay

s Yo

u Pa

y

High

Ded

uctib

le Pl

an F

Pa

ys (a

fter y

ou p

ay

$2,30

0 Ded

uctib

le***

You

Pay

(In ad

ditio

n to

$2,30

0 De

duct

ible*

**)

Bloo

d Fir

st 3 p

ints

Addit

ional

amou

nts

$0

100%

3 pint

s $0

$0

$0

3 pint

s $0

$0

$0

Hosp

ice C

are

You m

ust m

eet M

edica

re’s

requ

ireme

nts,

includ

ing a

docto

r’s ce

rtifica

tion o

f term

inal

illnes

s.

All b

ut ve

ry lim

ited

copa

ymen

t/coin

sura

nce f

or ou

tpatie

nt dr

ugs a

nd in

patie

nt re

spite

care

.

Medic

are

copa

ymen

t/coin

sura

nce

$0

Medic

are

copa

ymen

t/coin

sura

nce

$0

**Whe

n you

r Med

icare

Par

t A ho

spita

l ben

efits

are e

xhau

sted,

the in

sure

r stan

ds in

the p

lace o

f Med

icare

and w

ill pa

y wha

tever

amou

nt Me

dicar

e wou

ld ha

ve pa

id for

up

to an

addit

ional

365 d

ays a

s pro

vided

in th

e poli

cy’s

“Cor

e Ben

efits.

” Dur

ing th

is tim

e, the

hosp

ital is

proh

ibited

from

billin

g you

for t

he ba

lance

base

d on a

ny di

ffere

nce

betw

een i

ts bil

led ch

arge

s and

the a

moun

t Med

icare

wou

ld ha

ve pa

id. **

*High

Ded

uctib

le Pl

an F

pays

the s

ame b

enefi

ts as

Plan

F af

ter on

e has

paid

a cale

ndar

year

$2

,300 d

educ

tible.

Ben

efits

from

High

Ded

uctib

le Pl

an F

will

not b

egin

until

out-o

f-poc

ket e

xpen

ses e

xcee

d $2,3

00. O

ut-of-

pock

et ex

pens

es fo

r this

dedu

ctible

are

expe

nses

that

would

ordin

arily

be pa

id by

the p

olicy

/certif

icate.

The

se ex

pens

es in

clude

the M

edica

re de

ducti

bles f

or P

ay A

and P

art B

, but

do no

t inclu

de th

e plan

’s se

para

te Fo

reign

Tra

vel E

merg

ency

dedu

ctible

.

14 of

22

AMER

ICO

FINA

NCIA

L LI

FE A

ND A

NNUI

TY IN

SURA

NCE

COMP

ANY

Outli

ne o

f Cov

erag

e Me

dica

re S

uppl

emen

t Ben

efit

Plan

s A, B

, F, H

igh

Dedu

ctib

le F,

G, a

nd N

.

APA5

00-O

C (0

9/18

)

Effe

ctiv

e: 0

1/01

/201

9 Pl

an F

and

Hig

h D

educ

tible

Pla

n F

Plan

F an

d Hi

gh D

educ

tible

Plan

F

Medi

care

Par

t B –

Medi

cal S

ervic

es p

er C

alend

ar Y

ear

*Onc

e you

have

been

bille

d $18

5 of M

edica

re A

ppro

ved a

moun

ts for

cove

red s

ervic

es, y

our M

edica

re P

art B

Ded

uctib

le wi

ll hav

e bee

n met

for th

e cale

ndar

year

.

Serv

ices

Medi

care

Pay

s Pl

an F

Pay

s Yo

u Pa

y

High

Ded

uctib

le Pl

an F

Pay

s (af

ter

you

pay $

2,300

De

duct

ible*

**

You

Pay

(In ad

ditio

n to

$2

,300

Dedu

ctib

le***)

Me

dica

l Exp

ense

s In

or ou

t of th

e hos

pital

and o

utpati

ent h

ospit

al tre

atmen

t, suc

h as P

hysic

ian’s

servi

ces,

inpati

ent a

nd

outpa

tient

medic

al an

d sur

gical

servi

ces a

nd su

pplie

s, ph

ysica

l and

spee

ch th

erap

y, dia

gnos

tic te

sts, d

urab

le me

dical

equip

ment

First

$185

of M

edica

re ap

prov

ed am

ounts

* Re

maind

er of

Med

icare

appr

oved

amou

nts

$0

Gene

rally

80%

$185

Par

t B

Dedu

ctible

Ge

nera

lly 20

%

$0

$0

$185

Par

t B

Dedu

ctible

Ge

nera

lly 20

%

$0

$0

Part

B Ex

cess

Cha

rges

(abo

ve M

edica

re ap

prov

ed

amou

nts)

$0

100%

$0

10

0%

$0

Bloo

d Fir

st 3 p

ints

Next

$185

of M

edica

re ap

prov

ed am

ounts

* Re

maind

er of

Med

icare

appr

oved

amou

nts

$0

$0

80%

All c

osts

$185

Par

t B

Dedu

ctible

20

%

$0

$0

$0

All c

osts

$185

Par

t B

Dedu

ctible

20

%

$0

$0

$0

Clin

ical L

abor

ator

y Ser

vices

– Te

sts fo

r Diag

nosti

c se

rvice

s 10

0%

$0

$0

$0

$0

***Hi

gh D

educ

tible

Plan

F pa

ys th

e sam

e ben

efits

as P

lan F

after

one h

as pa

id a c

alend

ar ye

ar $2

,300 d

educ

tible.

Ben

efits

from

High

Ded

uctib

le Pl

an F

will

not b

egin

until

out-o

f-poc

ket e

xpen

ses e

xcee

d $2,3

00. O

ut-of-

pock

et ex

pens

es fo

r this

dedu

ctible

are e

xpen

ses t

hat w

ould

ordin

arily

be pa

id by

the p

olicy

/certif

icate.

The

se

expe

nses

inclu

de th

e Med

icare

dedu

ctible

s for

Pay

A an

d Par

t B, b

ut do

not in

clude

the p

lan’s

sepa

rate

Fore

ign T

rave

l Eme

rgen

cy de

ducti

ble.

15 of

22

AMER

ICO

FINA

NCIA

L LI

FE A

ND A

NNUI

TY IN

SURA

NCE

COMP

ANY

Outli

ne o

f Cov

erag

e Me

dica

re S

uppl

emen

t Ben

efit

Plan

s A, B

, F, H

igh

Dedu

ctib

le F,

G, a

nd N

.

APA5

00-O

C (0

9/18

)

Effe

ctiv

e: 0

1/01

/201

9 Pl

an F

and

Hig

h D

educ

tible

Pla

n F

Plan

F an

d Hi

gh D

educ

tible

Plan

F

Parts

A &

B

Serv

ices

Medi

care

Pa

ys

Plan

F P

ays

You

Pay

High

Ded

uctib

le

Plan

F P

ays (

afte

r yo

u pa

y $2,3

00

Dedu

ctib

le***

You

Pay

(In ad

ditio

n to

$2,30

0 De

duct

ible*

**)

Hom

e Hea

lth C

are

Medic

are E

ligibl

e Ser

vices

-

Medic

ally n

eces

sary

skille

d car

e ser

vices

and

med

ical s

uppli

es

- Du

rable

med

ical e

quipm

ent. F

irst $

185 o

f

Med

icare

appr

oved

amou

nts*

- Re

maind

er of

Med

icare

appr

oved

amou

nts

100%

$0

80

%

$0

$185

Par

t B

Dedu

ctible

20

%

$0

$0

$0

$0

$185

Par

t B

Dedu

ctible

20

%

$0

$0

$0

Othe

r Ben

efits

Not

Cov

ered

by M

edica

re

Serv

ices

Medi

care

Pa

ys

Plan

F P

ays

You

Pay

High

Ded

uctib

le

Plan

F P

ays (

afte

r yo

u pa

y $2,3

00

Dedu

ctib

le***

You

Pay

(In ad

ditio

n to

$2,30

0 De

duct

ible*

**)

Fore

ign

Trav

el

Medic

ally n

eces

sary

emer

genc

y car

e ser

vices

be

ginnin

g dur

ing th

e firs

t 60 d

ays o

f eac

h trip

ou

tside

the U

SA.

First

$250

each

calen

dar y

ear

Rema

inder

of ch

arge

s

$0

$0

$0

80%

to a

lifetim

e ma

ximum

bene

fit of

$50,0

00.

$250

20

% an

d amo

unts

over

the $

50,00

0 life

time m

axim

um.

$0

80%

to a

lifetim

e ma

ximum

bene

fit of

$50,0

00.

$250

20

% an

d amo

unts

over

the $

50,00

0 life

time m

axim

um.

**High

Ded

uctib

le Pl

an F

pays

the s

ame b

enefi

ts as

Plan

F af

ter on

e has

paid

a cale

ndar

year

$2,30

0 ded

uctib

le. B

enefi

ts fro

m Hi

gh D

educ

tible

Plan

F w

ill no

t beg

in un

til ou

t-of-p

ocke

t exp

ense

s exc

eed $

2,300

. Out-

of-po

cket

expe

nses

for t

his de

ducti

ble ar

e exp

ense

s tha

t wou

ld or

dinar

ily be

paid

by th

e poli

cy/ce

rtifica

te. T

hese

ex

pens

es in

clude

the M

edica

re de

ducti

bles f

or P

ay A

and P

art B

, but

do no

t inclu

de th

e plan

’s se

para

te Fo

reign

Tra

vel E

merg

ency

dedu

ctible

.

16 of

22

AMER

ICO

FINA

NCIA

L LI

FE A

ND A

NNUI

TY IN

SURA

NCE

COMP

ANY

Outli

ne o

f Cov

erag

e Me

dica

re S

uppl

emen

t Ben

efit

Plan

s A, B

, F, H

igh

Dedu

ctib

le F,

G, a

nd N

.

APA5

00-O

C (0

9/18

)

Effe

ctiv

e: 0

1/01

/201

9

Pl

an G

Plan

G

Medi

care

Par

t A –

Hosp

ital S

ervic

es P

er B

enef

it Pe

riod

*A be

nefit

perio

d beg

ins on

the f

irst d

ay yo

u rec

eive s

ervic

e as a

n inp

atien

t in a

hosp

ital a

nd en

ds af

ter yo

u hav

e bee

n out

of the

hosp

ital a

nd ha

ve no

t rec

eived

skille

d ca

re in

any o

ther f

acilit

y for

60 da

ys in

a ro

w.

Serv

ices

Medi

care

Pay

s Pl

an G

Pay

s Yo

u Pa

y Ho

spita

lizat

ion

Semi

priva

te ro

om an

d boa

rd, g

ener

al nu

rsing

and m

iscell

aneo

us

servi

ces a

nd su

pplie

s.

First

60 da

ys

All b

ut $1

,364

$1,36

4 Par

t A D

educ

tible

$0

61st t

hru 9

0th day

Al

l but

$341

a da

y $3

41 a

day

$0

91st d

ay an

d afte

r -

Whil

e usin

g 60 l

ifetim

e res

erve

days

-

Once

lifeti

me re

serve

days

are u

sed

Ad

dition

al 36

5 day

s

Beyo

nd th

e add

itiona

l 365

days

All b

ut $6

82 a

day

$0

$0

$682

a da

y 10

0% of

Med

icare

Elig

ible E

xpen

ses

$0

$0

$0**

All C

osts

Skille

d Nu

rsin

g Fa

cility

Car

e Yo

u mus

t mee

t Med

icare

’s re

quire

ments

, inclu

ding h

aving

been

in a

hosp

ital fo

r at le

ast 3

days

and e

ntere

d a M

edica

re ap

prov

ed fa

cility

wi

thin 3

0 day

s afte

r leav

ing th

e hos

pital.

First

20 da

ys

21st t

hru 1

00 da

ys

101st d

ay an

d afte

r

All a

ppro

ved a

moun

ts Al

l but

$170

.50 a

day

$0

$0

Up to

$170

.50 a

day

$0

$0

$0

All C

osts

Bloo

d Fir

st 3 p

ints

Addit

ional

amou

nts

$0

100%

3 pint

s $0

$0

$0

Hosp

ice C

are

You m

ust m

eet M

edica

re’s

requ

ireme

nts, in

cludin

g a do

ctor’s

ce

rtifica

tion o

f term

inal il

lness

.

All b

ut ve

ry lim

ited

copa

ymen

t/coin

sura

nce

for ou

tpatie

nt dr

ugs a

nd

inpati

ent r

espit

e car

e.

Medic

are c

opay

ment/

coins

uran

ce

$0

**Whe

n you

r Med

icare

Par

t A ho

spita

l ben

efits

are e

xhau

sted,

the in

sure

r stan

ds in

the p

lace o

f Med

icare

and w

ill pa

y wha

tever

amou

nt Me

dicar

e wou

ld ha

ve pa

id for

up

to an

addit

ional

365 d

ays a

s pro

vided

in th

e poli

cy’s

“Cor

e Ben

efits.

” Dur

ing th

is tim

e, the

hosp

ital is

proh

ibited

from

billin

g you

for t

he ba

lance

base

d on a

ny di

ffere

nce

betw

een i

ts bil

led ch

arge

s and

the a

moun

t Med

icare

wou

ld ha

ve pa

id.

17 of

22

AMER

ICO

FINA

NCIA

L LI

FE A

ND A

NNUI

TY IN

SURA

NCE

COMP

ANY

Outli

ne o

f Cov

erag

e Me

dica

re S

uppl

emen

t Ben

efit

Plan

s A, B

, F, H

igh

Dedu

ctib

le F,

G, a

nd N

.

APA5

00-O

C (0

9/18

)

Effe

ctiv

e: 0

1/01

/201

9

Pl

an G

Plan

G

Medi

care

Par

t B –

Medi

cal S

ervic

es p

er C

alend

ar Y

ear

*Onc

e you

have

been

bille

d $18

5 of M

edica

re ap

prov

ed am

ounts

for c

over

ed se

rvice

s, yo

ur M

edica

re P

art B

Ded

uctib

le wi

ll hav

e bee

n met

for th

e cale

ndar

year

. Se

rvice

s Me

dica

re P

ays

Plan

G P

ays

You

Pay

Medi

cal E

xpen

ses

In or

out o

f the h

ospit

al an

d outp

atien

t hos

pital

treatm

ent, s

uch a

s Ph

ysici

an’s

servi

ces,

inpati

ent a

nd ou

tpatie

nt me

dical

and s

urgic

al se

rvice

s an

d sup

plies

, phy

sical

and s

peec

h the

rapy

, diag

nosti

c tes

ts, du

rable

me

dical

equip

ment

First

$185

of M

edica

re ap

prov

ed am

ounts

* Re

maind

er of

Med

icare

appr

oved

amou

nts

$0

Gene

rally

80%

$0

Ge

nera

lly 20

%

$185

Par

t B D

educ

tible

$0

Part

B Ex

cess

Cha

rges

(abo

ve M

edica

re ap

prov

ed am

ounts

) $0

10

0%

$0

Bloo

d Fir

st 3 p

ints

Next

$185

of M

edica

re ap

prov

ed am

ounts

* Re

maind

er of

Med

icare

appr

oved

amou

nts

$0

$0

80%

All c

osts

$0

20%

$0

$185

Par

t B D

educ

tible

$0

Cl

inica

l Lab

orat

ory S

ervic

es –

Tests

for D

iagno

stic s

ervic

es

100%

$0

$0

Parts

A &

B

Serv

ices

Medi

care

Pay

s Pl

an G

Pay

s Yo

u Pa

y Ho

me H

ealth

Car

e Me

dicar

e Elig

ible S

ervic

es

- Me

dicall

y nec

essa

ry sk

illed c

are s

ervic

es an

d med

ical s

uppli

es

- Du

rable

med

ical e

quipm

ent. F

irst $

185 o

f Med

icare

appr

oved

amou

nts*

- Re

maind

er of

Med

icare

appr

oved

amou

nts

100%

$0

80

%

$0

$0

20%

$0

$185

Par

t B D

educ

tible

$0

18 of

22

AMER

ICO

FINA

NCIA

L LI

FE A

ND A

NNUI

TY IN

SURA

NCE

COMP

ANY

Outli

ne o

f Cov

erag

e Me

dica

re S

uppl

emen

t Ben

efit

Plan

s A, B

, F, H

igh

Dedu

ctib

le F,

G, a

nd N

.

APA5

00-O

C (0

9/18

)

Effe

ctiv

e: 0

1/01

/201

9

Pl

an G

Plan

G

Othe

r Ben

efits

Not

Cov

ered

by M

edica

re

Serv

ices

Medi

care

Pay

s Pl

an G

Pay

s Yo

u Pa

y Fo

reig

n Tr

avel

Me

dicall

y nec

essa

ry em

erge

ncy c

are s

ervic

es be

ginnin

g dur

ing th

e firs

t 60

days

of ea

ch tr

ip ou

tside

the U

SA.

First

$250

each

calen

dar y

ear

Rema

inder

of C

harg

es

$0

$0

$0

80%

to a

lifetim

e max

imum

be

nefit

of $5

0,000

.

$250

20

% an

d amo

unts

over

the

$50,0

00 lif

etime

max

imum

.

19 of

22

AMER

ICO

FINA

NCIA

L LI

FE A

ND A

NNUI

TY IN

SURA

NCE

COMP

ANY

Outli

ne o

f Cov

erag

e Me

dica

re S

uppl

emen

t Ben

efit

Plan

s A, B

, F, H

igh

Dedu

ctib

le F,

G, a

nd N

.

APA5

00-O

C (0

9/18

)

Effe

ctiv

e: 0

1/01

/201

9

Pl

an N

Plan

N

Medi

care

Par

t A –

Hosp

ital S

ervic

es P

er B

enef

it Pe

riod

*A be

nefit

perio

d beg

ins on

the f

irst d

ay yo

u rec

eive s

ervic

e as a

n inp

atien

t in a

hosp

ital a

nd en

ds af

ter yo

u hav

e bee

n out

of the

hosp

ital a

nd ha

ve no

t rec

eived

skille

d ca

re in

any o

ther f

acilit

y for

60 da

ys in

a ro

w.

Serv

ices

Medi

care

Pay

s Pl

an N

Pay

s Yo

u Pa

y Ho

spita

lizat

ion

Semi

priva

te ro

om an

d boa

rd, g

ener

al nu

rsing

and m

iscell

aneo

us

servi

ces a

nd su

pplie

s.

First

60 da

ys

All b

ut $1

,364

$1,36

4 Par

t A D

educ

tible

$0

61st t

hru 9

0th day

Al

l but

$341

a da

y $3

41 a

day

$0

91st d

ay an

d afte

r -

Whil

e usin

g 60 l

ifetim

e res

erve

days

-

Once

lifeti

me re

serve

days

are u

sed

Ad

dition

al 36

5 day

s

Beyo

nd th

e add

itiona

l 365

days

All b

ut $6

82 a

day

$0

$0

$682

a da

y 10

0% of

Med

icare

Elig

ible E

xpen

ses

$0

$0

$0**

All C

osts

Skille

d Nu

rsin

g Fa

cility

Car

e Yo

u mus

t mee

t Med

icare

’s re

quire

ments

, inclu

ding h

aving

been

in

a hos

pital

for at

leas

t 3 da

ys an

d ente

red a

Med

icare

appr

oved

fac

ility w

ithin

30 da

ys af

ter le

aving

the h

ospit

al.

First

20 da

ys

21st t

hru 1

00 da

ys

101st d

ay an

d afte

r

All a

ppro

ved a

moun

ts Al

l but

$170

.50 a

day

$0

$0

$Up t

o $17

0.50 a

day

$0

$0

$0

All C

osts

Bloo

d Fir

st 3 p

ints

Addit

ional

amou

nts

$0

100%

3 pint

s $0

$0

$0

Hosp

ice C

are

You m

ust m

eet M

edica

re’s

requ

ireme

nts, in

cludin

g a do

ctor’s

ce

rtifica

tion o

f term

inal il

lness

.

All b

ut ve

ry lim

ited

copa

ymen

t/coin

sura

nce

for ou

tpatie

nt dr

ugs a

nd

inpati

ent r

espit

e car

e.

Medic

are c

opay

ment/

coins

uran

ce

$0

**Whe

n you

r Med

icare

Par

t A ho

spita

l ben

efits

are e

xhau

sted,

the in

sure

r stan

ds in

the p

lace o

f Med

icare

and w

ill pa

y wha

tever

amou

nt Me

dicar

e wou

ld ha

ve pa

id for

up

to an

addit

ional

365 d

ays a

s pro

vided

in th

e poli

cy’s

“Cor

e Ben

efits.

” Dur

ing th

is tim

e, the

hosp

ital is

proh

ibited

from

billin

g you

for t

he ba

lance

base

d on a

ny di

ffere

nce

betw

een i

ts bil

led ch

arge

s and

the a

moun

t Med

icare

wou

ld ha

ve pa

id.

20 of

22

AMER

ICO

FINA

NCIA

L LI

FE A

ND A

NNUI

TY IN

SURA

NCE

COMP

ANY

Outli

ne o

f Cov

erag

e Me

dica

re S

uppl

emen

t Ben

efit

Plan

s A, B

, F, H

igh

Dedu

ctib

le F,

G, a

nd N

.

APA5

00-O

C (0

9/18

)

Effe

ctiv

e: 0

1/01

/201

9

Pl

an N

Plan

N

Medi

care

Par

t B –

Medi

cal S

ervic

es p

er C

alend

ar Y

ear

*Onc

e you

have

been

bille

d $18

5 of M

edica

re A

ppro

ved a

moun

ts for

cove

red s

ervic

es, y

our M

edica

re P

art B

Ded

uctib

le wi

ll hav

e bee

n met

for th

e cale

ndar

year

. Se

rvice

s Me

dica

re P

ays

Plan

N P

ays

You

Pay

Medi

cal E

xpen

ses

In or

out o

f the h

ospit

al an

d outp

atien

t hos

pital

treatm

ent, s

uch a

s Phy

sician

’s se

rvice

s, inp

atien

t and

outpa

tient

medic

al an

d sur

gical

servi

ces a

nd su

pplie

s, ph

ysica

l and

spee

ch th

erap

y, dia

gnos

tic te

sts, d

urab

le me

dical

equip

ment

First

$185

of M

edica

re ap

prov

ed am

ounts

* Re

maind

er of

Med

icare

appr

oved

amou

nts

$0

Gene

rally

80%

$0

Ba

lance

, othe

r tha

n up t

o $2

0 per

offic

e visi

t and

up to

$5

0 per

emer

genc

y roo

m vis

it. Th

e cop

ayme

nt of

up

to $5

0 is w

aived

if the

ins

ured

is ad

mitte

d to a

ny

hosp

ital a

nd th

e eme

rgen

cy

visit i

s cov

ered

as a

Medic

are P

art A

expe

nse.

$185

Par

t B D

educ

tible

Up to

$20 p

er of

fice v

isit

and u

p to $

50 pe

r em

erge

ncy r

oom

visit.

The

copa

ymen

t of u

p to $

50 is

wa

ived i

f the i

nsur

ed is

ad

mitte

d to a

ny ho

spita

l an

d the

emer

genc

y visi

t is

cove

red a

s a M

edica

re

Part

A ex

pens

e. Pa

rt B

Exce

ss C

harg

es (a

bove

Med

icare

appr

oved

amou

nts)

$0

$0

All c

osts

Bloo

d Fir

st 3 p

ints

Next

$185

of M

edica

re ap

prov

ed am

ounts

* Re

maind

er of

Med

icare

appr

oved

amou

nts

$0

$0

80%

All c

osts

$0

20%

$0

$185

Par

t B D

educ

tible

$0

Clin

ical L

abor

ator

y Ser

vices

– Te

sts fo

r diag

nosti

c ser

vices

10

0%

$0

$0

Parts

A &

B

Serv

ices

Medi

care

Pay

s Pl

an N

Pay

s Yo

u Pa

y Ho

me H

ealth

Car

e Me

dicar

e Elig

ible S

ervic

es

- Me

dicall

y nec

essa

ry sk

illed c

are s

ervic

es an

d med

ical s

uppli

es

- Du

rable

med

ical e

quipm

ent. F

irst $

185 o

f Med

icare

appr

oved

amou

nts

- Re

maind

er of

Med

icare

appr

oved

amou

nts

100%

$0

80

%

$0

$0

20%

$0

$185

Par

t B D

educ

tible

$0

21 of

22

AMER

ICO

FINA

NCIA

L LI

FE A

ND A

NNUI

TY IN

SURA

NCE

COMP

ANY

Outli

ne o

f Cov

erag

e Me

dica

re S

uppl

emen

t Ben

efit

Plan

s A, B

, F, H

igh

Dedu

ctib

le F,

G, a

nd N

.

APA5

00-O

C (0

9/18

)

Effe

ctiv

e: 0

1/01

/201

9

Pl

an N

Plan

N

Othe

r Ben

efits

Not

Cov

ered

by M

edica

re

Serv

ices

Medi

care

Pay

s Pl

an N

Pay

s Yo

u Pa

y Fo

reig

n Tr

avel

Medic

ally n

eces

sary

emer

genc

y car

e ser

vices

begin

ning d

uring

the f

irst 6

0 day

s of

each

trip

outsi

de th

e USA

. Fir

st $2

50 ea

ch ca

lenda

r yea

r Re

maind

er of

char

ges

$0

$0

$0

80%

to a

lifetim

e max

imum

be

nefit

of $5

0,000

.

$250

20

% an

d amo

unts

over

the

$50,0

00 lif

etime

max

imum

.

22 of

22

Documents

Americo Medicare Supplement...If, after purchasing this policy, you become eligible for Medicaid, the benefits and premiums under your Medicare Supplement policy can be suspended,