Call Now: (855) 494-0097

Medicare Supplements in NJ

When is Open Enrollment 2019 for Seniors in NJ?

elderly couple meeting with an agentThe open enrollment period for coverage, also known as the Annual Election Period (AEP), is from October 15th, 2017 to December 7th, 2019.

For the foreseeable future, this will always be the schedule. It’s a good idea to begin planning your enrollment during the summer, when you may even be able to secure a lower rate.

Working with an agent allows you to use their knowledge to help you select a plan. There is no cost to request this consultation so it’s smart to work with someone that knows your plan history, health needs, and ongoing premium payments.

For the most part, if you know that you will be participating in a Medicare plan in 2019, you should make your elections during the AEP. This is the best time to choose a new Medicare supplement plan from the right insurance company if you are a Medicare beneficiary age 65 or older.

Call now or fill out this form to receive a free consultation with a licensed insurance agent in your state.

(855) 494-0097

  • There's no cost or obligation!
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What Can I Do During the AEP in New Jersey? We Offer:

Medicare Advantage

Prescription Drug

You’ll have the best chance to switch plans during this time. Seniors age 65 and over in New Jersey can work with an agent to determine cost and benefits of a new plan. This includes:

  • Changing from original Medicare to Medicare Advantage, or from Advantage to original. Sometimes you will get automatically enrolled in coverage, which is something to avoid!
  • New enrollments for prescription drug plans through Medicare Part D
  • Changes in plans for Medicare Advantage or Medicare Part D

You must be enrolled in Medicare Part A and B to be enrolled in Medicare Advantage, and a plan must be available in your part of New Jersey.

What if I Want to Keep the Same Plan?

If you are happy with your existing plan, you may not want to make any changes. For example, you might have Humana insurance and there is no new plan for the current year. If that’s the case, you will be auto-enrolled in your current plan for next year (assuming that the plan is still available in your area).

However, it may be worth your time to spend a few minutes reviewing and discussing your plan, even if you don’t think you want to make a change. The reason for this is that providers are allowed to make changes to their plans every year, including changing premiums.

For example, in 2017 Amerihealth 65 HMO was discontinued for seniors in NJ. Many seniors needed to select a new plan or were going to be automatically enrolled in original Medicare. We released a video at the time to notify them of this change:

If your plan is being discontinued in your area, you can expect to receive a notice of non-renewal from your provider prior to October 15th. This could drastically change your out of pocket cost so use the time during the AEP to select something that makes sense for you.

Are there Changes in 2019 That Will Affect Me?

Please bookmark this page to be made aware of any new changes to Medicare in the New Jersey area.

There are several changes coming to Medicare in 2019, particularly with the issuance of new Medicare cards. Beware of scams during this time, as people will try to impersonate someone from Medicare.gov that is looking to steal your information!

Every year you should review your drug plan to make sure it’s still optimal for your needs.

There may also be relevant factors from a Medicare saving program, so it’s a good idea to look into this every so often.

BGA Insurance Group has an office in Cherry Hill and can assist you with your health insurance planning. We are a legal entity licensed to help you navigate through retirement and can provide one solid plan for you to select.

51 Haddonfield Road, Suite 130
Cherry Hill, NJ 08002

Contact BGA Insurance Group for more supplemental plan information and Medigap supplements.

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Outline of Medicare Supplement Coverage – Benefit Plans A, B, F, High-Deductible F, G, and N

This chart shows the benefits included in each of the standard Medicare Supplement plans. Every company must make Plan A available. Some plans may not be available in Your state.

BASIC BENEFITS:

Hospitalization: Part A coinsurance plus coverage for 365 additional days after Medicare benefits end.

Medical Expenses: Part B coinsurance (generally 20% of Medicare-approved expenses) or copayments for hospital outpatient services. Plans K, L, and N require Insureds to pay a portion of Part B coinsurance or copayments.

Blood: First three pints of blood each year.

Hospice: Part A coinsurance.

A

B

C

D

F

HDF*

G

K

L

M

N

Basic,

Basic,

Basic,

Basic,

Basic,

Basic,

Hospitalization

Hospitalization

Basic,

Basic,

including

including

including

including

including

including

and preventive

and preventive

including

including

100% Part B

100% Part B

100% Part B

100% Part B

100% Part B

100% Part B

care paid at

care paid at

100% Part B

100% Part B

coinsurance

coinsurance

coinsurance

coinsurance

coinsurance*

coinsurance

100%; other

100%; other

coinsurance

coinsurance,

basic benefits

basic benefits

except up to

paid at 50%

paid at 75%

$20 co-

payment for

office visit and

up to $50

copayment for

ER visit

Skilled

Skilled

Skilled

Skilled

50% Skilled

75% Skilled

Skilled

Skilled

nursing

nursing

nursing

nursing

nursing facility

nursing facility

nursing

nursing facility

facility

facility

facility

facility

coinsurance

coinsurance

facility

coinsurance

coinsurance

coinsurance

coinsurance

coinsurance

coinsurance

Part A

Part A

Part A

Part A

Part A

50% Part A

75% Part A

50% Part A

Part A

deductible

deductible

deductible

deductible

deductible

deductible

deductible

deductible

deductible

Part B

Part B

deductible

deductible

Part B excess

Part B excess

(100%)

(100%)

Foreign

Foreign

Foreign

Foreign

Foreign

Foreign travel

travel

travel

travel

travel

travel

emergency

emergency

emergency

emergency

emergency

emergency

Out-of-pocket

Out-of-pocket

limit $5,120;

limit $2,560;

paid at 100%

paid at 100%

after reached

after reached

*Plan F also has an option called a high-deductible Plan F. This high-deductible Plan pays the same benefits as Plan F after one has paid a calendar year $2,200 deductible. Benefits from high-deductible Plan F will not begin until out-of-pocket expenses exceed $2,200. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. These expenses include the Medicare deductibles for Part A and Part B, but do not include the Plan’s separate foreign travel emergency deductible.

CHLIC-HHD-OC-AA-PA

PAGE 1

01/17

Cigna Health and Life Insurance Company

MEDICARE SUPPLEMENT

New Jersey – POLICY FORM SERIES CHLIC-MS-AA

Attained Age Rates — Effective 10/1/2016 — Area I (155, 157-188, 195-196)

PREFERRED ANNUAL & MONTHLY BANK DRAFT RATES

FEMALE RATES

MALE RATES

Plan A

Plan B

Plan F

Plan HDF

Plan G

Plan N

Attained Age

Plan A

Plan B

Plan F

Plan HDF

Plan G

Plan N

Annual

Monthly

Annual

Monthly

Annual

Monthly

Annual

Monthly

Annual

Monthly

Annual

Monthly

Annual

Monthly

Annual

Monthly

Annual

Monthly

Annual

Monthly

Annual

Monthly

Annual

Monthly

2,359.12

196.51

2,451.80

204.24

3,073.06

255.99

931.23

77.57

2,544.49

211.96

2,237.86

186.41

Under 65 UW

2,672.88

222.65

2,777.89

231.40

3,481.78

290.03

1,055.08

87.89

2,882.91

240.15

2,535.50

211.21

1,217.31

101.40

1,234.85

102.86

1,506.42

125.48

456.49

38.03

1,252.38

104.32

1,063.74

88.61

Under 65 OE

1,379.21

114.89

1,399.08

116.54

1,706.77

142.17

517.20

43.08

1,418.95

118.20

1,205.21

100.39

1,217.31

101.40

1,234.85

102.86

1,506.42

125.48

456.49

38.03

1,252.38

104.32

1,063.74

88.61

65

1,379.21

114.89

1,399.08

116.54

1,706.77

142.17

517.20

43.08

1,418.95

118.20

1,205.21

100.39

1,217.31

101.40

1,234.85

102.86

1,506.42

125.48

456.49

38.03

1,252.38

104.32

1,063.74

88.61

66

1,379.21

114.89

1,399.08

116.54

1,706.77

142.17

517.20

43.08

1,418.95

118.20

1,205.21

100.39

1,217.31

101.40

1,234.85

102.86

1,506.42

125.48

456.49

38.03

1,252.38

104.32

1,063.74

88.61

67

1,379.21

114.89

1,399.08

116.54

1,706.77

142.17

517.20

43.08

1,418.95

118.20

1,205.21

100.39

1,225.55

102.09

1,252.09

104.30

1,516.62

126.33

459.58

38.28

1,278.63

106.51

1,069.42

89.08

68

1,388.55

115.67

1,418.62

118.17

1,718.33

143.14

520.70

43.37

1,448.69

120.68

1,211.66

100.93

1,271.90

105.95

1,299.60

108.26

1,573.98

131.11

476.96

39.73

1,327.30

110.56

1,110.79

92.53

69

1,441.06

120.04

1,472.45

122.66

1,783.32

148.55

540.40

45.02

1,503.83

125.27

1,258.52

104.83

1,316.75

109.69

1,342.05

111.79

1,629.48

135.74

493.78

41.13

1,367.35

113.90

1,142.80

95.20

70

1,491.88

124.27

1,520.55

126.66

1,846.20

153.79

559.46

46.60

1,549.21

129.05

1,294.79

107.86

1,358.90

113.20

1,385.25

115.39

1,681.64

140.08

509.59

42.45

1,411.60

117.59

1,181.75

98.44

71

1,539.64

128.25

1,569.49

130.74

1,905.30

158.71

577.36

48.09

1,599.34

133.23

1,338.92

111.53

1,401.05

116.71

1,428.44

118.99

1,733.80

144.43

525.39

43.77

1,455.83

121.27

1,218.73

101.52

72

1,587.39

132.23

1,618.42

134.81

1,964.39

163.63

595.27

49.59

1,649.45

137.40

1,380.82

115.02

1,443.18

120.22

1,471.61

122.59

1,785.94

148.77

541.19

45.08

1,500.04

124.95

1,255.71

104.60

73

1,635.13

136.21

1,667.34

138.89

2,023.47

168.55

613.17

51.08

1,699.55

141.57

1,422.72

118.51

1,485.31

123.73

1,514.78

126.18

1,838.08

153.11

556.99

46.40

1,544.24

128.64

1,292.69

107.68

74

1,682.86

140.18

1,716.24

142.96

2,082.54

173.48

631.07

52.57

1,749.63

145.74

1,464.62

122.00

1,534.91

127.86

1,566.33

130.48

1,899.45

158.22

575.59

47.95

1,597.75

133.09

1,329.67

110.76

75

1,739.05

144.86

1,774.65

147.83

2,152.08

179.27

652.14

54.32

1,810.25

150.79

1,506.52

125.49

1,585.04

132.03

1,619.48

134.90

1,961.49

163.39

594.39

49.51

1,653.93

137.77

1,368.03

113.96

76

1,795.85

149.59

1,834.88

152.85

2,222.36

185.12

673.44

56.10

1,873.90

156.10

1,549.98

129.11

1,629.99

135.78

1,668.16

138.96

2,025.47

168.72

613.78

51.13

1,706.32

142.14

1,424.64

118.67

77

1,846.78

153.84

1,890.02

157.44

2,294.86

191.16

695.41

57.93

1,933.26

161.04

1,614.12

134.46

1,671.35

139.22

1,712.49

142.65

2,089.71

174.07

633.25

52.75

1,753.64

146.08

1,479.25

123.22

78

1,893.64

157.74

1,940.25

161.62

2,367.64

197.22

717.47

59.77

1,986.87

165.51

1,675.99

139.61

1,714.51

142.82

1,756.82

146.34

2,156.75

179.66

653.56

54.44

1,799.13

149.87

1,533.59

127.75

79

1,942.54

161.81

1,990.47

165.81

2,443.60

203.55

740.48

61.68

2,038.41

169.80

1,737.56

144.74

1,757.84

146.43

1,802.18

150.12

2,224.26

185.28

674.02

56.15

1,846.52

153.82

1,585.94

132.11

80

1,991.63

165.90

2,041.87

170.09

2,520.08

209.92

763.66

63.61

2,092.11

174.27

1,796.87

149.68

1,781.15

148.37

1,832.20

152.62

2,274.39

189.46

689.21

57.41

1,883.25

156.87

1,611.54

134.24

81

2,018.04

168.10

2,075.88

172.92

2,576.89

214.65

780.87

65.05

2,133.72

177.74

1,825.87

152.10

1,805.32

150.38

1,859.57

154.90

2,325.95

193.75

704.83

58.71

1,913.82

159.42

1,641.99

136.78

82

2,045.42

170.38

2,106.89

175.50

2,635.30

219.52

798.58

66.52

2,168.36

180.62

1,860.38

154.97

1,828.73

152.33

1,887.82

157.26

2,376.22

197.94

720.07

59.98

1,946.91

162.18

1,692.49

140.98

83

2,071.95

172.59

2,138.90

178.17

2,692.26

224.27

815.84

67.96

2,205.85

183.75

1,917.60

159.74

1,862.03

155.11

1,923.34

160.21

2,425.54

202.05

735.01

61.23

1,984.65

165.32

1,729.16

144.04

84

2,109.68

175.74

2,179.14

181.52

2,748.14

228.92

832.77

69.37

2,248.61

187.31

1,959.14

163.20

1,897.76

158.08

1,960.37

163.30

2,472.08

205.92

749.11

62.40

2,022.99

168.51

1,756.22

146.29

85

2,150.16

179.11

2,221.10

185.02

2,800.87

233.31

848.75

70.70

2,292.04

190.93

1,989.79

165.75

1,939.51

161.56

2,005.00

167.02

2,526.46

210.45

765.60

63.77

2,070.49

172.47

1,799.88

149.93

86

2,197.46

183.05

2,271.66

189.23

2,862.48

238.44

867.42

72.26

2,345.86

195.41

2,039.26

169.87

1,982.18

165.12

2,050.61

170.82

2,582.05

215.08

782.44

65.18

2,119.05

176.52

1,844.44

153.64

87

2,245.81

187.08

2,323.34

193.53

2,925.46

243.69

886.50

73.85

2,400.88

199.99

2,089.75

174.08

2,025.79

168.75

2,097.24

174.70

2,638.85

219.82

799.65

66.61

2,168.70

180.65

1,889.93

157.43

88

2,295.21

191.19

2,376.17

197.94

2,989.82

249.05

906.01

75.47

2,457.13

204.68

2,141.29

178.37

2,070.35

172.46

2,144.90

178.67

2,696.91

224.65

817.24

68.08

2,219.46

184.88

1,936.37

161.30

89

2,345.71

195.40

2,430.18

202.43

3,055.60

254.53

925.94

77.13

2,514.64

209.47

2,193.91

182.75

2,115.90

176.25

2,193.63

182.73

2,756.24

229.59

835.22

69.57

2,271.35

189.20

1,983.79

165.25

90

2,397.32

199.70

2,485.38

207.03

3,122.82

260.13

946.31

78.83

2,573.44

214.37

2,247.63

187.23

2,162.45

180.13

2,243.00

186.84

2,816.88

234.65

853.60

71.10

2,323.55

193.55

2,032.56

169.31

91

2,450.06

204.09

2,541.32

211.69

3,191.52

265.85

967.13

80.56

2,632.59

219.29

2,302.89

191.83

2,210.02

184.10

2,293.48

191.05

2,878.85

239.81

872.38

72.67

2,376.94

198.00

2,082.32

173.46

92

2,503.96

208.58

2,598.52

216.46

3,261.73

271.70

988.40

82.33

2,693.08

224.33

2,359.27

196.53

2,258.64

188.15

2,345.09

195.35

2,942.18

245.08

891.57

74.27

2,431.54

202.55

2,133.11

177.69

93

2,559.04

213.17

2,656.99

221.33

3,333.49

277.68

1,010.15

84.15

2,754.94

229.49

2,416.81

201.32

2,308.33

192.28

2,397.86

199.74

3,006.91

250.48

911.18

75.90

2,487.38

207.20

2,184.95

182.01

94

2,615.34

217.86

2,716.77

226.31

3,406.83

283.79

1,032.37

86.00

2,818.21

234.76

2,475.54

206.21

2,359.12

196.51

2,451.80

204.24

3,073.06

255.99

931.23

77.57

2,544.49

211.96

2,237.86

186.41

95

2,672.88

222.65

2,777.89

231.40

3,481.78

290.03

1,055.08

87.89

2,882.91

240.15

2,535.50

211.21

2,359.12

196.51

2,451.80

204.24

3,073.06

255.99

931.23

77.57

2,544.49

211.96

2,237.86

186.41

96

2,672.88

222.65

2,777.89

231.40

3,481.78

290.03

1,055.08

87.89

2,882.91

240.15

2,535.50

211.21

2,359.12

196.51

2,451.80

204.24

3,073.06

255.99

931.23

77.57

2,544.49

211.96

2,237.86

186.41

97

2,672.88

222.65

2,777.89

231.40

3,481.78

290.03

1,055.08

87.89

2,882.91

240.15

2,535.50

211.21

2,359.12

196.51

2,451.80

204.24

3,073.06

255.99

931.23

77.57

2,544.49

211.96

2,237.86

186.41

98

2,672.88

222.65

2,777.89

231.40

3,481.78

290.03

1,055.08

87.89

2,882.91

240.15

2,535.50

211.21

2,359.12

196.51

2,451.80

204.24

3,073.06

255.99

931.23

77.57

2,544.49

211.96

2,237.86

186.41

99

2,672.88

222.65

2,777.89

231.40

3,481.78

290.03

1,055.08

87.89

2,882.91

240.15

2,535.50

211.21

Policies may be issued on an annual, semi-annual, quarterly or monthly mode.

To obtain semi-annual premiums, multiply the above-quoted annual premium by 0.52. To obtain quarterly premiums, multiply the above quoted premium by 0.265.

During open enrollment and guaranteed issue periods, Preferred rates will apply.

Applicants who qualify for Household Discount multiply above rates by 0.93.

CHLIC-HHD-OC-AA-PA

PAGE 2

01/17

Cigna Health and Life Insurance Company

MEDICARE SUPPLEMENT

PENNSYLVANIA – POLICY FORM SERIES CHLIC-MS-AA

Attained Age Rates — Effective 10/1/2016 — Area I (155, 157-188, 195-196)

STANDARD ANNUAL & MONTHLY BANK DRAFT RATES

FEMALE RATES

MALE RATES

Plan A

Plan B

Plan F

Plan HDF

Plan G

Plan N

Attained Age

Plan A

Plan B

Plan F

Plan HDF

Plan G

Plan N

Annual

Monthly

Annual

Monthly

Annual

Monthly

Annual

Monthly

Annual

Monthly

Annual

Monthly

Annual

Monthly

Annual

Monthly

Annual

Monthly

Annual

Monthly

Annual

Monthly

Annual

Monthly

2,595.03

216.17

2,696.98

224.66

3,380.37

281.58

1,024.35

85.33

2,798.94

233.15

2,461.65

205.06

Under 65 UW

2,940.17

244.92

3,055.68

254.54

3,829.96

319.04

1,160.59

96.68

3,171.20

264.16

2,789.05

232.33

1,339.04

111.54

1,358.33

113.15

1,657.06

138.03

502.14

41.83

1,377.62

114.76

1,170.11

97.47

Under 65 OE

1,517.13

126.38

1,538.99

128.20

1,877.45

156.39

568.92

47.39

1,560.84

130.02

1,325.73

110.43

1,339.04

111.54

1,358.33

113.15

1,657.06

138.03

502.14

41.83

1,377.62

114.76

1,170.11

97.47

65

1,517.13

126.38

1,538.99

128.20

1,877.45

156.39

568.92

47.39

1,560.84

130.02

1,325.73

110.43

1,339.04

111.54

1,358.33

113.15

1,657.06

138.03

502.14

41.83

1,377.62

114.76

1,170.11

97.47

66

1,517.13

126.38

1,538.99

128.20

1,877.45

156.39

568.92

47.39

1,560.84

130.02

1,325.73

110.43

1,339.04

111.54

1,358.33

113.15

1,657.06

138.03

502.14

41.83

1,377.62

114.76

1,170.11

97.47

67

1,517.13

126.38

1,538.99

128.20

1,877.45

156.39

568.92

47.39

1,560.84

130.02

1,325.73

110.43

1,348.10

112.30

1,377.30

114.73

1,668.28

138.97

505.54

42.11

1,406.49

117.16

1,176.37

97.99

68

1,527.40

127.23

1,560.48

129.99

1,890.16

157.45

572.78

47.71

1,593.56

132.74

1,332.82

111.02

1,399.09

116.54

1,429.56

119.08

1,731.38

144.22

524.66

43.70

1,460.03

121.62

1,221.87

101.78

69

1,585.17

132.04

1,619.69

134.92

1,961.65

163.41

594.44

49.52

1,654.22

137.80

1,384.37

115.32

1,448.43

120.65

1,476.26

122.97

1,792.43

149.31

543.16

45.25

1,504.09

125.29

1,257.08

104.71

70

1,641.07

136.70

1,672.60

139.33

2,030.82

169.17

615.40

51.26

1,704.13

141.95

1,424.27

118.64

1,494.79

124.52

1,523.78

126.93

1,849.81

154.09

560.55

46.69

1,552.76

129.34

1,299.93

108.28

71

1,693.60

141.08

1,726.44

143.81

2,095.83

174.58

635.10

52.90

1,759.27

146.55

1,472.82

122.69

1,541.15

128.38

1,571.28

130.89

1,907.17

158.87

577.93

48.14

1,601.41

133.40

1,340.60

111.67

72

1,746.12

145.45

1,780.26

148.30

2,160.83

180.00

654.80

54.54

1,814.40

151.14

1,518.90

126.52

1,587.50

132.24

1,618.77

134.84

1,964.53

163.65

595.31

49.59

1,650.05

137.45

1,381.28

115.06

73

1,798.64

149.83

1,834.07

152.78

2,225.82

185.41

674.49

56.18

1,869.50

155.73

1,564.99

130.36

1,633.84

136.10

1,666.26

138.80

2,021.88

168.42

612.69

51.04

1,698.67

141.50

1,421.96

118.45

74

1,851.15

154.20

1,887.87

157.26

2,290.79

190.82

694.18

57.83

1,924.59

160.32

1,611.08

134.20

1,688.40

140.64

1,722.96

143.52

2,089.39

174.05

633.15

52.74

1,757.52

146.40

1,462.64

121.84

75

1,912.96

159.35

1,952.12

162.61

2,367.28

197.19

717.36

59.76

1,991.27

165.87

1,657.17

138.04

1,743.54

145.24

1,781.43

148.39

2,157.63

179.73

653.83

54.46

1,819.32

151.55

1,504.83

125.35

76

1,975.43

164.55

2,018.36

168.13

2,444.60

203.64

740.79

61.71

2,061.29

171.71

1,704.97

142.02

1,792.99

149.36

1,834.97

152.85

2,228.02

185.59

675.16

56.24

1,876.95

156.35

1,567.10

130.54

77

2,031.46

169.22

2,079.02

173.18

2,524.34

210.28

764.95

63.72

2,126.59

177.14

1,775.53

147.90

1,838.48

153.15

1,883.74

156.92

2,298.68

191.48

696.57

58.02

1,929.00

160.69

1,627.17

135.54

78

2,083.00

173.51

2,134.28

177.79

2,604.41

216.95

789.21

65.74

2,185.56

182.06

1,843.59

153.57

1,885.96

157.10

1,932.50

160.98

2,372.42

197.62

718.92

59.89

1,979.04

164.85

1,686.95

140.52

79

2,136.79

177.99

2,189.52

182.39

2,687.96

223.91

814.53

67.85

2,242.25

186.78

1,911.31

159.21

1,933.62

161.07

1,982.40

165.13

2,446.68

203.81

741.42

61.76

2,031.17

169.20

1,744.53

145.32

80

2,190.79

182.49

2,246.06

187.10

2,772.09

230.92

840.03

69.97

2,301.32

191.70

1,976.55

164.65

1,959.26

163.21

2,015.42

167.88

2,501.83

208.40

758.13

63.15

2,071.58

172.56

1,772.69

147.67

81

2,219.84

184.91

2,283.47

190.21

2,834.57

236.12

858.96

71.55

2,347.10

195.51

2,008.46

167.30

1,985.85

165.42

2,045.52

170.39

2,558.55

213.13

775.32

64.58

2,105.20

175.36

1,806.19

150.46

82

2,249.96

187.42

2,317.58

193.05

2,898.84

241.47

878.43

73.17

2,385.19

198.69

2,046.42

170.47

2,011.60

167.57

2,076.60

172.98

2,613.84

217.73

792.07

65.98

2,141.60

178.40

1,861.74

155.08

83

2,279.15

189.85

2,352.79

195.99

2,961.48

246.69

897.42

74.76

2,426.44

202.12

2,109.36

175.71

2,048.23

170.62

2,115.67

176.24

2,668.09

222.25

808.51

67.35

2,183.11

181.85

1,902.07

158.44

84

2,320.65

193.31

2,397.06

199.67

3,022.95

251.81

916.05

76.31

2,473.47

206.04

2,155.05

179.52

2,087.53

173.89

2,156.41

179.63

2,719.29

226.52

824.03

68.64

2,225.29

185.37

1,931.84

160.92

85

2,365.18

197.02

2,443.21

203.52

3,080.95

256.64

933.62

77.77

2,521.25

210.02

2,188.77

182.32

2,133.46

177.72

2,205.50

183.72

2,779.11

231.50

842.15

70.15

2,277.53

189.72

1,979.86

164.92

86

2,417.21

201.35

2,498.83

208.15

3,148.73

262.29

954.16

79.48

2,580.45

214.95

2,243.19

186.86

2,180.40

181.63

2,255.67

187.90

2,840.25

236.59

860.68

71.69

2,330.95

194.17

2,028.88

169.01

87

2,470.39

205.78

2,555.68

212.89

3,218.01

268.06

975.15

81.23

2,640.97

219.99

2,298.73

191.48

2,228.36

185.62

2,306.96

192.17

2,902.74

241.80

879.62

73.27

2,385.57

198.72

2,078.92

173.17

88

2,524.74

210.31

2,613.79

217.73

3,288.80

273.96

996.61

83.02

2,702.85

225.15

2,355.42

196.21

2,277.39

189.71

2,359.39

196.54

2,966.60

247.12

898.97

74.88

2,441.40

203.37

2,130.01

177.43

89

2,580.28

214.94

2,673.19

222.68

3,361.15

279.98

1,018.53

84.84

2,766.11

230.42

2,413.30

201.03

2,327.49

193.88

2,412.99

201.00

3,031.86

252.55

918.75

76.53

2,498.49

208.12

2,182.17

181.77

90

2,637.05

219.67

2,733.92

227.74

3,435.10

286.14

1,040.94

86.71

2,830.78

235.80

2,472.40

205.95

2,378.70

198.15

2,467.30

205.53

3,098.56

258.11

938.96

78.22

2,555.91

212.91

2,235.81

186.24

91

2,695.06

224.50

2,795.45

232.86

3,510.67

292.44

1,063.84

88.62

2,895.85

241.22

2,533.17

211.01

2,431.03

202.50

2,522.83

210.15

3,166.73

263.79

959.62

79.94

2,614.64

217.80

2,290.55

190.80

92

2,754.35

229.44

2,858.37

238.10

3,587.91

298.87

1,087.24

90.57

2,962.38

246.77

2,595.19

216.18

2,484.51

206.96

2,579.60

214.88

3,236.40

269.59

980.73

81.69

2,674.70

222.80

2,346.42

195.46

93

2,814.95

234.49

2,922.69

243.46

3,666.84

305.45

1,111.16

92.56

3,030.43

252.44

2,658.49

221.45

2,539.17

211.51

2,637.65

219.72

3,307.60

275.52

1,002.30

83.49

2,736.12

227.92

2,403.44

200.21

94

2,876.88

239.64

2,988.45

248.94

3,747.51

312.17

1,135.61

94.60

3,100.03

258.23

2,723.10

226.83

2,595.03

216.17

2,696.98

224.66

3,380.37

281.58

1,024.35

85.33

2,798.94

233.15

2,461.65

205.06

95

2,940.17

244.92

3,055.68

254.54

3,829.96

319.04

1,160.59

96.68

3,171.20

264.16

2,789.05

232.33

2,595.03

216.17

2,696.98

224.66

3,380.37

281.58

1,024.35

85.33

2,798.94

233.15

2,461.65

205.06

96

2,940.17

244.92

3,055.68

254.54

3,829.96

319.04

1,160.59

96.68

3,171.20

264.16

2,789.05

232.33

2,595.03

216.17

2,696.98

224.66

3,380.37

281.58

1,024.35

85.33

2,798.94

233.15

2,461.65

205.06

97

2,940.17

244.92

3,055.68

254.54

3,829.96

319.04

1,160.59

96.68

3,171.20

264.16

2,789.05

232.33

2,595.03

216.17

2,696.98

224.66

3,380.37

281.58

1,024.35

85.33

2,798.94

233.15

2,461.65

205.06

98

2,940.17

244.92

3,055.68

254.54

3,829.96

319.04

1,160.59

96.68

3,171.20

264.16

2,789.05

232.33

2,595.03

216.17

2,696.98

224.66

3,380.37

281.58

1,024.35

85.33

2,798.94

233.15

2,461.65

205.06

99

2,940.17

244.92

3,055.68

254.54

3,829.96

319.04

1,160.59

96.68

3,171.20

264.16

2,789.05

232.33

Policies may be issued on an annual, semi-annual, quarterly or monthly mode.

To obtain semi-annual premiums, multiply the above-quoted annual premium by 0.52. To obtain quarterly premiums, multiply the above quoted premium by 0.265.

During open enrollment and guaranteed issue periods, Preferred rates will apply.

Applicants who qualify for Household Discount multiply above rates by 0.93.

CHLIC-HHD-OC-AA-PA

PAGE 3

01/17

Cigna Health and Life Insurance Company

MEDICARE SUPPLEMENT

PENNSYLVANIA – POLICY FORM SERIES CHLIC-MS-AA

Attained Age Rates — Effective 10/1/2016 — Area II (150-154, 156)

PREFERRED ANNUAL & MONTHLY BANK DRAFT RATES

FEMALE RATES

MALE RATES

Plan A

Plan B

Plan F

Plan HDF

Plan G

Plan N

Attained Age

Plan A

Plan B

Plan F

Plan HDF

Plan G

Plan N

Annual

Monthly

Annual

Monthly

Annual

Monthly

Annual

Monthly

Annual

Monthly

Annual

Monthly

Annual

Monthly

Annual

Monthly

Annual

Monthly

Annual

Monthly

Annual

Monthly

Annual

Monthly

2,607.45

217.20

2,709.89

225.73

3,396.54

282.93

1,029.26

85.74

2,812.33

234.27

2,473.43

206.04

Under 65 UW

2,954.24

246.09

3,070.30

255.76

3,848.28

320.56

1,166.15

97.14

3,186.37

265.42

2,802.39

233.44

1,345.45

112.08

1,364.83

113.69

1,664.99

138.69

504.54

42.03

1,384.21

115.30

1,175.71

97.94

Under 65 OE

1,524.39

126.98

1,546.35

128.81

1,886.43

157.14

571.65

47.62

1,568.31

130.64

1,332.08

110.96

1,345.45

112.08

1,364.83

113.69

1,664.99

138.69

504.54

42.03

1,384.21

115.30

1,175.71

97.94

65

1,524.39

126.98

1,546.35

128.81

1,886.43

157.14

571.65

47.62

1,568.31

130.64

1,332.08

110.96

1,345.45

112.08

1,364.83

113.69

1,664.99

138.69

504.54

42.03

1,384.21

115.30

1,175.71

97.94

66

1,524.39

126.98

1,546.35

128.81

1,886.43

157.14

571.65

47.62

1,568.31

130.64

1,332.08

110.96

1,345.45

112.08

1,364.83

113.69

1,664.99

138.69

504.54

42.03

1,384.21

115.30

1,175.71

97.94

67

1,524.39

126.98

1,546.35

128.81

1,886.43

157.14

571.65

47.62

1,568.31

130.64

1,332.08

110.96

1,354.55

112.83

1,383.89

115.28

1,676.26

139.63

507.96

42.31

1,413.22

117.72

1,181.99

98.46

68

1,534.71

127.84

1,567.95

130.61

1,899.20

158.20

575.52

47.94

1,601.18

133.38

1,339.20

111.56

1,405.79

117.10

1,436.40

119.65

1,739.66

144.91

527.17

43.91

1,467.02

122.20

1,227.71

102.27

69

1,592.75

132.68

1,627.44

135.57

1,971.03

164.19

597.28

49.75

1,662.13

138.46

1,391.00

115.87

1,455.36

121.23

1,483.32

123.56

1,801.01

150.02

545.76

45.46

1,511.28

125.89

1,263.10

105.22

70

1,648.92

137.36

1,680.60

139.99

2,040.54

169.98

618.35

51.51

1,712.29

142.63

1,431.09

119.21

1,501.95

125.11

1,531.07

127.54

1,858.66

154.83

563.23

46.92

1,560.19

129.96

1,306.15

108.80

71

1,701.70

141.75

1,734.70

144.50

2,105.86

175.42

638.14

53.16

1,767.69

147.25

1,479.86

123.27

1,548.53

128.99

1,578.80

131.51

1,916.30

159.63

580.70

48.37

1,609.07

134.04

1,347.02

112.21

72

1,754.48

146.15

1,788.78

149.01

2,171.17

180.86

657.93

54.81

1,823.08

151.86

1,526.17

127.13

1,595.10

132.87

1,626.52

135.49

1,973.93

164.43

598.16

49.83

1,657.94

138.11

1,387.89

115.61

73

1,807.24

150.54

1,842.85

153.51

2,236.47

186.30

677.72

56.45

1,878.45

156.47

1,572.48

130.99

1,641.66

136.75

1,674.23

139.46

2,031.56

169.23

615.62

51.28

1,706.80

142.18

1,428.76

119.02

74

1,860.00

154.94

1,896.90

158.01

2,301.75

191.74

697.50

58.10

1,933.80

161.09

1,618.79

134.85

1,696.48

141.32

1,731.21

144.21

2,099.39

174.88

636.18

52.99

1,765.93

147.10

1,469.64

122.42

75

1,922.11

160.11

1,961.46

163.39

2,378.61

198.14

720.79

60.04

2,000.80

166.67

1,665.10

138.70

1,751.89

145.93

1,789.96

149.10

2,167.96

180.59

656.96

54.72

1,828.03

152.27

1,512.03

125.95

76

1,984.89

165.34

2,028.02

168.93

2,456.30

204.61

744.33

62.00

2,071.16

172.53

1,713.13

142.70

1,801.57

150.07

1,843.75

153.58

2,238.68

186.48

678.39

56.51

1,885.93

157.10

1,574.60

131.16

77

2,041.18

170.03

2,088.97

174.01

2,536.42

211.28

768.61

64.03

2,136.76

177.99

1,784.02

148.61

1,847.28

153.88

1,892.76

157.67

2,309.68

192.40

699.90

58.30

1,938.23

161.45

1,634.96

136.19

78

2,092.97

174.34

2,144.49

178.64

2,616.87

217.99

792.99

66.06

2,196.02

182.93

1,852.41

154.31

1,894.98

157.85

1,941.75

161.75

2,383.77

198.57

722.36

60.17

1,988.51

165.64

1,695.02

141.20

79

2,147.01

178.85

2,200.00

183.26

2,700.82

224.98

818.43

68.18

2,252.98

187.67

1,920.46

159.97

1,942.87

161.84

1,991.88

165.92

2,458.39

204.78

744.97

62.06

2,040.89

170.01

1,752.88

146.01

80

2,201.27

183.37

2,256.80

187.99

2,785.36

232.02

844.05

70.31

2,312.33

192.62

1,986.01

165.43

1,968.64

163.99

2,025.06

168.69

2,513.80

209.40

761.76

63.45

2,081.49

173.39

1,781.17

148.37

81

2,230.47

185.80

2,294.40

191.12

2,848.14

237.25

863.07

71.89

2,358.33

196.45

2,018.07

168.11

1,995.35

166.21

2,055.31

171.21

2,570.79

214.15

779.03

64.89

2,115.27

176.20

1,814.84

151.18

82

2,260.73

188.32

2,328.67

193.98

2,912.71

242.63

882.64

73.52

2,396.60

199.64

2,056.21

171.28

2,021.23

168.37

2,086.54

173.81

2,626.35

218.77

795.86

66.30

2,151.85

179.25

1,870.65

155.83

83

2,290.05

190.76

2,364.05

196.93

2,975.65

247.87

901.71

75.11

2,438.05

203.09

2,119.45

176.55

2,058.03

171.43

2,125.80

177.08

2,680.86

223.32

812.38

67.67

2,193.56

182.72

1,911.17

159.20

84

2,331.75

194.23

2,408.53

200.63

3,037.41

253.02

920.43

76.67

2,485.30

207.03

2,165.36

180.37

2,097.52

174.72

2,166.73

180.49

2,732.30

227.60

827.97

68.97

2,235.93

186.25

1,941.08

161.69

85

2,376.49

197.96

2,454.90

204.49

3,095.69

257.87

938.09

78.14

2,533.31

211.02

2,199.24

183.20

2,143.67

178.57

2,216.05

184.60

2,792.41

232.61

846.18

70.49

2,288.43

190.63

1,989.34

165.71

86

2,428.77

202.32

2,510.78

209.15

3,163.80

263.54

958.73

79.86

2,592.79

215.98

2,253.92

187.75

2,190.83

182.50

2,266.47

188.80

2,853.84

237.72

864.80

72.04

2,342.10

195.10

2,038.59

169.81

87

2,482.21

206.77

2,567.91

213.91

3,233.40

269.34

979.82

81.62

2,653.60

221.05

2,309.72

192.40

2,239.03

186.51

2,318.00

193.09

2,916.63

242.95

883.83

73.62

2,396.98

199.67

2,088.87

174.00

88

2,536.82

211.32

2,626.30

218.77

3,304.54

275.27

1,001.37

83.41

2,715.78

226.22

2,366.69

197.15

2,288.28

190.61

2,370.68

197.48

2,980.79

248.30

903.27

75.24

2,453.08

204.34

2,140.20

178.28

89

2,592.63

215.97

2,685.98

223.74

3,377.24

281.32

1,023.41

85.25

2,779.34

231.52

2,424.85

201.99

2,338.63

194.81

2,424.53

201.96

3,046.37

253.76

923.14

76.90

2,510.44

209.12

2,192.61

182.64

90

2,649.66

220.72

2,747.00

228.82

3,451.54

287.51

1,045.92

87.13

2,844.33

236.93

2,484.23

206.94

2,390.08

199.09

2,479.11

206.51

3,113.39

259.35

943.45

78.59

2,568.14

213.93

2,246.51

187.13

91

2,707.96

225.57

2,808.83

233.98

3,527.47

293.84

1,068.93

89.04

2,909.70

242.38

2,545.29

212.02

2,442.66

203.47

2,534.90

211.16

3,181.88

265.05

964.21

80.32

2,627.15

218.84

2,301.51

191.72

92

2,767.53

230.54

2,872.05

239.24

3,605.07

300.30

1,092.45

91.00

2,976.56

247.95

2,607.61

217.21

2,496.40

207.95

2,591.95

215.91

3,251.89

270.88

985.42

82.09

2,687.50

223.87

2,357.64

196.39

93

2,828.42

235.61

2,936.68

244.63

3,684.39

306.91

1,116.48

93.00

3,044.93

253.64

2,671.21

222.51

2,551.32

212.52

2,650.27

220.77

3,323.43

276.84

1,007.10

83.89

2,749.21

229.01

2,414.94

201.16

94

2,890.64

240.79

3,002.75

250.13

3,765.44

313.66

1,141.04

95.05

3,114.86

259.47

2,736.13

227.92

2,607.45

217.20

2,709.89

225.73

3,396.54

282.93

1,029.26

85.74

2,812.33

234.27

2,473.43

206.04

95

2,954.24

246.09

3,070.30

255.76

3,848.28

320.56

1,166.15

97.14

3,186.37

265.42

2,802.39

233.44

2,607.45

217.20

2,709.89

225.73

3,396.54

282.93

1,029.26

85.74

2,812.33

234.27

2,473.43

206.04

96

2,954.24

246.09

3,070.30

255.76

3,848.28

320.56

1,166.15

97.14

3,186.37

265.42

2,802.39

233.44

2,607.45

217.20

2,709.89

225.73

3,396.54

282.93

1,029.26

85.74

2,812.33

234.27

2,473.43

206.04

97

2,954.24

246.09

3,070.30

255.76

3,848.28

320.56

1,166.15

97.14

3,186.37

265.42

2,802.39

233.44

2,607.45

217.20

2,709.89

225.73

3,396.54

282.93

1,029.26

85.74

2,812.33

234.27

2,473.43

206.04

98

2,954.24

246.09

3,070.30

255.76

3,848.28

320.56

1,166.15

97.14

3,186.37

265.42

2,802.39

233.44

2,607.45

217.20

2,709.89

225.73

3,396.54

282.93

1,029.26

85.74

2,812.33

234.27

2,473.43

206.04

99

2,954.24

246.09

3,070.30

255.76

3,848.28

320.56

1,166.15

97.14

3,186.37

265.42

2,802.39

233.44

Policies may be issued on an annual, semi-annual, quarterly or monthly mode.

To obtain semi-annual premiums, multiply the above-quoted annual premium by 0.52. To obtain quarterly premiums, multiply the above quoted premium by 0.265.

During open enrollment and guaranteed issue periods, Preferred rates will apply.

Applicants who qualify for Household Discount multiply above rates by 0.93.

CHLIC-HHD-OC-AA-PA

PAGE 4

01/17

Cigna Health and Life Insurance Company

MEDICARE SUPPLEMENT

PENNSYLVANIA – POLICY FORM SERIES CHLIC-MS-AA

Attained Age Rates — Effective 10/1/2016 — Area II (150-154, 156)

STANDARD ANNUAL & MONTHLY BANK DRAFT RATES

FEMALE RATES

MALE RATES

Plan A

Plan B

Plan F

Plan HDF

Plan G

Plan N

Attained Age

Plan A

Plan B

Plan F

Plan HDF

Plan G

Plan N

Annual

Monthly

Annual

Monthly

Annual

Monthly

Annual

Monthly

Annual

Monthly

Annual

Monthly

Annual

Monthly

Annual

Monthly

Annual

Monthly

Annual

Monthly

Annual

Monthly

Annual

Monthly

2,868.19

238.92

2,980.88

248.31

3,736.20

311.23

1,132.18

94.31

3,093.56

257.69

2,720.77

226.64

Under 65 UW

3,249.66

270.70

3,377.33

281.33

4,233.11

352.62

1,282.76

106.85

3,505.01

291.97

3,082.63

256.78

1,479.99

123.28

1,501.31

125.06

1,831.49

152.56

555.00

46.23

1,522.63

126.84

1,293.28

107.73

Under 65 OE

1,676.83

139.68

1,700.99

141.69

2,075.08

172.85

628.81

52.38

1,725.14

143.70

1,465.29

122.06

1,479.99

123.28

1,501.31

125.06

1,831.49

152.56

555.00

46.23

1,522.63

126.84

1,293.28

107.73

65

1,676.83

139.68

1,700.99

141.69

2,075.08

172.85

628.81

52.38

1,725.14

143.70

1,465.29

122.06

1,479.99

123.28

1,501.31

125.06

1,831.49

152.56

555.00

46.23

1,522.63

126.84

1,293.28

107.73

66

1,676.83

139.68

1,700.99

141.69

2,075.08

172.85

628.81

52.38

1,725.14

143.70

1,465.29

122.06

1,479.99

123.28

1,501.31

125.06

1,831.49

152.56

555.00

46.23

1,522.63

126.84

1,293.28

107.73

67

1,676.83

139.68

1,700.99

141.69

2,075.08

172.85

628.81

52.38

1,725.14

143.70

1,465.29

122.06

1,490.01

124.12

1,522.28

126.81

1,843.89

153.60

558.75

46.54

1,554.55

129.49

1,300.19

108.31

68

1,688.18

140.63

1,724.74

143.67

2,089.12

174.02

633.07

52.73

1,761.30

146.72

1,473.12

122.71

1,546.36

128.81

1,580.04

131.62

1,913.63

159.40

579.89

48.30

1,613.72

134.42

1,350.48

112.50

69

1,752.03

145.94

1,790.19

149.12

2,168.14

180.61

657.01

54.73

1,828.35

152.30

1,530.10

127.46

1,600.89

133.35

1,631.65

135.92

1,981.11

165.03

600.34

50.01

1,662.41

138.48

1,389.41

115.74

70

1,813.81

151.09

1,848.66

153.99

2,244.59

186.97

680.18

56.66

1,883.51

156.90

1,574.20

131.13

1,652.14

137.62

1,684.17

140.29

2,044.52

170.31

619.55

51.61

1,716.21

142.96

1,436.76

119.68

71

1,871.88

155.93

1,908.17

158.95

2,316.45

192.96

701.95

58.47

1,944.46

161.97

1,627.85

135.60

1,703.38

141.89

1,736.68

144.67

2,107.93

175.59

638.77

53.21

1,769.98

147.44

1,481.72

123.43

72

1,929.93

160.76

1,967.66

163.91

2,388.28

198.94

723.72

60.29

2,005.39

167.05

1,678.79

139.84

1,754.61

146.16

1,789.17

149.04

2,171.33

180.87

657.98

54.81

1,823.74

151.92

1,526.68

127.17

73

1,987.97

165.60

2,027.13

168.86

2,460.11

204.93

745.49

62.10

2,066.29

172.12

1,729.73

144.09

1,805.83

150.43

1,841.65

153.41

2,234.71

186.15

677.19

56.41

1,877.48

156.39

1,571.64

130.92

74

2,046.00

170.43

2,086.59

173.81

2,531.93

210.91

767.25

63.91

2,127.18

177.19

1,780.67

148.33

1,866.13

155.45

1,904.33

158.63

2,309.33

192.37

699.80

58.29

1,942.53

161.81

1,616.60

134.66

75

2,114.32

176.12

2,157.60

179.73

2,616.47

217.95

792.87

66.05

2,200.88

183.33

1,831.61

152.57

1,927.07

160.53

1,968.95

164.01

2,384.75

198.65

722.65

60.20

2,010.83

167.50

1,663.23

138.55

76

2,183.37

181.88

2,230.82

185.83

2,701.93

225.07

818.77

68.20

2,278.27

189.78

1,884.44

156.97

1,981.73

165.08

2,028.13

168.94

2,462.55

205.13

746.23

62.16

2,074.53

172.81

1,732.06

144.28

77

2,245.30

187.03

2,297.87

191.41

2,790.06

232.41

845.47

70.43

2,350.44

195.79

1,962.43

163.47

2,032.01

169.27

2,082.03

173.43

2,540.65

211.64

769.89

64.13

2,132.06

177.60

1,798.46

149.81

78

2,302.26

191.78

2,358.94

196.50

2,878.56

239.78

872.29

72.66

2,415.62

201.22

2,037.65

169.74

2,084.48

173.64

2,135.92

177.92

2,622.15

218.43

794.59

66.19

2,187.36

182.21

1,864.52

155.31

79

2,361.71

196.73

2,420.00

201.59

2,970.90

247.48

900.27

74.99

2,478.28

206.44

2,112.51

175.97

2,137.16

178.03

2,191.07

182.52

2,704.23

225.26

819.46

68.26

2,244.98

187.01

1,928.17

160.62

80

2,421.40

201.70

2,482.48

206.79

3,063.89

255.22

928.45

77.34

2,543.56

211.88

2,184.61

181.98

2,165.50

180.39

2,227.57

185.56

2,765.18

230.34

837.93

69.80

2,289.64

190.73

1,959.29

163.21

81

2,453.51

204.38

2,523.84

210.24

3,132.95

260.97

949.38

79.08

2,594.16

216.09

2,219.87

184.92

2,194.88

182.83

2,260.84

188.33

2,827.87

235.56

856.93

71.38

2,326.80

193.82

1,996.32

166.29

82

2,486.80

207.15

2,561.53

213.38

3,203.98

266.89

970.90

80.88

2,636.26

219.60

2,261.83

188.41

2,223.35

185.21

2,295.19

191.19

2,888.98

240.65

875.45

72.92

2,367.04

197.17

2,057.72

171.41

83

2,519.06

209.84

2,600.45

216.62

3,273.22

272.66

991.88

82.62

2,681.85

223.40

2,331.39

194.21

2,263.84

188.58

2,338.38

194.79

2,948.95

245.65

893.62

74.44

2,412.92

201.00

2,102.29

175.12

84

2,564.93

213.66

2,649.38

220.69

3,341.16

278.32

1,012.47

84.34

2,733.83

227.73

2,381.90

198.41

2,307.27

192.20

2,383.40

198.54

3,005.53

250.36

910.77

75.87

2,459.53

204.88

2,135.19

177.86

85

2,614.14

217.76

2,700.39

224.94

3,405.26

283.66

1,031.90

85.96

2,786.64

232.13

2,419.17

201.52

2,358.03

196.42

2,437.65

203.06

3,071.65

255.87

930.80

77.54

2,517.27

209.69

2,188.27

182.28

86

2,671.65

222.55

2,761.86

230.06

3,480.18

289.90

1,054.60

87.85

2,852.07

237.58

2,479.31

206.53

2,409.91

200.75

2,493.11

207.68

3,139.23

261.50

951.28

79.24

2,576.32

214.61

2,242.45

186.80

87

2,730.43

227.44

2,824.70

235.30

3,556.74

296.28

1,077.80

89.78

2,918.97

243.15

2,540.70

211.64

2,462.93

205.16

2,549.80

212.40

3,208.29

267.25

972.21

80.98

2,636.68

219.64

2,297.76

191.40

88

2,790.50

232.45

2,888.93

240.65

3,634.99

302.79

1,101.51

91.76

2,987.36

248.85

2,603.36

216.86

2,517.11

209.68

2,607.75

217.23

3,278.87

273.13

993.60

82.77

2,698.39

224.78

2,354.22

196.11

89

2,851.89

237.56

2,954.58

246.12

3,714.96

309.46

1,125.75

93.77

3,057.28

254.67

2,667.33

222.19

2,572.49

214.29

2,666.99

222.16

3,351.01

279.14

1,015.46

84.59

2,761.48

230.03

2,411.87

200.91

90

2,914.63

242.79

3,021.70

251.71

3,796.69

316.26

1,150.51

95.84

3,128.76

260.63

2,732.65

227.63

2,629.08

219.00

2,727.02

227.16

3,424.73

285.28

1,037.80

86.45

2,824.95

235.32

2,471.16

205.85

91

2,978.75

248.13

3,089.71

257.37

3,880.22

323.22

1,175.82

97.95

3,200.67

266.62

2,799.82

233.23

2,686.92

223.82

2,788.39

232.27

3,500.07

291.56

1,060.63

88.35

2,889.86

240.73

2,531.66

210.89

92

3,044.28

253.59

3,159.25

263.17

3,965.58

330.33

1,201.69

100.10

3,274.21

272.74

2,868.37

238.94

2,746.04

228.74

2,851.14

237.50

3,577.07

297.97

1,083.96

90.29

2,956.25

246.26

2,593.41

216.03

93

3,111.26

259.17

3,230.34

269.09

4,052.82

337.60

1,228.13

102.30

3,349.43

279.01

2,938.33

244.76

2,806.45

233.78

2,915.29

242.84

3,655.77

304.53

1,107.81

92.28

3,024.14

251.91

2,656.43

221.28

94

3,179.71

264.87

3,303.03

275.14

4,141.99

345.03

1,255.15

104.55

3,426.35

285.41

3,009.74

250.71

2,868.19

238.92

2,980.88

248.31

3,736.20

311.23

1,132.18

94.31

3,093.56

257.69

2,720.77

226.64

95

3,249.66

270.70

3,377.33

281.33

4,233.11

352.62

1,282.76

106.85

3,505.01

291.97

3,082.63

256.78

2,868.19

238.92

2,980.88

248.31

3,736.20

311.23

1,132.18

94.31

3,093.56

257.69

2,720.77

226.64

96

3,249.66

270.70

3,377.33

281.33

4,233.11

352.62

1,282.76

106.85

3,505.01

291.97

3,082.63

256.78

2,868.19

238.92

2,980.88

248.31

3,736.20

311.23

1,132.18

94.31

3,093.56

257.69

2,720.77

226.64

97

3,249.66

270.70

3,377.33

281.33

4,233.11

352.62

1,282.76

106.85

3,505.01

291.97

3,082.63

256.78

2,868.19

238.92

2,980.88

248.31

3,736.20

311.23

1,132.18

94.31

3,093.56

257.69

2,720.77

226.64

98

3,249.66

270.70

3,377.33

281.33

4,233.11

352.62

1,282.76

106.85

3,505.01

291.97

3,082.63

256.78

2,868.19

238.92

2,980.88

248.31

3,736.20

311.23

1,132.18

94.31

3,093.56

257.69

2,720.77

226.64

99

3,249.66

270.70

3,377.33

281.33

4,233.11

352.62

1,282.76

106.85

3,505.01

291.97

3,082.63

256.78

Policies may be issued on an annual, semi-annual, quarterly or monthly mode.

To obtain semi-annual premiums, multiply the above-quoted annual premium by 0.52. To obtain quarterly premiums, multiply the above quoted premium by 0.265.

During open enrollment and guaranteed issue periods, Preferred rates will apply.

Applicants who qualify for Household Discount multiply above rates by 0.93.

CHLIC-HHD-OC-AA-PA

PAGE 5

01/17

Cigna Health and Life Insurance Company

MEDICARE SUPPLEMENT

PENNSYLVANIA – POLICY FORM SERIES CHLIC-MS-AA

Attained Age Rates — Effective 10/1/2016 — Area III (189-194)

PREFERRED ANNUAL & MONTHLY BANK DRAFT RATES

FEMALE RATES

MALE RATES

Plan A

Plan B

Plan F

Plan HDF

Plan G

Plan N

Attained Age

Plan A

Plan B

Plan F

Plan HDF

Plan G

Plan N

Annual

Monthly

Annual

Monthly

Annual

Monthly

Annual

Monthly

Annual

Monthly

Annual

Monthly

Annual

Monthly

Annual

Monthly

Annual

Monthly

Annual

Monthly

Annual

Monthly

Annual

Monthly

2,930.27

244.09

3,045.40

253.68

3,817.07

317.96

1,156.69

96.35

3,160.52

263.27

2,779.66

231.55

Under 65 UW

3,320.00

276.56

3,450.44

287.42

4,324.74

360.25

1,310.53

109.17

3,580.87

298.29

3,149.36

262.34

1,512.03

125.95

1,533.81

127.77

1,871.13

155.87

567.01

47.23

1,555.59

129.58

1,321.27

110.06

Under 65 OE

1,713.13

142.70

1,737.80

144.76

2,119.99

176.60

642.42

53.51

1,762.48

146.81

1,497.00

124.70

1,512.03

125.95

1,533.81

127.77

1,871.13

155.87

567.01

47.23

1,555.59

129.58

1,321.27

110.06

65

1,713.13

142.70

1,737.80

144.76

2,119.99

176.60

642.42

53.51

1,762.48

146.81

1,497.00

124.70

1,512.03

125.95

1,533.81

127.77

1,871.13

155.87

567.01

47.23

1,555.59

129.58

1,321.27

110.06

66

1,713.13

142.70

1,737.80

144.76

2,119.99

176.60

642.42

53.51

1,762.48

146.81

1,497.00

124.70

1,512.03

125.95

1,533.81

127.77

1,871.13

155.87

567.01

47.23

1,555.59

129.58

1,321.27

110.06

67

1,713.13

142.70

1,737.80

144.76

2,119.99

176.60

642.42

53.51

1,762.48

146.81

1,497.00

124.70

1,522.26

126.80

1,555.23

129.55

1,883.80

156.92

570.85

47.55

1,588.19

132.30

1,328.34

110.65

68

1,724.72

143.67

1,762.07

146.78

2,134.34

177.79

646.77

53.88

1,799.42

149.89

1,505.00

125.37

1,579.83

131.60

1,614.24

134.47

1,955.05

162.86

592.44

49.35

1,648.65

137.33

1,379.72

114.93

69

1,789.95

149.10

1,828.94

152.35

2,215.07

184.52

671.23

55.91

1,867.92

155.60

1,563.22

130.22

1,635.55

136.24

1,666.97

138.86

2,023.99

168.60

613.33

51.09

1,698.40

141.48

1,419.48

118.24

70

1,853.07

154.36

1,888.68

157.33

2,293.18

191.02

694.90

57.89

1,924.28

160.29

1,608.27

133.97

1,687.90

140.60

1,720.63

143.33

2,088.78

174.00

632.96

52.73

1,753.35

146.05

1,467.86

122.27

71

1,912.39

159.30

1,949.47

162.39

2,366.59

197.14

717.15

59.74

1,986.55

165.48

1,663.08

138.53

1,740.25

144.96

1,774.27

147.80

2,153.56

179.39

652.59

54.36

1,808.29

150.63

1,513.79

126.10

72

1,971.70

164.24

2,010.25

167.45

2,439.98

203.25

739.39

61.59

2,048.79

170.66

1,715.13

142.87

1,792.59

149.32

1,827.90

152.26

2,218.32

184.79

672.22

56.00

1,863.21

155.21

1,559.73

129.93

73

2,031.00

169.18

2,071.01

172.51

2,513.36

209.36

761.62

63.44

2,111.02

175.85

1,767.17

147.21

1,844.92

153.68

1,881.51

156.73

2,283.08

190.18

691.84

57.63

1,918.11

159.78

1,605.66

133.75

74

2,090.29

174.12

2,131.76

177.58

2,586.73

215.47

783.86

65.30

2,173.22

181.03

1,819.21

151.54

1,906.52

158.81

1,945.55

162.06

2,359.32

196.53

714.94

59.55

1,984.57

165.31

1,651.59

137.58

75

2,160.08

179.94

2,204.30

183.62

2,673.10

222.67

810.03

67.48

2,248.52

187.30

1,871.25

155.88

1,968.79

164.00

2,011.57

167.56

2,436.37

202.95

738.29

61.50

2,054.35

171.13

1,699.23

141.55

76

2,230.63

185.81

2,279.11

189.85

2,760.41

229.94

836.49

69.68

2,327.58

193.89

1,925.23

160.37

2,024.62

168.65

2,072.03

172.60

2,515.85

209.57

762.38

63.51

2,119.43

176.55

1,769.55

147.40

77

2,293.90

191.08

2,347.61

195.56

2,850.46

237.44

863.77

71.95

2,401.31

200.03

2,004.90

167.01

2,075.99

172.93

2,127.10

177.19

2,595.64

216.22

786.56

65.52

2,178.20

181.44

1,837.38

153.05

78

2,352.10

195.93

2,410.00

200.75

2,940.86

244.97

891.17

74.23

2,467.90

205.58

2,081.76

173.41

2,129.60

177.40

2,182.15

181.77

2,678.91

223.15

811.79

67.62

2,234.71

186.15

1,904.88

158.68

79

2,412.83

200.99

2,472.38

205.95

3,035.20

252.83

919.76

76.62

2,531.92

210.91

2,158.23

179.78

2,183.42

181.88

2,238.50

186.47

2,762.76

230.14

837.20

69.74

2,293.57

191.05

1,969.90

164.09

80

2,473.81

206.07

2,536.22

211.27

3,130.21

260.75

948.55

79.01

2,598.62

216.47

2,231.90

185.92

2,212.37

184.29

2,275.78

189.57

2,825.03

235.33

856.07

71.31

2,339.20

194.86

2,001.70

166.74

81

2,506.62

208.80

2,578.46

214.79

3,200.76

266.62

969.93

80.80

2,650.31

220.77

2,267.92

188.92

2,242.39

186.79

2,309.78

192.40

2,889.08

240.66

875.48

72.93

2,377.16

198.02

2,039.53

169.89

82

2,540.63

211.63

2,616.98

217.99

3,273.33

272.67

991.92

82.63

2,693.33

224.35

2,310.79

192.49

2,271.47

189.21

2,344.87

195.33

2,951.52

245.86

894.40

74.50

2,418.27

201.44

2,102.26

175.12

83

2,573.58

214.38

2,656.74

221.31

3,344.07

278.56

1,013.35

84.41

2,739.90

228.23

2,381.86

198.41

2,312.84

192.66

2,388.99

199.00

3,012.78

250.96

912.96

76.05

2,465.14

205.35

2,147.80

178.91

84

2,620.45

218.28

2,706.73

225.47

3,413.47

284.34

1,034.39

86.16

2,793.01

232.66

2,433.45

202.71

2,357.21

196.36

2,434.99

202.83

3,070.58

255.78

930.48

77.51

2,512.76

209.31

2,181.40

181.71

85

2,670.72

222.47

2,758.84

229.81

3,478.97

289.80

1,054.23

87.82

2,846.96

237.15

2,471.53

205.88

2,409.07

200.68

2,490.42

207.45

3,138.14

261.41

950.95

79.21

2,571.76

214.23

2,235.64

186.23

86

2,729.48

227.37

2,821.64

235.04

3,555.51

296.17

1,077.43

89.75

2,913.81

242.72

2,532.97

211.00

2,462.07

205.09

2,547.08

212.17

3,207.17

267.16

971.87

80.96

2,632.08

219.25

2,290.99

190.84

87

2,789.53

232.37

2,885.84

240.39

3,633.73

302.69

1,101.13

91.72

2,982.15

248.41

2,595.69

216.22

2,516.24

209.60

2,604.99

217.00

3,277.73

273.04

993.25

82.74

2,693.75

224.39

2,347.49

195.55

88

2,850.90

237.48

2,951.46

245.86

3,713.67

309.35

1,125.35

93.74

3,052.02

254.23

2,659.71

221.55

2,571.60

214.21

2,664.20

221.93

3,349.84

279.04

1,015.10

84.56

2,756.80

229.64

2,405.18

200.35

89

2,913.62

242.70

3,018.53

251.44

3,795.37

316.15

1,150.11

95.80

3,123.45

260.18

2,725.07

227.00

2,628.17

218.93

2,724.71

226.97

3,423.54

285.18

1,037.44

86.42

2,821.26

235.01

2,464.08

205.26

90

2,977.72

248.04

3,087.10

257.16

3,878.87

323.11

1,175.41

97.91

3,196.48

266.27

2,791.80

232.56

2,685.99

223.74

2,786.04

232.08

3,498.86

291.45

1,060.26

88.32

2,886.10

240.41

2,524.65

210.30

91

3,043.23

253.50

3,156.59

262.94

3,964.20

330.22

1,201.27

100.07

3,269.95

272.39

2,860.43

238.27

2,745.08

228.67

2,848.75

237.30

3,575.83

297.87

1,083.59

90.26

2,952.41

245.94

2,586.46

215.45

92

3,110.18

259.08

3,227.63

268.86

4,051.42

337.48

1,227.70

102.27

3,345.08

278.65

2,930.46

244.11

2,805.47

233.70

2,912.85

242.64

3,654.50

304.42

1,107.42

92.25

3,020.23

251.59

2,649.54

220.71

93

3,178.60

264.78

3,300.26

274.91

4,140.55

344.91

1,254.71

104.52

3,421.93

285.05

3,001.93

250.06

2,867.19

238.84

2,978.39

248.10

3,734.90

311.12

1,131.79

94.28

3,089.59

257.36

2,713.93

226.07

94

3,248.53

270.60

3,374.52

281.10

4,231.64

352.50

1,282.32

106.82

3,500.51

291.59

3,074.89

256.14

2,930.27

244.09

3,045.40

253.68

3,817.07

317.96

1,156.69

96.35

3,160.52

263.27

2,779.66

231.55

95

3,320.00

276.56

3,450.44

287.42

4,324.74

360.25

1,310.53

109.17

3,580.87

298.29

3,149.36

262.34

2,930.27

244.09

3,045.40

253.68

3,817.07

317.96

1,156.69

96.35

3,160.52

263.27

2,779.66

231.55

96

3,320.00

276.56

3,450.44

287.42

4,324.74

360.25

1,310.53

109.17

3,580.87

298.29

3,149.36

262.34

2,930.27

244.09

3,045.40

253.68

3,817.07

317.96

1,156.69

96.35

3,160.52

263.27

2,779.66

231.55

97

3,320.00

276.56

3,450.44

287.42

4,324.74

360.25

1,310.53

109.17

3,580.87

298.29

3,149.36

262.34

2,930.27

244.09

3,045.40

253.68

3,817.07

317.96

1,156.69

96.35

3,160.52

263.27

2,779.66

231.55

98

3,320.00

276.56

3,450.44

287.42

4,324.74

360.25

1,310.53

109.17

3,580.87

298.29

3,149.36

262.34

2,930.27

244.09

3,045.40

253.68

3,817.07

317.96

1,156.69

96.35

3,160.52

263.27

2,779.66

231.55

99

3,320.00

276.56

3,450.44

287.42

4,324.74

360.25

1,310.53

109.17

3,580.87

298.29

3,149.36

262.34

Policies may be issued on an annual, semi-annual, quarterly or monthly mode.

To obtain semi-annual premiums, multiply the above-quoted annual premium by 0.52. To obtain quarterly premiums, multiply the above quoted premium by 0.265.

During open enrollment and guaranteed issue periods, Preferred rates will apply.

Applicants who qualify for Household Discount multiply above rates by 0.93.

CHLIC-HHD-OC-AA-PA

PAGE 6

01/17

Cigna Health and Life Insurance Company

MEDICARE SUPPLEMENT

PENNSYLVANIA – POLICY FORM SERIES CHLIC-MS-AA

Attained Age Rates — Effective 10/1/2016 — Area III (189-194)

STANDARD ANNUAL & MONTHLY BANK DRAFT RATES

FEMALE RATES

MALE RATES

Plan A

Plan B

Plan F

Plan HDF

Plan G

Plan N

Attained Age

Plan A

Plan B

Plan F

Plan HDF

Plan G

Plan N

Annual

Monthly

Annual

Monthly

Annual

Monthly

Annual

Monthly

Annual

Monthly

Annual

Monthly

Annual

Monthly

Annual

Monthly

Annual

Monthly

Annual

Monthly

Annual

Monthly

Annual

Monthly

3,223.30

268.50

3,349.94

279.05

4,198.77

349.76

1,272.36

105.99

3,476.58

289.60

3,057.63

254.70

Under 65 UW

3,652.00

304.21

3,795.48

316.16

4,757.21

396.28

1,441.58

120.08

3,938.96

328.12

3,464.29

288.58

1,663.23

138.55

1,687.19

140.54

2,058.25

171.45

623.71

51.96

1,711.15

142.54

1,453.40

121.07

Under 65 OE

1,884.44

156.97

1,911.58

159.23

2,331.99

194.26

706.66

58.87

1,938.73

161.50

1,646.70

137.17

1,663.23

138.55

1,687.19

140.54

2,058.25

171.45

623.71

51.96

1,711.15

142.54

1,453.40

121.07

65

1,884.44

156.97

1,911.58

159.23

2,331.99

194.26

706.66

58.87

1,938.73

161.50

1,646.70

137.17

1,663.23

138.55

1,687.19

140.54

2,058.25

171.45

623.71

51.96

1,711.15

142.54

1,453.40

121.07

66

1,884.44

156.97

1,911.58

159.23

2,331.99

194.26

706.66

58.87

1,938.73

161.50

1,646.70

137.17

1,663.23

138.55

1,687.19

140.54

2,058.25

171.45

623.71

51.96

1,711.15

142.54

1,453.40

121.07

67

1,884.44

156.97

1,911.58

159.23

2,331.99

194.26

706.66

58.87

1,938.73

161.50

1,646.70

137.17

1,674.49

139.48

1,710.75

142.51

2,072.18

172.61

627.93

52.31

1,747.01

145.53

1,461.17

121.72

68

1,897.19

158.04

1,938.28

161.46

2,347.78

195.57

711.45

59.26

1,979.37

164.88

1,655.51

137.90

1,737.82

144.76

1,775.67

147.91

2,150.55

179.14

651.68

54.29

1,813.52

151.07

1,517.69

126.42

69

1,968.95

164.01

2,011.83

167.59

2,436.57

202.97

738.36

61.51

2,054.71

171.16

1,719.54

143.24

1,799.10

149.87

1,833.67

152.74

2,226.39

185.46

674.66

56.20

1,868.24

155.62

1,561.43

130.07

70

2,038.38

169.80

2,077.55

173.06

2,522.50

210.12

764.39

63.67

2,116.71

176.32

1,769.10

147.37

1,856.69

154.66

1,892.69

157.66

2,297.66

191.39

696.26

58.00

1,928.69

160.66

1,614.64

134.50

71

2,103.63

175.23

2,144.42

178.63

2,603.24

216.85

788.86

65.71

2,185.20

182.03

1,829.39

152.39

1,914.27

159.46

1,951.70

162.58

2,368.91

197.33

717.85

59.80

1,989.12

165.69

1,665.17

138.71

72

2,168.87

180.67

2,211.27

184.20

2,683.98

223.58

813.33

67.75

2,253.67

187.73

1,886.64

157.16

1,971.84

164.25

2,010.69

167.49

2,440.16

203.27

739.44

61.60

2,049.53

170.73

1,715.70

142.92

73

2,234.10

186.10

2,278.11

189.77

2,764.70

230.30

837.79

69.79

2,322.12

193.43

1,943.89

161.93

2,029.41

169.05

2,069.67

172.40

2,511.39

209.20

761.03

63.39

2,109.93

175.76

1,766.22

147.13

74

2,299.32

191.53

2,344.93

195.33

2,845.41

237.02

862.24

71.82

2,390.55

199.13

2,001.13

166.69

2,097.17

174.69

2,140.10

178.27

2,595.25

216.18

786.44

65.51

2,183.03

181.85

1,816.75

151.34

75

2,376.09

197.93

2,424.73

201.98

2,940.42

244.94

891.03

74.22

2,473.37

206.03

2,058.38

171.46

2,165.66

180.40

2,212.73

184.32

2,680.01

223.24

812.12

67.65

2,259.79

188.24

1,869.16

155.70

76

2,453.70

204.39

2,507.02

208.83

3,036.45

252.94

920.14

76.65

2,560.34

213.28

2,117.76

176.41

2,227.08

185.52

2,279.23

189.86

2,767.43

230.53

838.62

69.86

2,331.37

194.20

1,946.51

162.14

77

2,523.29

210.19

2,582.37

215.11

3,135.50

261.19

950.15

79.15

2,641.45

220.03

2,205.39

183.71

2,283.59

190.22

2,339.81

194.91

2,855.21

237.84

865.21

72.07

2,396.02

199.59

2,021.12

168.36

78

2,587.31

215.52

2,651.00

220.83

3,234.95

269.47

980.29

81.66

2,714.70

226.13

2,289.93

190.75

2,342.56

195.13

2,400.37

199.95

2,946.80

245.47

892.97

74.38

2,458.18

204.77

2,095.37

174.54

79

2,654.12

221.09

2,719.62

226.54

3,338.72

278.12

1,011.73

84.28

2,785.12

232.00

2,374.05

197.76

2,401.76

200.07

2,462.35

205.11

3,039.04

253.15

920.92

76.71

2,522.93

210.16

2,166.89

180.50

80

2,721.19

226.68

2,789.84

232.39

3,443.23

286.82

1,043.40

86.92

2,858.48

238.11

2,455.09

204.51

2,433.61

202.72

2,503.36

208.53

3,107.54

258.86

941.68

78.44

2,573.12

214.34

2,201.87

183.42

81

2,757.28

229.68

2,836.31

236.26

3,520.84

293.29

1,066.92

88.87

2,915.34

242.85

2,494.72

207.81

2,466.63

205.47

2,540.76

211.64

3,177.99

264.73

963.03

80.22

2,614.88

217.82

2,243.48

186.88

82

2,794.69

232.80

2,878.68

239.79

3,600.66

299.93

1,091.11

90.89

2,962.66

246.79

2,541.87

211.74

2,498.62

208.14

2,579.36

214.86

3,246.67

270.45

983.84

81.95

2,660.10

221.59

2,312.48

192.63

83

2,830.94

235.82

2,922.41

243.44

3,678.47

306.42

1,114.69

92.85

3,013.89

251.06

2,620.04

218.25

2,544.12

211.93

2,627.89

218.90

3,314.05

276.06

1,004.26

83.65

2,711.66

225.88

2,362.58

196.80

84

2,882.49

240.11

2,977.40

248.02

3,754.82

312.78

1,137.82

94.78

3,072.31

255.92

2,676.80

222.98

2,592.94

215.99

2,678.49

223.12

3,377.64

281.36

1,023.53

85.26

2,764.04

230.24

2,399.54

199.88

85

2,937.80

244.72

3,034.73

252.79

3,826.87

318.78

1,159.66

96.60

3,131.66

260.87

2,718.68

226.47

2,649.98

220.74

2,739.46

228.20

3,451.95

287.55

1,046.05

87.14

2,828.94

235.65

2,459.20

204.85

86

3,002.43

250.10

3,103.81

258.55

3,911.06

325.79

1,185.17

98.72

3,205.19

266.99

2,786.27

232.10

2,708.28

225.60

2,801.78

233.39

3,527.89

293.87

1,069.06

89.05

2,895.29

241.18

2,520.09

209.92

87

3,068.48

255.60

3,174.42

264.43

3,997.10

332.96

1,211.24

100.90

3,280.36

273.25

2,855.26

237.84

2,767.86

230.56

2,865.49

238.70

3,605.51

300.34

1,092.58

91.01

2,963.12

246.83

2,582.24

215.10

88

3,135.99

261.23

3,246.60

270.44

4,085.04

340.28

1,237.89

103.12

3,357.22

279.66

2,925.68

243.71

2,828.76

235.64

2,930.62

244.12

3,684.83

306.95

1,116.61

93.01

3,032.48

252.61

2,645.70

220.39

89

3,204.98

266.97

3,320.39

276.59

4,174.91

347.77

1,265.12

105.38

3,435.80

286.20

2,997.58

249.70

2,890.99

240.82

2,997.19

249.67

3,765.89

313.70

1,141.18

95.06

3,103.38

258.51

2,710.48

225.78

90

3,275.49

272.85

3,395.81

282.87

4,266.76

355.42

1,292.96

107.70

3,516.13

292.89

3,070.98

255.81

2,954.59

246.12

3,064.65

255.29

3,848.74

320.60

1,166.29

97.15

3,174.71

264.45

2,777.11

231.33

91

3,347.55

278.85

3,472.25

289.24

4,360.62

363.24

1,321.40

110.07

3,596.94

299.63

3,146.47

262.10

3,019.59

251.53

3,133.62

261.03

3,933.41

327.65

1,191.94

99.29

3,247.65

270.53

2,845.11

237.00

92

3,421.20

284.99

3,550.39

295.75

4,456.56

371.23

1,350.47

112.49

3,679.59

306.51

3,223.50

268.52

3,086.02

257.07

3,204.14

266.90

4,019.95

334.86

1,218.17

101.47

3,322.26

276.74

2,914.50

242.78

93

3,496.46

291.26

3,630.29

302.40

4,554.60

379.40

1,380.18

114.97

3,764.12

313.55

3,302.13

275.07

3,153.91

262.72

3,276.23

272.91

4,108.39

342.23

1,244.97

103.71

3,398.55

283.10

2,985.33

248.68

94

3,573.38

297.66

3,711.97

309.21

4,654.80

387.75

1,410.55

117.50

3,850.56

320.75

3,382.37

281.75

3,223.30

268.50

3,349.94

279.05

4,198.77

349.76

1,272.36

105.99

3,476.58

289.60

3,057.63

254.70

95

3,652.00

304.21

3,795.48

316.16

4,757.21

396.28

1,441.58

120.08

3,938.96

328.12

3,464.29

288.58

3,223.30

268.50

3,349.94

279.05

4,198.77

349.76

1,272.36

105.99

3,476.58

289.60

3,057.63

254.70

96

3,652.00

304.21

3,795.48

316.16

4,757.21

396.28

1,441.58

120.08

3,938.96

328.12

3,464.29

288.58

3,223.30

268.50

3,349.94

279.05

4,198.77

349.76

1,272.36

105.99

3,476.58

289.60

3,057.63

254.70

97

3,652.00

304.21

3,795.48

316.16

4,757.21

396.28

1,441.58

120.08

3,938.96

328.12

3,464.29

288.58

3,223.30

268.50

3,349.94

279.05

4,198.77

349.76

1,272.36

105.99

3,476.58

289.60

3,057.63

254.70

98

3,652.00

304.21

3,795.48

316.16

4,757.21

396.28

1,441.58

120.08

3,938.96

328.12

3,464.29

288.58

3,223.30

268.50

3,349.94

279.05

4,198.77

349.76

1,272.36

105.99

3,476.58

289.60

3,057.63

254.70

99

3,652.00

304.21

3,795.48

316.16

4,757.21

396.28

1,441.58

120.08

3,938.96

328.12

3,464.29

288.58

Policies may be issued on an annual, semi-annual, quarterly or monthly mode.

To obtain semi-annual premiums, multiply the above-quoted annual premium by 0.52. To obtain quarterly premiums, multiply the above quoted premium by 0.265.

During open enrollment and guaranteed issue periods, Preferred rates will apply.

Applicants who qualify for Household Discount multiply above rates by 0.93.

CHLIC-HHD-OC-AA-PA

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CHLIC-HHD-OC-AA-PA

PAGE 8

01/17

Locate appropriate Area according to the Applicant’s ZIP Code in the ZIP Code chart below.

PENNSYLVANIA ZIP CODES:

Area

3-digit ZIP Codes

Area I

155, 157-188, 195-196

Area II

150-154, 156

Area III

189-194

CHLIC-HHD-OC-AA-PA

PAGE 9

01/17

PREMIUM INFORMATION

Your premium will increase each year because of the increase in Your attained age. We, Cigna Health and Life Insurance Company, can also raise Your premium if (a) We change the rates or discounts which apply to all policies of this form issued by Us and in force in the state where Your policy was issued; or

(b)coverage under Medicare changes. We will send You a written notice at least thirty (30) days in advance when We change the premium rates or discounts for all policies of this form issued by Us and in force in the state where Your policy was issued.

DISCLOSURES

Use this Outline to compare benefits and premiums among policies.

READ YOUR POLICY VERY CAREFULLY

This is only an Outline describing Your policy’s most important features. The policy is Your insurance contract. You must read the policy itself to understand all of the rights and duties of both You and Cigna Health and Life Insurance Company.

30-DAY RIGHT TO RETURN POLICY

If You find that You are not satisfied with Your policy, You may return it to Cigna Health and Life Insurance Company, PO Box 26580, Austin, TX 78755-0580. If You send the policy back to Us within thirty (30) days after You receive it, We will treat the policy as if it had never been issued and return all of Your premiums.

POLICY REPLACEMENT

If You are replacing another health insurance policy, do NOT cancel it until You have actually received Your new policy and are sure You want to keep it.

NOTICE

This policy may not fully cover all of Your medical costs. Neither Cigna 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 and You for more details.

COMPLETE ANSWERS ARE VERY IMPORTANT

When You fill out the application for the new policy, be sure to answer truthfully and completely all questions about Your medical and health history. We 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.

RENEWABILITY

The policy is guaranteed renewable for life.

CHLIC-HHD-OC-AA-PA

PAGE 10

01/17

HOUSEHOLD DISCOUNT

Affiliate means an insurance company that is under common ownership or control with Cigna Health and Life Insurance Company and that is a member of the same insurance holding company system.

Household Discount is a discount that is available when more than one member of Your household enrolls or is enrolled in a Medicare Supplement policy provided by or through an Affiliate of Cigna Health and Life Insurance Company. Household is defined as a condominium unit, a single-family home, or an apartment unit within an apartment complex. Assisted Living facilities, Group Homes, Adult Day Care facilities and Nursing Homes, or any other health residential facility are not included in the definition of “Household.”

The household premium discount will be removed if the other Medicare Supplement policyholder whose policy status entitles You to the discount no longer resides with You or no longer has a Medicare Supplement policy through Cigna Health and Life Insurance Company or an Affiliate of Cigna Health and Life Insurance Company. However, if that person becomes deceased, Your discount will still apply. The addition or removal of the discount will occur on the billing cycle following the date We learn Your eligibility has changed.

CHLIC-HHD-OC-AA-PA

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CHLIC-HHD-OC-AA-PA

PAGE 12

01/17

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 A PAYS

YOU PAY

HOSPITALIZATION*

Semi-private room and board, general nursing, and

miscellaneous services and supplies

All but $1,316

$0

$1,316 (Part A deductible)

First 60 days

61st thru 90th day

All but $329 per day

$329 per day

$0

91st day and after:

All but $658 per day

$658 per day

$0

– while using 60 lifetime reserve days

– 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 entering

a Medicare-approved facility within 30 days after leaving

the hospital

All approved amounts

$0

$0

First 20 days

21st thru 100th day

All but $164.50 per day

$0

Up to $164.50 per day

101st day and after

$0

$0

All costs

BLOOD

$0

3 pints

$0

First 3 pints

Additional amounts

100%

$0

$0

HOSPICE CARE

All but very limited

Medicare copayment/coinsurance

$0

You must meet Medicare’s requirements, including a

doctor’s certification of terminal illness

copayment/coinsurance

for outpatient drugs and

inpatient respite care

**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.

CHLIC-HHD-OC-AA-PA

PAGE 13

01/17

PLAN A

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

*Once You have been billed $183 of Medicare-approved amounts for covered services (which are noted with an asterisk), Your Part B deductible will have been met for the calendar year.

SERVICES

MEDICARE PAYS

PLAN A 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

$0

$0

$183 (Part B deductible)

First $183 of Medicare-approved amounts*

Remainder of Medicare-approved amounts

Generally 80%

Generally 20%

$0

PART B EXCESS CHARGES

$0

$0

All costs

(above Medicare-approved amounts)

BLOOD

$0

All costs

$0

First 3 pints

Next $183 of Medicare-approved amounts*

$0

$0

$183 (Part B deductible)

Remainder of Medicare-approved amounts

80%

20%

$0

CLINICAL LABORATORY SERVICES

100%

$0

$0

Tests for diagnostic services

PARTS A & B

SERVICES

MEDICARE PAYS

PLAN A PAYS

YOU PAY

HOME HEALTH CARE MEDICARE-

APPROVED SERVICES

Medically-necessary skilled care services and

100%

$0

$0

medical supplies

– Durable medical equipment

$0

$0

$183 (Part B deductible)

First $183 of Medicare-approved amounts*

Remainder of Medicare-approved amounts

80%

20%

$0

CHLIC-HHD-OC-AA-PA

PAGE 14

01/17

PLAN B

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 B PAYS

YOU PAY

HOSPITALIZATION*

Semi-private room and board, general nursing, and

miscellaneous services and supplies

All but $1,316

$1,316 (Part A deductible)

$0

First 60 days

61st thru 90th day

All but $329 per day

$329 per day

$0

91st day and after:

All but $658 per day

$658 per day

$0

– while using 60 lifetime reserve days

– 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 entering

a Medicare-approved facility within 30 days after leaving

the hospital

All approved amounts

$0

$0

First 20 days

21st thru 100th day

All but $164.50 per day

$0

Up to $164.50 per day

101st day and after

$0

$0

All costs

BLOOD

$0

3 pints

$0

First 3 pints

Additional amounts

100%

$0

$0

HOSPICE CARE

All but very limited

Medicare copayment/coinsurance

$0

You must meet Medicare’s requirements, including a

doctor’s certification of terminal illness

copayment/coinsurance

for outpatient drugs and

inpatient respite care

**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.

CHLIC-HHD-OC-AA-PA

PAGE 15

01/17

PLAN B

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

*Once You have been billed $183 of Medicare-approved amounts for covered services (which are noted with an asterisk), Your Part B deductible will have been met for the calendar year.

SERVICES

MEDICARE PAYS

PLAN B 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

$0

$0

$183 (Part B deductible)

First $183 of Medicare-approved amounts*

Remainder of Medicare-approved amounts

Generally 80%

Generally 20%

$0

PART B EXCESS CHARGES

$0

$0

All costs

(above Medicare-approved amounts)

BLOOD

$0

All costs

$0

First 3 pints

Next $183 of Medicare-approved amounts*

$0

$0

$183 (Part B deductible)

Remainder of Medicare-approved amounts

80%

20%

$0

CLINICAL LABORATORY SERVICES

100%

$0

$0

Tests for diagnostic services

PARTS A & B

SERVICES

MEDICARE PAYS

PLAN A PAYS

YOU PAY

HOME HEALTH CARE MEDICARE-

APPROVED SERVICES

Medically-necessary skilled care services and

100%

$0

$0

medical supplies

– Durable medical equipment

$0

$0

$183 (Part B deductible)

First $183 of Medicare-approved amounts*

Remainder of Medicare-approved amounts

80%

20%

$0

CHLIC-HHD-OC-AA-PA

PAGE 16

01/17

PLAN F

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

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

SERVICES

MEDICARE PAYS

PLAN F PAYS

YOU PAY

HOSPITALIZATION*

Semi-private room and board, general nursing, and

miscellaneous services and supplies

All but $1,316

$1,316 (Part A deductible)

$0

First 60 days

61st thru 90th day

All but $329 per day

$329 per day

$0

91st day and after:

All but $658 per day

$658 per day

$0

– while using 60 lifetime reserve days

– 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 entering

a Medicare-approved facility within 30 days after leaving

the hospital

All approved amounts

$0

$0

First 20 days

21st thru 100th day

All but $164.50 per day

Up to $164.50 per day

$0

101st day and after

$0

$0

All costs

BLOOD

$0

3 pints

$0

First 3 pints

Additional amounts

100%

$0

$0

HOSPICE CARE

All but very limited

Medicare copayment/coinsurance

$0

You must meet Medicare’s requirements, including a

doctor’s certification of terminal illness

copayment/coinsurance

for outpatient drugs and

inpatient respite care

**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.

CHLIC-HHD-OC-AA-PA

PAGE 17

01/17

PLAN F

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

*Once You have been billed $183 of Medicare-approved amounts for covered services (which are noted with an asterisk), Your Part B deductible will have been met for the calendar year.

SERVICES

MEDICARE PAYS

PLAN F 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

$0

$183 (Part B deductible)

$0

First $183 of Medicare-approved amounts*

Remainder of Medicare-approved amounts

Generally 80%

Generally 20%

$0

PART B EXCESS CHARGES

$0

100%

$0

(above Medicare-approved amounts)

BLOOD

$0

All costs

$0

First 3 pints

Next $183 of Medicare-approved amounts*

$0

$183 (Part B deductible)

$0

Remainder of Medicare-approved amounts

80%

20%

$0

CLINICAL LABORATORY SERVICES

100%

$0

$0

Tests for diagnostic services

PARTS A & B

SERVICES

MEDICARE PAYS

PLAN F PAYS

YOU PAY

HOME HEALTH CARE MEDICARE-

APPROVED SERVICES

Medically-necessary skilled care services and

100%

$0

$0

medical supplies

– Durable medical equipment

$0

$183 (Part B deductible)

$0

First $183 of Medicare-approved amounts*

Remainder of Medicare-approved amounts

80%

20%

$0

CHLIC-HHD-OC-AA-PA

PAGE 18

01/17

PLAN F

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

OTHER BENEFITS – NOT COVERED BY MEDICARE

SERVICES

MEDICARE PAYS

PLAN F 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

$0

$0

$250

First $250 each calendar year

Remainder of charges

$0

80% to a lifetime maximum

20% and amounts over the

benefit of $50,000

$50,000 lifetime maximum

CHLIC-HHD-OC-AA-PA

PAGE 19

01/17

HIGH-DEDUCTIBLE PLAN F

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

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

**This high-deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,200 deductible. Benefits from the high-deductible Plan F will not begin until out-of-pocket expenses are $2,200. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductible for Part A and Part B, but does not include the plan’s separate foreign travel emergency deductible.

SERVICES

MEDICARE PAYS

AFTER YOU PAY $2,200

IN ADDITION TO $2,200

DEDUCTIBLE**, PLAN PAYS

DEDUCTIBLE**, YOU PAY

HOSPITALIZATION*

Semi-private room and board, general nursing, and

miscellaneous services and supplies

All but $1,316

$1,316 (Part A deductible)

$0

First 60 days

61st thru 90th day

All but $329 per day

$329 per day

$0

91st day and after:

All but $658 per day

$658 per day

$0

– while using 60 lifetime reserve days

– 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 entering

a Medicare-approved facility within 30 days after leaving

the hospital

All approved amounts

$0

$0

First 20 days

21st thru 100th day

All but $164.50 per day

Up to $164.50 per day

$0

101st day and after

$0

$0

All costs

BLOOD

$0

3 pints

$0

First 3 pints

Additional amounts

100%

$0

$0

HOSPICE CARE

All but very limited

Medicare copayment/coinsurance

$0

You must meet Medicare’s requirements, including a

doctor’s certification of terminal illness

copayment/coinsurance

for outpatient drugs and

inpatient respite care

***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.

CHLIC-HHD-OC-AA-PA

PAGE 20

01/17

HIGH-DEDUCTIBLE PLAN F

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

*Once You have been billed $183 of Medicare-approved amounts for covered services (which are noted with an asterisk), Your Part B deductible will have been met for the calendar year.

**This high-deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,200 deductible. Benefits from the high-deductible Plan F will not begin until out-of-pocket expenses are $2,200. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductible for Part A and Part B, but does not include the plan’s separate foreign travel emergency deductible.

SERVICES

MEDICARE PAYS

AFTER YOU PAY $2,200

IN ADDITION TO $2,200

DEDUCTIBLE**, PLAN PAYS

DEDUCTIBLE**, 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

$0

$183 (Part B deductible)

$0

First $183 of Medicare-approved amounts*

Remainder of Medicare-approved amounts

Generally 80%

Generally 20%

$0

PART B EXCESS CHARGES

$0

100%

$0

(above Medicare-approved amounts)

BLOOD

$0

All costs

$0

First 3 pints

Next $183 of Medicare-approved amounts*

$0

$183 (Part B deductible)

$0

Remainder of Medicare-approved amounts

80%

20%

$0

CLINICAL LABORATORY SERVICES

100%

$0

$0

Tests for diagnostic services

MEDICARE (PARTS A & B)

SERVICES

MEDICARE PAYS

AFTER YOU PAY $2,200

IN ADDITION TO $2,200

DEDUCTIBLE**, PLAN PAYS

DEDUCTIBLE**, YOU PAY

HOME HEALTH CARE MEDICARE-

APPROVED SERVICES

Medically-necessary skilled care services and

100%

$0

$0

medical supplies

– Durable medical equipment

$0

$183 (Part B deductible)

$0

First $183 of Medicare-approved amounts*

Remainder of Medicare-approved amounts

80%

20%

$0

CHLIC-HHD-OC-AA-PA

PAGE 21

01/17

HIGH-DEDUCTIBLE PLAN F

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

OTHER BENEFITS – NOT COVERED BY MEDICARE

SERVICES

MEDICARE PAYS

AFTER YOU PAY $2,200

IN ADDITION TO $2,200

DEDUCTIBLE**, PLAN PAYS

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

$0

$0

$250

First $250 each calendar year

Remainder of charges

$0

80% to a lifetime maximum

20% and amounts over the

benefit of $50,000

$50,000 lifetime maximum

CHLIC-HHD-OC-AA-PA

PAGE 22

01/17

PLAN G

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

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

SERVICES

MEDICARE PAYS

PLAN G PAYS

YOU PAY

HOSPITALIZATION*

Semi-private room and board, general nursing, and

miscellaneous services and supplies

All but $1,316

$1,316 (Part A deductible)

$0

First 60 days

61st thru 90th day

All but $329 per day

$329 per day

$0

91st day and after:

All but $658 per day

$658 per day

$0

– while using 60 lifetime reserve days

– 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 entering

a Medicare-approved facility within 30 days after leaving

the hospital

All approved amounts

$0

$0

First 20 days

21st thru 100th day

All but $164.50 per day

Up to $164.50 per day

$0

101st day and after

$0

$0

All costs

BLOOD

$0

3 pints

$0

First 3 pints

Additional amounts

100%

$0

$0

HOSPICE CARE

All but very limited

Medicare copayment/coinsurance

$0

You must meet Medicare’s requirements, including a

doctor’s certification of terminal illness

copayment/coinsurance

for outpatient drugs and

inpatient respite care

**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.

CHLIC-HHD-OC-AA-PA

PAGE 23

01/17

PLAN G

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

*Once You have been billed $183 of Medicare-approved amounts for covered services (which are noted with an asterisk), Your Part B deductible will have been met for the calendar year.

SERVICES

MEDICARE PAYS

PLAN G 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

$0

$0

$183 (Part B deductible)

First $183 of Medicare-approved amounts*

Remainder of Medicare-approved amounts

Generally 80%

Generally 20%

$0

PART B EXCESS CHARGES

$0

100%

$0

(above Medicare-approved amounts)

BLOOD

$0

All costs

$0

First 3 pints

Next $183 of Medicare-approved amounts*

$0

$0

$183 (Part B deductible)

Remainder of Medicare-approved amounts

80%

20%

$0

CLINICAL LABORATORY SERVICES

100%

$0

$0

Tests for diagnostic services

PARTS A & B

SERVICES

MEDICARE PAYS

PLAN G PAYS

YOU PAY

HOME HEALTH CARE MEDICARE-

APPROVED SERVICES

Medically-necessary skilled care services and

100%

$0

$0

medical supplies

– Durable medical equipment

$0

$0

$183 (Part B deductible)

First $183 of Medicare-approved amounts*

Remainder of Medicare-approved amounts

80%

20%

$0

CHLIC-HHD-OC-AA-PA

PAGE 24

01/17

PLAN G

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

OTHER BENEFITS – NOT COVERED BY MEDICARE

SERVICES

MEDICARE PAYS

PLAN G 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

$0

$0

$250

First $250 each calendar year

Remainder of charges

$0

80% to a lifetime maximum

20% and amounts over the

benefit of $50,000

$50,000 lifetime maximum

CHLIC-HHD-OC-AA-PA

PAGE 25

01/17

PLAN N

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 N PAYS

YOU PAY

HOSPITALIZATION*

Semi-private room and board, general nursing, and

miscellaneous services and supplies

All but $1,316

$1,316 (Part A deductible)

$0

First 60 days

61st thru 90th day

All but $329 per day

$329 per day

$0

91st day and after:

All but $658 per day

$658 per day

$0

– while using 60 lifetime reserve days

– 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 entering

a Medicare-approved facility within 30 days after leaving

the hospital

All approved amounts

$0

$0

First 20 days

21st thru 100th day

All but $164.50 per day

Up to $164.50 per day

$0

101st day and after

$0

$0

All costs

BLOOD

$0

3 pints

$0

First 3 pints

Additional amounts

100%

$0

$0

HOSPICE CARE

All but very limited

Medicare copayment/coinsurance

$0

You must meet Medicare’s requirements, including a

doctor’s certification of terminal illness

copayment/coinsurance

for outpatient drugs and

inpatient respite care

**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.

CHLIC-HHD-OC-AA-PA

PAGE 26

01/17

PLAN N

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

*Once You have been billed $183 of Medicare-approved amounts for covered services (which are noted with an asterisk), Your Part B deductible will have been met for the calendar year.

SERVICES

MEDICARE PAYS

PLAN N 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

$0

$0

$183 (Part B deductible)

First $183 of Medicare-approved amounts*

Remainder of Medicare-approved amounts

Generally 80%

Balance, other than up to $20 per

Up to $20 per office visit and

office visit and up to $50 per

up to $50 per emergency

emergency room visit.

room visit.

The copayment of up to $50 is

The copayment of up to $50 is

waived if the Insured is admitted

waived if the Insured is

to any hospital and the

admitted to any hospital and

emergency visit is covered as a

the emergency visit is covered

Medicare Part A expense.

as a Medicare Part A expense.

PART B EXCESS CHARGES

$0

$0

All costs

(above Medicare-approved amounts)

BLOOD

$0

All costs

$0

First 3 pints

Next $183 of Medicare-approved amounts*

$0

$0

$183 (Part B deductible)

Remainder of Medicare-approved amounts

80%

20%

$0

CLINICAL LABORATORY SERVICES

100%

$0

$0

Tests for diagnostic services

CHLIC-HHD-OC-AA-PA

PAGE 27

01/17

PLAN N

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

PARTS A & B

SERVICES

MEDICARE PAYS

PLAN N PAYS

YOU PAY

HOME HEALTH CARE MEDICARE-

APPROVED SERVICES

Medically-necessary skilled care services and

100%

$0

$0

medical supplies

– Durable medical equipment

$0

$0

$183 (Part B deductible)

First $183 of Medicare-approved amounts*

Remainder of Medicare-approved amounts

80%

20%

$0

OTHER BENEFITS – NOT COVERED BY MEDICARE

SERVICES

MEDICARE PAYS

PLAN N 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

$0

$0

$250

First $250 each calendar year

Remainder of charges

$0

80% to a lifetime maximum

20% and amounts over the

benefit of $50,000

$50,000 lifetime maximum

CHLIC-HHD-OC-AA-PA

PAGE 28

01/17

We assist seniors that live in the following areas:

Absecon
Allamuchy-Panther Valley
Allendale borough
Allenhurst borough
Allentown borough
Allenwood
Alloway
Alpha borough
Alpine borough
Andover borough
Annandale
Asbury Park
Ashland
Atlantic City
Atlantic Highlands borough
Audubon borough
Audubon Park borough
Avalon borough
Avenel
Avon-by-the-Sea borough
Barclay-Kingston
Barnegat
Barnegat Light borough
Barrington borough
Bay Head borough
Bayonne
Beach Haven borough
Beach Haven West
Beachwood borough
Beatyestown
Beckett
Belford
Belleville
Bellmawr borough
Belmar borough
Belvidere
Bergenfield borough
Berkeley Heights
Berlin borough
Bernardsville borough
Beverly
Blackwood
Bloomfield
Bloomingdale borough
Bloomsbury borough
Bogota borough
Boonton
Bordentown
Bound Brook borough
Bradley Beach borough
Branchville borough
Brass Castle
Bridgeton
Brielle borough
Brigantine
Brooklawn borough
Browns Mills
Brownville
Budd Lake
Buena borough
Burlington
Butler borough
Caldwell borough
Califon borough
Camden
Cape May
Cape May Court House
Cape May Point borough
Carlstadt borough
Carneys Point
Carteret borough
Cedar Glen Lakes
Cedar Glen West
Cedar Grove
Cedarville
Chatham borough
Cherry Hill Mall
Chesilhurst borough
Chester borough
Clark
Clayton borough
Clearbrook Park
Clementon borough
Cliffside Park borough
Cliffwood Beach
Clifton
Clinton
Closter borough
Collings Lakes
Collingswood borough
Colonia
Concordia
Corbin City
Country Lake Estates
Cranbury
Crandon Lakes
Cranford
Cresskill borough
Crestwood Village
Dayton
Deal borough
Demarest borough
Diamond Beach
Dover
Dover Beaches North
Dover Beaches South
Dumont borough
Dunellen borough
East Brunswick
East Freehold
East Newark borough
East Orange
East Rutherford borough
Eatontown borough
Echelon
Edgewater borough
Edison
Egg Harbor City
Elizabeth
Elmer borough
Elmwood Park borough
Elwood-Magnolia
Emerson borough
Englewood
Englewood Cliffs borough
Englishtown borough
Erlton-Ellisburg
Erma
Essex Fells borough
Estell Manor
Ewing
Fairfield
Fair Haven borough
Fair Lawn borough
Fairton
Fairview borough
Fairview
Fanwood borough
Far Hills borough
Farmingdale borough
Fieldsboro borough
Flemington borough
Florence-Roebling
Florham Park borough
Folsom borough
Fords
Forked River
Fort Dix
Fort Lee borough
Franklin borough
Franklin Lakes borough
Freehold borough
Frenchtown borough
Garfield
Garwood borough
Gibbsboro borough
Gibbstown
Glassboro borough
Glendora
Glen Gardner borough
Glen Ridge borough
Glen Rock borough
Gloucester City
Golden Triangle
Great Meadows-Vienna
Greentree
Guttenberg
Hackensack
Hackettstown
Haddonfield borough
Haddon Heights borough
Haledon borough
Hamburg borough
Hammonton
Hampton borough
Harrington Park borough
Harrison
Harvey Cedars borough
Hasbrouck Heights borough
Haworth borough
Hawthorne borough
Heathcote
Helmetta borough
High Bridge borough
Highland Lake
Highland Park borough
Highlands borough
Hightstown borough
Hillsdale borough
Hillside
Hi-Nella borough
Hoboken
Ho-Ho-Kus borough
Holiday City-Berkeley
Holiday City South
Holiday Heights
Hopatcong borough
Hopewell borough
Interlaken borough
Irvington
Iselin
Island Heights borough
Jamesburg borough
Jersey City
Keansburg borough
Kearny
Kendall Park
Kenilworth borough
Keyport borough
Kingston
Kinnelon borough
Lakehurst borough
Lake Mohawk
Lake Telemark
Lakewood
Lambertville
Laurel Lake
Laurel Springs borough
Laurence Harbor
Lavallette borough
Lawnside borough
Lawrenceville
Lebanon borough
Leisure Knoll
Leisuretowne
Leisure Village
Leisure Village East
Leisure Village West-Pine Lake Park
Leonardo
Leonia borough
Lincoln Park borough
Lincroft
Linden
Lindenwold borough
Linwood
Little Falls
Little Ferry borough
Little Silver borough
Livingston
Loch Arbour village
Lodi borough
Long Branch
Longport borough
Long Valley
Lyndhurst
McGuire AFB
Madison borough
Madison Park
Magnolia borough
Manahawkin
Manasquan borough
Mantoloking borough
Manville borough
Maplewood
Margate City
Marlton
Matawan borough
Mays Landing
Maywood borough
Medford Lakes borough
Mendham borough
Mercer County
Mercerville-Hamilton Square
Merchantville borough
Metuchen borough
Middlesex borough
Midland Park borough
Milford borough
Millburn
Millstone borough
Milltown borough
Millville
Monmouth Beach borough
Monmouth Junction
Montclair
Montvale borough
Moonachie borough
Moorestown-Lenola
Morganville
Morris Plains borough
Morristown
Mountain Lakes borough
Mountainside borough
Mount Arlington borough
Mount Ephraim borough
Mullica Hill
Mystic Island
National Park borough
Navesink
Neptune City borough
Netcong borough
Newark
New Brunswick
New Egypt
Newfield borough
New Milford borough
New Providence borough
Newton
North Arlington borough
North Beach Haven
North Brunswick Township
North Caldwell borough
North Cape May
Northfield
North Haledon borough
North Middletown
North Plainfield borough
Northvale borough
North Wildwood
Norwood borough
Nutley
Oakhurst
Oakland borough
Oaklyn borough
Oak Valley
Ocean Acres
Ocean City
Ocean Gate borough
Ocean Grove
Oceanport borough
Ogdensburg borough
Old Bridge
Old Tappan borough
Olivet
Oradell borough
Orange
Oxford
Palisades Park borough
Palmyra borough
Paramus borough
Park Ridge borough
Passaic
Paterson
Paulsboro borough
Peapack and Gladstone borough
Pemberton borough
Pemberton Heights
Pennington borough
Pennsauken
Penns Grove borough
Pennsville
Perth Amboy
Phillipsburg
Pine Beach borough
Pine Hill borough
Pine Ridge at Crestwood
Pine Valley borough
Pitman borough
Plainfield
Plainsboro Center
Pleasantville
Point Pleasant borough
Point Pleasant Beach borough
Pomona
Pompton Lakes borough
Port Monmouth
Port Norris
Port Reading
Port Republic
Presidential Lakes Estates
Princeton borough
Princeton Junction
Princeton Meadows
Princeton North
Prospect Park borough
Rahway
Ramblewood
Ramsey borough
Ramtown
Raritan borough
Red Bank borough
Ridgefield borough
Ridgefield Park village
Ridgewood village
Ringwood borough
Rio Grande
Riverdale borough
River Edge borough
Riverton borough
River Vale
Rochelle Park
Rockaway borough
Rockleigh borough
Rocky Hill borough
Roosevelt borough
Roseland borough
Roselle borough
Roselle Park borough
Rosenhayn
Rossmoor
Rumson borough
Runnemede borough
Rutherford borough
Saddle Brook
Saddle River borough
Salem
Sayreville borough
Scotch Plains
Sea Bright borough
Seabrook Farms
Sea Girt borough
Sea Isle City
Seaside Heights borough
Seaside Park borough
Secaucus
Sewaren
Shark River Hills
Shiloh borough
Ship Bottom borough
Shrewsbury borough
Silver Ridge
Society Hill
Somerdale borough
Somerset
Somers Point
Somerville borough
South Amboy
South Belmar borough
South Bound Brook borough
South Orange
South Plainfield borough
South River borough
South Toms River borough
Spotswood borough
Springdale
Springfield
Spring Lake borough
Spring Lake Heights borough
Stanhope borough
Stockton borough
Stone Harbor borough
Stratford borough
Strathmere
Strathmore
Succasunna-Kenvil
Summit
Surf City borough
Sussex borough
Swedesboro borough
Tavistock borough
Teaneck
Tenafly borough
Teterboro borough
Tinton Falls borough
Toms River
Totowa borough
Trenton
Tuckerton borough
Turnersville
Twin Rivers
Union
Union Beach borough
Union City
Upper Saddle River borough
Ventnor City
Vernon Valley
Verona
Victory Gardens borough
Victory Lakes
Villas
Vineland
Vista Center
Waldwick borough
Wallington borough
Wanamassa
Wanaque borough
Waretown
Washington borough
Washington Township
Watchung borough
Wayne
Wenonah borough
West Belmar
West Caldwell
West Cape May borough
Westfield
West Freehold
West Long Branch borough
West Milford
West New York
West Orange
West Paterson borough
Westville borough
West Wildwood borough
Westwood borough
Wharton borough
White Horse
White House Station
White Meadow Lake
Whitesboro-Burleigh
Whittingham
Wildwood
Wildwood Crest borough
Williamstown
Woodbine borough
Woodbridge
Woodbury
Woodbury Heights borough
Woodcliff Lake borough
Woodlynne borough
Wood-Ridge borough
Woodstown borough
Wrightstown borough
Wyckoff
Yardville-Groveville
Yorketown

[/read]

Summary
Review Date
Reviewed Item
NJ Medicare Supplement Plans 2019
Author Rating
51star1star1star1star1star
Medicare Help