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OMAHA INSURANCE COMPANY A Mutual of Omaha Company OUTLINE OF MEDICARE SUPPLEMENT COVERAGE COVER PAGE BENEFIT PLANS A, C, D, F, AND G This chart shows the benefits included in each of the standard Medicare supplement plans. Every company must make available. Some plans may not be available in your state. Basic Benefits: Hospitalization: Medical Expenses: Part A coinsurance plus coverage for 365 additional days after Medicare benefits end. 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 3 pints of blood each year. Hospice: Part A coinsurance. A B C D F F* G K L M N Basic, including 100% Part B Coinsurance Basic, including 100% Part B Coinsurance Part A Basic, including 100% Part B Coinsurance Skilled Nursing Facility Coinsurance Part A Part B Foreign Travel Emergency Basic, including 100% Part B Coinsurance Skilled Nursing Facility Coinsurance Part A Foreign Travel Emergency Basic, including 100% Part B Coinsurance * Skilled Nursing Facility Coinsurance Part A Part B Part B Excess (100%) Foreign Travel Emergency Basic, including 100% Part B Coinsurance Skilled Nursing Facility Coinsurance Part A Part B Excess (100%) Foreign Travel Emergency Hospitalization and preventive care paid at 100%; other basic benefits paid at 50% 50% Skilled Nursing Facility Coinsurance 50% Part A Out-of-pocket limit $4,660; paid at 100% after limit reached Hospitalization and preventive care paid at 100%; other basic benefits paid at 75% 75% Skilled Nursing Facility Coinsurance 75% Part A Out-of-pocket limit $2,330; paid at 100% after limit reached Basic, including 100% Part B Coinsurance Skilled Nursing Facility Coinsurance 50% Part A Foreign Travel Emergency Basic, including 100% Part B Coinsurance, except up to $20 copayment for office visit, and up to $50 copayment for ER Skilled Nursing Facility Coinsurance Part A Foreign Travel Emergency * also has an option called a high deductible. This high deductible plan pays the same benefits as after one has paid a calendar year $2,070 deductible. Benefits from high deductible will not begin until out-of-pocket expenses exceed $2,070. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy/certificate. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan's separate foreign travel emergency deductible.

MONTHLY NON-TOBACCO PREMIUMS ZIP CODES: 430-435, 437-439, 446-449, 455-458 FEMALE MALE Attained Age 81.04 116.73 97.49 117.45 98.66 65 93.15 134.17 112.05 135.00 113.40 81.04 116.73 97.49 117.45 98.66 66 93.15 134.17 112.05 135.00 113.40 81.04 116.73 97.49 117.45 98.66 67 93.15 134.17 112.05 135.00 113.40 84.64 121.95 101.82 122.67 103.05 68 97.29 140.16 117.03 141.00 118.44 88.25 127.17 106.15 127.89 107.43 69 101.43 146.16 122.01 147.00 123.48 91.85 132.39 110.48 133.11 111.81 70 105.57 152.17 127.00 153.00 128.52 95.45 137.60 114.82 138.33 116.20 71 109.71 158.17 131.97 159.00 133.56 99.05 142.82 119.15 143.55 120.59 72 113.85 164.17 136.95 165.00 138.60 102.65 148.04 123.48 148.77 124.97 73 117.99 170.17 141.93 171.00 143.64 106.25 153.26 127.81 153.99 129.35 74 122.13 176.17 146.91 177.00 148.68 109.85 158.48 132.15 159.21 133.73 75 126.27 182.17 151.89 183.00 153.72 113.46 163.71 136.48 164.43 138.12 76 130.41 188.17 156.87 189.00 158.76 117.06 168.93 140.81 169.65 142.51 77 134.55 194.16 161.85 195.00 163.80 120.66 174.15 145.14 174.87 146.89 78 138.69 200.16 166.83 201.00 168.84 124.26 179.37 149.47 180.09 151.27 79 142.83 206.17 171.81 207.00 173.89 127.87 184.59 153.81 185.31 155.66 80 146.97 212.17 176.80 213.00 178.92 131.47 189.81 158.14 190.53 160.05 81 151.11 218.17 181.77 219.00 183.96 135.07 195.02 162.48 195.75 164.43 82 155.25 224.17 186.75 225.00 189.00 138.67 200.24 166.81 200.97 168.82 83 159.39 230.17 191.73 231.00 194.04 142.27 205.46 171.14 206.19 173.20 84 163.53 236.17 196.71 237.00 199.08 145.87 210.68 175.47 211.41 177.58 85 167.67 242.17 201.69 243.00 204.12 149.47 215.90 179.80 216.63 181.97 86 171.81 248.16 206.67 249.00 209.16 153.08 221.13 184.13 221.85 186.35 87 175.95 254.16 211.65 255.00 214.20 156.68 226.35 188.46 227.07 190.74 88 180.09 260.17 216.64 261.00 219.25 160.28 231.57 192.80 232.29 195.12 89 184.23 266.17 221.61 267.00 224.29 163.49 236.20 196.66 236.94 199.02 90 187.91 271.49 226.05 272.34 228.77 165.12 238.56 198.62 239.30 201.01 91 189.79 274.21 228.30 275.06 231.06 166.77 240.95 200.61 241.70 203.03 92 191.69 276.95 230.58 277.81 233.37 168.44 243.35 202.62 244.12 205.05 93 193.61 279.72 232.89 280.59 235.69 170.13 245.79 204.65 246.56 207.11 94 195.54 282.52 235.22 283.40 238.05 171.83 248.24 206.69 249.02 209.17 95 197.50 285.34 237.57 286.23 240.44 173.54 250.73 208.76 251.51 211.27 96 199.48 288.19 239.95 289.10 242.84 175.28 253.24 210.84 254.03 213.39 97 201.47 291.08 242.35 291.98 245.26 177.03 255.77 212.96 256.57 215.52 98 203.49 293.99 244.78 294.91 247.72 178.80 258.32 215.08 259.13 217.67 99+ 205.52 296.93 247.22 297.86 250.20 *See PREMIUM INFORMATION regarding Risk Class and Household Premium Discount rating. To obtain annual, semiannual, and quarterly premiums, multiply the above-quoted premiums by 12, 6, and 3, respectively. CO7.D-OH N6_OH_0012

MONTHLY TOBACCO PREMIUMS ZIP CODES: 430-435, 437-439, 446-449, 455-458 FEMALE MALE Attained Age 87.61 126.19 105.39 126.97 106.66 65 100.70 145.04 121.13 145.95 122.60 87.61 126.19 105.39 126.97 106.66 66 100.70 145.04 121.13 145.95 122.60 87.61 126.19 105.39 126.97 106.66 67 100.70 145.04 121.13 145.95 122.60 91.50 131.84 110.08 132.62 111.40 68 105.18 151.53 126.51 152.43 128.04 95.40 137.48 114.76 138.26 116.14 69 109.65 158.02 131.90 158.92 133.49 99.30 143.12 119.44 143.91 120.88 70 114.13 164.51 137.29 165.41 138.94 103.19 148.76 124.13 149.55 125.62 71 118.61 170.99 142.67 171.90 144.39 107.08 154.40 128.81 155.19 130.36 72 123.08 177.48 148.05 178.38 149.84 110.98 160.05 133.49 160.84 135.10 73 127.56 183.97 153.44 184.87 155.29 114.87 165.69 138.18 166.47 139.83 74 132.03 190.45 158.82 191.35 160.74 118.76 171.33 142.86 172.12 144.58 75 136.51 196.94 164.20 197.84 166.18 122.66 176.98 147.54 177.76 149.32 76 140.98 203.42 169.59 204.32 171.63 126.55 182.62 152.23 183.40 154.06 77 145.46 209.91 174.97 210.81 177.08 130.44 188.27 156.91 189.05 158.80 78 149.93 216.39 180.35 217.29 182.53 134.33 193.91 161.59 194.69 163.54 79 154.41 222.89 185.74 223.79 187.99 138.24 199.55 166.28 200.34 168.28 80 158.89 229.37 191.13 230.27 193.43 142.13 205.20 170.96 205.98 173.03 81 163.36 235.86 196.51 236.76 198.87 146.02 210.83 175.65 211.62 177.76 82 167.84 242.34 201.89 243.24 204.32 149.91 216.48 180.34 217.27 182.50 83 172.31 248.83 207.27 249.73 209.77 153.81 222.12 185.02 222.91 187.25 84 176.79 255.31 212.66 256.22 215.22 157.70 227.77 189.69 228.55 191.98 85 181.26 261.80 218.04 262.70 220.67 161.59 233.41 194.38 234.19 196.72 86 185.74 268.29 223.42 269.19 226.12 165.49 239.05 199.06 239.84 201.46 87 190.21 274.77 228.81 275.67 231.57 169.38 244.70 203.75 245.48 206.20 88 194.69 281.27 234.20 282.17 237.02 173.27 250.34 208.44 251.12 210.94 89 199.17 287.75 239.58 288.65 242.47 176.74 255.35 212.60 256.15 215.16 90 203.15 293.51 244.38 294.42 247.32 178.51 257.90 214.73 258.71 217.31 91 205.18 296.44 246.81 297.36 249.79 180.29 260.48 216.88 261.30 219.49 92 207.23 299.40 249.28 300.34 252.29 182.10 263.08 219.05 263.91 221.68 93 209.30 302.40 251.77 303.34 254.80 183.92 265.72 221.24 266.55 223.91 94 211.40 305.42 254.29 306.37 257.35 185.76 268.37 223.45 269.21 226.13 95 213.51 308.47 256.84 309.44 259.93 187.61 271.06 225.68 271.91 228.40 96 215.65 311.56 259.40 312.54 262.53 189.49 273.77 227.94 274.63 230.69 97 217.80 314.68 262.00 315.66 265.15 191.39 276.51 230.22 277.37 232.99 98 219.99 317.82 264.62 318.82 267.81 193.30 279.27 232.52 280.14 235.32 99+ 222.18 321.00 267.27 322.01 270.49 *See PREMIUM INFORMATION regarding Risk Class and Household Premium Discount rating. To obtain annual, semiannual, and quarterly premiums, multiply the above-quoted premiums by 12, 6, and 3, respectively. CO7.D-OH N6_OH_0012

MONTHLY NON-TOBACCO PREMIUMS ZIP CODES: 450-454, 459 FEMALE MALE Attained Age 85.81 123.59 103.22 124.36 104.46 65 98.63 142.06 118.64 142.94 120.07 85.81 123.59 103.22 124.36 104.46 66 98.63 142.06 118.64 142.94 120.07 85.81 123.59 103.22 124.36 104.46 67 98.63 142.06 118.64 142.94 120.07 89.62 129.12 107.81 129.89 109.11 68 103.01 148.41 123.91 149.29 125.41 93.44 134.65 112.40 135.42 113.74 69 107.39 154.76 129.19 155.64 130.74 97.25 140.18 116.98 140.94 118.39 70 111.78 161.12 134.47 162.00 136.08 101.07 145.70 121.57 146.47 123.04 71 116.17 167.47 139.74 168.36 141.42 104.88 151.22 126.16 152.00 127.68 72 120.55 173.83 145.00 174.71 146.75 108.69 156.75 130.74 157.53 132.32 73 124.93 180.18 150.28 181.06 152.09 112.50 162.28 135.33 163.05 136.96 74 129.31 186.53 155.55 187.41 157.43 116.32 167.81 139.92 168.57 141.60 75 133.70 192.88 160.82 193.76 162.76 120.13 173.34 144.51 174.10 146.25 76 138.08 199.23 166.10 200.12 168.10 123.94 178.86 149.09 179.63 150.89 77 142.47 205.59 171.37 206.47 173.43 127.76 184.39 153.68 185.16 155.53 78 146.84 211.94 176.64 212.82 178.77 131.57 189.92 158.27 190.68 160.17 79 151.23 218.30 181.92 219.18 184.12 135.39 195.45 162.85 196.21 164.82 80 155.62 224.65 187.20 225.53 189.44 139.20 200.97 167.44 201.74 169.46 81 160.00 231.00 192.47 231.88 194.78 143.02 206.49 172.04 207.27 174.10 82 164.39 237.35 197.74 238.24 200.12 146.83 212.02 176.62 212.80 178.75 83 168.77 243.71 203.01 244.59 205.45 150.64 217.55 181.21 218.32 183.39 84 173.15 250.06 208.28 250.94 210.79 154.45 223.08 185.79 223.84 188.03 85 177.53 256.41 213.55 257.29 216.13 158.27 228.60 190.38 229.37 192.67 86 181.92 262.76 218.82 263.64 221.46 162.08 234.13 194.96 234.90 197.31 87 186.30 269.11 224.10 270.00 226.80 165.89 239.66 199.55 240.43 201.96 88 190.68 275.47 229.38 276.36 232.14 169.71 245.19 204.15 245.95 206.60 89 195.07 281.83 234.65 282.71 237.48 173.10 250.09 208.23 250.87 210.73 90 198.97 287.46 239.34 288.36 242.22 174.83 252.59 210.31 253.38 212.84 91 200.96 290.33 241.73 291.24 244.65 176.58 255.12 212.41 255.92 214.97 92 202.96 293.24 244.15 294.16 247.09 178.35 257.67 214.54 258.47 217.12 93 205.00 296.17 246.59 297.10 249.56 180.14 260.25 216.68 261.06 219.30 94 207.04 299.13 249.06 300.07 252.06 181.93 262.85 218.85 263.67 221.48 95 209.12 302.12 251.55 303.07 254.58 183.75 265.48 221.04 266.31 223.70 96 211.21 305.14 254.06 306.10 257.13 185.59 268.13 223.24 268.97 225.94 97 213.32 308.20 256.60 309.16 259.69 187.45 270.81 225.48 271.66 228.20 98 215.46 311.28 259.17 312.25 262.30 189.32 273.52 227.73 274.38 230.48 99+ 217.61 314.39 261.76 315.38 264.92 *See PREMIUM INFORMATION regarding Risk Class and Household Premium Discount rating. To obtain annual, semiannual, and quarterly premiums, multiply the above-quoted premiums by 12, 6, and 3, respectively. CO7.D-OH N6_OH_0012

MONTHLY TOBACCO PREMIUMS ZIP CODES: 450-454, 459 FEMALE MALE Attained Age 92.76 133.61 111.59 134.44 112.93 65 106.62 153.58 128.26 154.53 129.81 92.76 133.61 111.59 134.44 112.93 66 106.62 153.58 128.26 154.53 129.81 92.76 133.61 111.59 134.44 112.93 67 106.62 153.58 128.26 154.53 129.81 96.89 139.59 116.55 140.42 117.95 68 111.37 160.44 133.96 161.40 135.58 101.02 145.57 121.51 146.39 122.97 69 116.10 167.31 139.66 168.26 141.35 105.14 151.54 126.47 152.37 127.99 70 120.84 174.19 145.37 175.14 147.11 109.26 157.51 131.43 158.35 133.01 71 125.59 181.05 151.07 182.01 152.88 113.38 163.49 136.39 164.32 138.03 72 130.32 187.92 156.76 188.87 158.65 117.50 169.46 141.35 170.30 143.05 73 135.06 194.79 162.47 195.74 164.42 121.63 175.44 146.30 176.27 148.06 74 139.80 201.65 168.17 202.61 170.19 125.75 181.41 151.26 182.24 153.08 75 144.54 208.52 173.86 209.48 175.96 129.87 187.39 156.22 188.22 158.10 76 149.27 215.39 179.57 216.34 181.73 133.99 193.37 161.18 194.19 163.13 77 154.02 222.26 185.27 223.21 187.50 138.11 199.34 166.14 200.17 168.14 78 158.75 229.12 190.96 230.08 193.27 142.24 205.32 171.10 206.15 173.16 79 163.49 236.00 196.67 236.95 199.04 146.37 211.29 176.06 212.12 178.18 80 168.24 242.87 202.37 243.82 204.80 150.49 217.27 181.02 218.10 183.20 81 172.97 249.73 208.07 250.69 210.57 154.61 223.24 185.99 224.07 188.22 82 177.71 256.60 213.77 257.55 216.34 158.73 229.21 190.94 230.05 193.24 83 182.45 263.47 219.47 264.42 222.11 162.86 235.19 195.90 236.03 198.26 84 187.19 270.33 225.17 271.29 227.88 166.98 241.16 200.85 241.99 203.27 85 191.93 277.20 230.87 278.15 233.65 171.10 247.14 205.81 247.97 208.30 86 196.67 284.07 236.57 285.02 239.42 175.22 253.12 210.77 253.94 213.31 87 201.40 290.93 242.27 291.89 245.19 179.34 259.09 215.73 259.92 218.33 88 206.15 297.81 247.98 298.76 250.97 183.47 265.07 220.70 265.90 223.35 89 210.89 304.68 253.67 305.63 256.73 187.14 270.37 225.11 271.22 227.82 90 215.10 310.77 258.75 311.74 261.86 189.01 273.07 227.36 273.92 230.09 91 217.25 313.88 261.33 314.86 264.48 190.90 275.81 229.64 276.67 232.40 92 219.42 317.02 263.94 318.01 267.13 192.81 278.56 231.93 279.43 234.72 93 221.62 320.18 266.58 321.18 269.79 194.74 281.35 234.25 282.23 237.08 94 223.83 323.39 269.25 324.40 272.49 196.69 284.16 236.59 285.05 239.44 95 226.07 326.62 271.94 327.65 275.22 198.65 287.00 238.96 287.90 241.84 96 228.34 329.89 274.66 330.92 277.97 200.64 289.87 241.34 290.78 244.26 97 230.62 333.19 277.41 334.22 280.75 202.64 292.77 243.77 293.69 246.70 98 232.93 336.52 280.19 337.57 283.56 204.67 295.70 246.20 296.62 249.17 99+ 235.25 339.89 282.99 340.95 286.40 *See PREMIUM INFORMATION regarding Risk Class and Household Premium Discount rating. To obtain annual, semiannual, and quarterly premiums, multiply the above-quoted premiums by 12, 6, and 3, respectively. CO7.D-OH N6_OH_0012

MONTHLY NON-TOBACCO PREMIUMS ZIP CODES: 436, 440-445 FEMALE MALE Attained Age 99.15 142.82 119.28 143.70 120.71 65 113.97 164.16 137.09 165.18 138.75 99.15 142.82 119.28 143.70 120.71 66 113.97 164.16 137.09 165.18 138.75 99.15 142.82 119.28 143.70 120.71 67 113.97 164.16 137.09 165.18 138.75 103.56 149.21 124.58 150.09 126.08 68 119.04 171.50 143.18 172.52 144.92 107.98 155.59 129.88 156.48 131.44 69 124.10 178.84 149.28 179.86 151.08 112.38 161.98 135.18 162.87 136.81 70 129.17 186.19 155.38 187.21 157.25 116.79 168.36 140.48 169.25 142.17 71 134.24 193.53 161.47 194.55 163.42 121.19 174.75 145.78 175.64 147.54 72 139.30 200.87 167.56 201.89 169.58 125.60 181.14 151.08 182.03 152.90 73 144.37 208.21 173.66 209.23 175.75 130.01 187.52 156.38 188.41 158.26 74 149.43 215.55 179.75 216.57 181.91 134.41 193.91 161.68 194.80 163.63 75 154.50 222.89 185.84 223.91 188.08 138.82 200.30 166.98 201.18 168.99 76 159.56 230.23 191.94 231.25 194.25 143.22 206.69 172.28 207.57 174.36 77 164.63 237.57 198.03 238.59 200.41 147.63 213.07 177.59 213.96 179.72 78 169.69 244.91 204.12 245.93 206.58 152.03 219.46 182.89 220.35 185.09 79 174.76 252.26 210.22 253.28 212.76 156.45 225.85 188.19 226.73 190.46 80 179.83 259.60 216.32 260.62 218.91 160.86 232.24 193.49 233.12 195.83 81 184.89 266.94 222.41 267.96 225.08 165.26 238.61 198.80 239.51 201.18 82 189.96 274.28 228.49 275.30 231.25 169.67 245.00 204.10 245.90 206.55 83 195.02 281.62 234.58 282.64 237.41 174.07 251.39 209.40 252.28 211.92 84 200.09 288.96 240.68 289.98 243.58 178.48 257.78 214.69 258.66 217.28 85 205.15 296.30 246.77 297.32 249.75 182.89 264.17 219.99 265.05 222.65 86 210.22 303.64 252.86 304.66 255.91 187.29 270.55 225.29 271.44 228.00 87 215.28 310.98 258.96 312.00 262.08 191.70 276.94 230.59 277.83 233.37 88 220.35 318.33 265.06 319.35 268.25 196.10 283.33 235.90 284.21 238.74 89 225.42 325.67 271.15 326.69 274.42 200.03 289.00 240.62 289.90 243.51 90 229.92 332.18 276.58 333.22 279.90 202.03 291.88 243.02 292.79 245.95 91 232.22 335.50 279.34 336.55 282.70 204.05 294.81 245.45 295.73 248.41 92 234.54 338.86 282.13 339.91 285.53 206.09 297.75 247.91 298.68 250.89 93 236.88 342.24 284.95 343.31 288.38 208.16 300.73 250.39 301.67 253.41 94 239.25 345.67 287.80 346.74 291.27 210.24 303.73 252.89 304.69 255.93 95 241.65 349.12 290.68 350.22 294.18 212.33 306.77 255.42 307.73 258.50 96 244.07 352.61 293.58 353.72 297.12 214.46 309.84 257.97 310.81 261.09 97 246.50 356.14 296.52 357.25 300.09 216.60 312.94 260.56 313.92 263.69 98 248.98 359.70 299.49 360.83 303.10 218.77 316.07 263.16 317.06 266.33 99+ 251.46 363.30 302.48 364.44 306.13 *See PREMIUM INFORMATION regarding Risk Class and Household Premium Discount rating. To obtain annual, semiannual, and quarterly premiums, multiply the above-quoted premiums by 12, 6, and 3, respectively. CO7.D-OH N6_OH_0012

MONTHLY TOBACCO PREMIUMS ZIP CODES: 436, 440-445 FEMALE MALE Attained Age 107.19 154.40 128.95 155.36 130.50 65 123.21 177.47 148.21 178.57 150.00 107.19 154.40 128.95 155.36 130.50 66 123.21 177.47 148.21 178.57 150.00 107.19 154.40 128.95 155.36 130.50 67 123.21 177.47 148.21 178.57 150.00 111.96 161.30 134.68 162.26 136.30 68 128.69 185.40 154.79 186.50 156.67 116.73 168.21 140.41 169.17 142.10 69 134.16 193.34 161.39 194.44 163.33 121.49 175.12 146.14 176.07 147.90 70 139.64 201.28 167.98 202.38 170.00 126.26 182.01 151.87 182.98 153.70 71 145.12 209.22 174.56 210.32 176.67 131.02 188.92 157.60 189.88 159.51 72 150.59 217.15 181.15 218.25 183.33 135.78 195.82 163.33 196.79 165.30 73 156.07 225.09 187.74 226.19 190.00 140.55 202.73 169.06 203.68 171.09 74 161.54 233.02 194.32 234.13 196.66 145.31 209.63 174.79 210.59 176.89 75 167.02 240.96 200.91 242.06 203.33 150.07 216.54 180.52 217.50 182.70 76 172.49 248.89 207.50 250.00 210.00 154.84 223.44 186.25 224.40 188.50 77 177.98 256.83 214.08 257.93 216.66 159.60 230.35 191.98 231.31 194.29 78 183.45 264.76 220.67 265.87 223.33 164.36 237.26 197.71 238.21 200.10 79 188.93 272.71 227.26 273.81 230.01 169.14 244.16 203.45 245.12 205.90 80 194.41 280.64 233.85 281.75 236.66 173.90 251.07 209.18 252.02 211.70 81 199.88 288.58 240.44 289.68 243.33 178.66 257.96 214.92 258.93 217.50 82 205.36 296.51 247.02 297.62 250.00 183.43 264.87 220.65 265.83 223.30 83 210.83 304.45 253.60 305.55 256.66 188.19 271.77 226.38 272.74 229.10 84 216.31 312.39 260.20 313.49 263.33 192.95 278.68 232.10 279.64 234.89 85 221.78 320.32 266.78 321.42 269.99 197.71 285.58 237.83 286.54 240.70 86 227.26 328.26 273.36 329.36 276.66 202.48 292.49 243.56 293.45 246.49 87 232.73 336.19 279.96 337.29 283.33 207.24 299.40 249.29 300.35 252.29 88 238.21 344.14 286.55 345.24 290.00 212.00 306.30 255.03 307.26 258.10 89 243.69 352.07 293.13 353.17 296.67 216.25 312.43 260.13 313.40 263.26 90 248.56 359.11 299.00 360.24 302.60 218.41 315.55 262.73 316.53 265.89 91 251.05 362.70 301.99 363.83 305.63 220.59 318.71 265.36 319.71 268.55 92 253.55 366.33 305.00 367.47 308.68 222.80 321.89 268.01 322.90 271.23 93 256.09 369.99 308.05 371.15 311.76 225.04 325.11 270.69 326.13 273.96 94 258.65 373.69 311.14 374.86 314.88 227.28 328.36 273.40 329.39 276.68 95 261.24 377.43 314.25 378.61 318.03 229.55 331.65 276.13 332.69 279.46 96 263.86 381.20 317.39 382.40 321.21 231.85 334.96 278.89 336.01 282.26 97 266.49 385.02 320.56 386.21 324.42 234.17 338.31 281.68 339.37 285.07 98 269.16 388.87 323.77 390.08 327.67 236.51 341.69 284.49 342.76 287.92 99+ 271.85 392.76 327.01 393.98 330.95 *See PREMIUM INFORMATION regarding Risk Class and Household Premium Discount rating. To obtain annual, semiannual, and quarterly premiums, multiply the above-quoted premiums by 12, 6, and 3, respectively. CO7.D-OH N6_OH_0012

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 us. Right to Return Policy If you find that you are not satisfied with your policy, you may return it to us at Mutual of Omaha Plaza, Omaha, NE 68175. If you send the policy back to us within 30 days after you receive it, we will treat the policy as if it had never been issued and return all of your payments. Policy Replacement If you are replacing another health insurance policy, do NOT cancel it until you have actually received your new policy and are sure you want to keep it. Notice The policy may not fully cover all of your medical costs. Neither we nor our agents are connected with Medicare. This outline does not give all the details of Medicare coverage. Contact your local Social Security office or consult "Medicare & You" for more details. Complete Answers Are Very Important When you fill out the application for the new policy, be sure to answer truthfully and completely 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.

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 Pays You Pay HOSPITALIZATION* Semiprivate room and board, general nursing, and miscellaneous services and supplies First 60 days All but $1,156 $0 $1,156 (Part A deductible) 61 st through 90 th day All but $289 a day $289 a day $0 91 st day and after: While using 60 lifetime reserve days All but $578 a day $578 a day $0 Once lifetime reserve days are used: Additional 365 days $0 100% of Medicareeligible $0** expenses Beyond the additional 365 days $0 $0 All costs SKILLED NURSING FACILITY CARE* You must meet Medicare s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital. First 20 days All approved amounts $0 $0 21 st through 100 th day All but $144.50 a day $0 Up to $144.50 a day 101 st day and after $0 $0 All costs First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE You must meet Medicare's requirements, including a doctor's certification of terminal illness. All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care Medicare copayment/ coinsurance **NOTICE: When your Medicare Part A hospital benefits are exhausted, we stand 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/certificate'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. $0

PLAN A MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR *Once you have been billed $140 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 Pays You Pay MEDICAL EXPENSES IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $140 of Medicare-approved Amounts* $0 $0 $140 (Part B deductible) Remainder of Medicare-approved amounts Generally 80% Generally 20% $0 Part B Excess Charges (above Medicare-approved amounts) $0 $0 All costs First 3 pints $0 All costs $0 Next $140 of Medicare-approved amounts* $0 $0 $140 (Part B deductible) CLINICAL LABORATORY SERVICES TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 PARTS A AND B HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies 100% $0 $0 Durable medical equipment First $140 of Medicare-approved amounts* $0 $0 $140 (Part B deductible)

PLAN C 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 Pays You Pay HOSPITALIZATION* Semiprivate room and board, general nursing, and miscellaneous services and supplies First 60 days All but $1,156 $1,156 (Part A $0 deductible) 61 st through 90 th day All but $289 a day $289 a day $0 91 st day and after: While using 60 lifetime reserve days All but $578 a day $578 a day $0 Once lifetime reserve days are used: Additional 365 days $0 100% of Medicareeligible expenses Beyond the additional 365 days $0 $0 All costs SKILLED NURSING FACILITY CARE* You must meet Medicare s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital. First 20 days All approved amounts $0 $0 21 st through 100 th day All but $144.50 a day Up to $144.50 a day $0 101 st day and after $0 $0 All costs First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE You must meet Medicare's requirements, including a doctor's certification of terminal illness. All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care Medicare copayment/coinsurance **NOTICE: When your Medicare Part A hospital benefits are exhausted, we stand 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/certificate'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. $0** $0

PLAN C MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR *Once you have been billed $140 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 Pays You Pay MEDICAL EXPENSES IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $140 of Medicare-approved amounts* $0 $140 (Part B deductible) $0 Remainder of Medicare-approved amounts Generally 80% Generally 20% $0 Part B Excess Charges (above Medicare-approved amounts) $0 $0 All costs First 3 pints $0 All costs $0 Next $140 of Medicare-approved amounts* $0 $140 (Part B deductible) $0 CLINICAL LABORATORY SERVICES TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 PARTS A AND B HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies 100% $0 $0 Durable medical equipment First $140 of Medicare-approved amounts* $0 $140 (Part B deductible) $0 OTHER BENEFITS NOT COVERED BY MEDICARE Services Medicare Pays Pays You Pay FOREIGN TRAVEL NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year $0 $0 $250 Remainder of charges $0 80% to a lifetime maximum 20% and amounts over the benefit of $50,000 $50,000 lifetime maximum benefit

PLAN D 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 Pays You Pay HOSPITALIZATION* Semiprivate room and board, general nursing, and miscellaneous services and supplies First 60 days All but $1,156 $1,156 (Part A deductible) $0 61 st through 90 th day All but $289 a day $289 a day $0 91 st day and after: While using 60 lifetime reserve days All but $578 a day $578 a day $0 Once lifetime reserve days are used: Additional 365 days $0 100% of Medicare-eligible $0** expenses Beyond the additional 365 days $0 $0 All costs SKILLED NURSING FACILITY CARE* You must meet Medicare s requirements, including having been in a hospital for at least 3 days and entered a Medicare approved facility within 30 days after leaving the hospital. First 20 days All approved amounts $0 $0 21 st through 100 th day All but $144.50 a day Up to $144.50 a day $0 101 st day and after $0 $0 All costs First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE You must meet Medicare's requirements, including a doctor's certification of terminal illness. All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care Medicare copayment/coinsurance **NOTICE: When your Medicare Part A hospital benefits are exhausted, we stand 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/certificate'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. $0

PLAN D MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR *Once you have been billed $140 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 Pays You Pay MEDICAL EXPENSES IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $140 of Medicare-approved amounts* $0 $0 $140 (Part B deductible) Remainder of Medicare-approved amounts Generally 80% Generally 20% $0 Part B Excess Charges (above Medicare-approved amounts) $0 $0 All costs First 3 pints $0 All costs $0 Next $140 of Medicare-approved amounts* $0 $0 $140 (Part B deductible) CLINICAL LABORATORY SERVICES TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 PARTS A AND B HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies 100% $0 $0 Durable medical equipment First $140 of Medicare-approved amounts* $0 $0 $140 (Part B deductible) OTHER BENEFITS NOT COVERED BY MEDICARE Services Medicare Pays Pays You Pay FOREIGN TRAVEL NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year $0 $0 $250 Remainder of charges $0 80% to a lifetime maximum benefit of $50,000 20% and amounts over the $50,000 lifetime maximum benefit

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 Pays You Pay HOSPITALIZATION* Semiprivate room and board, general nursing, and miscellaneous services and supplies First 60 days All but $1,156 $1,156 (Part A $0 deductible) 61 st through 90 th day All but $289 a day $289 a day $0 91 st day and after: While using 60 lifetime reserve days All but $578 a day $578 a day $0 Once lifetime reserve days are used: Additional 365 days $0 100% of Medicare-eligible expenses Beyond the additional 365 days $0 $0 All costs SKILLED NURSING FACILITY CARE* You must meet Medicare s requirements, including having been in a hospital for at least 3 days and entered a Medicare approved facility within 30 days after leaving the hospital. First 20 days All approved amounts $0 $0 21 st through 100 th day All but $144.50 a day Up to $144.50 a day $0 101 st day and after $0 $0 All costs First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE You must meet Medicare's requirements, including a doctor's certification of terminal illness. All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care Medicare copayment/coinsurance **NOTICE: When your Medicare Part A hospital benefits are exhausted, we stand 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/certificate'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. $0** $0

PLAN F MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR *Once you have been billed $140 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 Pays You Pay MEDICAL EXPENSES IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $140 of Medicare-approved amounts* $0 $140 (Part B deductible) $0 Remainder of Medicare-approved amounts Generally 80% Generally 20% $0 Part B Excess Charges (above Medicare-approved amounts) $0 100% $0 First 3 pints $0 All costs $0 Next $140 of Medicare-approved amounts* $0 $140 (Part B deductible) $0 CLINICAL LABORATORY SERVICES TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 PARTS A AND B HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies 100% $0 $0 Durable medical equipment First $140 of Medicare-approved amounts* $0 $140 (Part B deductible) $0 OTHER BENEFITS NOT COVERED BY MEDICARE Services Medicare Pays Pays You Pay FOREIGN TRAVEL NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year $0 $0 $250 Remainder of charges $0 80% to a lifetime maximum benefit of $50,000 20% and amounts over the $50,000 lifetime maximum benefit

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 Pays You Pay HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,156 $1,156 (Part A deductible) $0 61 st through 90 th day All but $289 a day $289 a day $0 91 st day and after: While using 60 lifetime reserve days All but $578 a day $578 a day $0 Once lifetime reserve days are used: Additional 365 days $0 100% of Medicare-eligible $0** expenses Beyond the additional 365 days $0 $0 All costs SKILLED NURSING FACILITY CARE* You must meet Medicare s requirements, including having been in a hospital for at least 3 days and entered a Medicare approved facility within 30 days after leaving the hospital. First 20 days All approved amounts $0 $0 21 st through 100 th day All but $144.50 a day Up to $144.50 a day $0 101 st day and after $0 $0 All costs First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE You must meet Medicare's requirements, including a doctor's certification of terminal illness. All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care Medicare copayment/coinsurance **NOTICE: When your Medicare Part A hospital benefits are exhausted, we stand 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/certificate'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. $0

PLAN G MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR *Once you have been billed $140 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 Pays You Pay MEDICAL EXPENSES IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as physician s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $140 of Medicare-approved amounts* $0 $0 $140 (Part B deductible) Remainder of Medicare-approved amounts Generally 80% Generally 20% $0 Part B Excess Charges (above Medicare-approved amounts) $0 100% $0 First 3 pints $0 All costs $0 Next $140 of Medicare-approved amounts* $0 $0 $140 (Part B deductible) CLINICAL LABORATORY SERVICES TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0 PARTS A AND B HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically necessary skilled care services and medical supplies 100% $0 $0 Durable medical equipment First $140 of Medicare-approved amounts* $0 $0 $140 (Part B deductible) OTHER BENEFITS NOT COVERED BY MEDICARE Services Medicare Pays Pays You Pay FOREIGN TRAVEL NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year $0 $0 $250 Remainder of charges $0 80% to a lifetime maximum benefit of $50,000 20% and amounts over the $50,000 lifetime maximum benefit

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