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PLAN A BENEFIT SUMMARYMedicare (Part A) Hospital Services Per Benefit PeriodServiceMedicare PaysPlan PaysYou PayHospitalization1Semi-private room and board, general nursingand miscellaneous services and supplies.First 60 daysAll but 1,556 0 1,556 (Part Adeductible)61st thru 90th dayAll but 389 a day 389 a day 091st day and after: While using 60 lifetime reserve daysAll but 778 a day 778 a day 0 Once lifetime reserve days are used:- Additional 365 days 0100% ofMedicareeligibleexpenses 02 0 0All costsFirst 20 daysAll approvedamounts 0 021st thru 100th dayAll but 194.50a day 0Up to 194.50a day101st day and after 0 0All costsBloodFirst 3 pints 03 pints 0Additional amounts100% 0 0Hospice CareYou must meet Medicare’s requirements,including a doctor’s certification ofterminal illness.All but verylimitedcopayment/coinsurance foroutpatient drugsand inpatientrespite careMedicarecopayment/coinsurance 0- Beyond the additional 365 daysSkilled Nursing Facility Care1You must meet Medicare’s requirements,including having been in a hospital for at least 3days and entered a Medicare-approved facilitywithin 30 days after leaving the hospital.Questions? ˆˇˆ TTY HorizonBlue.com/Medicare

Medicare (Part B) Medical Services Per Calendar YearServiceMedicare PaysPlan PaysYou PayMedical ExpensesIN OR OUT OF THE HOSPITAL ANDOUTPATIENT HOSPITAL TREATMENT, such asphysicians’ services, inpatient and outpatientmedical and surgical services and supplies,physical and speech therapy, diagnostic tests,durable medical equipment.First 233 of Medicare-approved amounts3 0 0 233 (Part Bdeductible)Remainder of Medicare-approved amountsGenerally 80%20% 0Part B Excess ChargesAbove Medicare-approved amounts 0 0All costsBloodFirst 3 pints 0All costs 0 0 0 233 (Part Bdeductible)Remainder of Medicare-approved amountsGenerally 80%20% 0Clinical Laboratory ServicesTESTS FOR DIAGNOSTIC SERVICES100% 0 0Next 233 of Medicare-approved amounts3Parts A & BHome Health CareMEDICARE-APPROVED SERVICESMedically necessary skilled care servicesand medical supplies100% 0 0Durable medical equipment First 233 of Medicare-approved amounts3 0 0 233 (Part Bdeductible) Remainder Medicare-approved amounts80%20% 0

PLAN C BENEFIT SUMMARYMedicare (Part A) Hospital Services Per Benefit PeriodServiceMedicare PaysPlan PaysYou PayHospitalization1Semi-private room and board, general nursingand miscellaneous services and supplies.First 60 daysAll but 1,556 1,556 (Part Adeductible) 061st thru 90th dayAll but 389 a day 389 a day 091st day and after: While using 60 lifetime reserve daysAll but 778 a day 778 a day 0 Once lifetime reserve days are used:- Additional 365 days 0100% ofMedicareeligibleexpenses 02 0 0All costsFirst 20 daysAll approvedamounts 0 021st thru 100th dayAll but 194.50a dayUp to 194.50a day 0101st day and after 0 0All costsBloodFirst 3 pints 03 pints 0Additional amounts100% 0 0Hospice CareYou must meet Medicare’s requirements,including a doctor’s certification ofterminal illness.All but verylimitedcopayment/coinsurance foroutpatient drugsand inpatientrespite careMedicarecopayment/coinsurance 0- Beyond the additional 365 daysSkilled Nursing Facility Care1You must meet Medicare’s requirements,including having been in a hospital for at least 3days and entered a Medicare-approved facilitywithin 30 days after leaving the hospital.Questions? 1-888-328-4542 (TTY 711) HorizonBlue.com/Medicare

Medicare (Part B) Medical Services Per Calendar YearServiceMedicare PaysPlan PaysYou PayMedical ExpensesIN OR OUT OF THE HOSPITAL ANDOUTPATIENT HOSPITAL TREATMENT, such asphysicians’ services, inpatient and outpatientmedical and surgical services and supplies,physical and speech therapy, diagnostic tests,durable medical equipment.First 233 of Medicare-approved amounts3 0 233 (Part Bdeductible) 0Remainder of Medicare-approved amountsGenerally 80%Generally 20% 0Part B Excess ChargesAbove Medicare-approved amounts 0 0All costsBloodFirst 3 pints 0All costs 0 0 233 (Part Bdeductible) 0Remainder of Medicare-approved amounts80%20% 0Clinical Laboratory ServicesTESTS FOR DIAGNOSTIC SERVICES100% 0 0Next 233 of Medicare-approved amounts3Parts A & BHome Health CareMEDICARE-APPROVED SERVICESMedically necessary skilled care servicesand medical supplies100% 0 0Durable medical equipment First 233 of Medicare-approved amounts3 0 233 (Part Bdeductible) 0 Remainder Medicare-approved amounts80%20% 0Other Benefits Not Covered by MedicareForeign Travel Not Covered by MedicareMedically necessary emergency care servicesbeginning during the first 60 days of each tripoutside the USA.First 250 each calendar year 0 0 250Remainder of charges 080% to a lifetimemaximumbenefit of 50,00020% andamounts overthe 50,000lifetimemaximum

PLAN D BENEFIT SUMMARYMedicare (Part A) Hospital Services Per Benefit PeriodServiceMedicare PaysPlan PaysYou PayHospitalization1Semi-private room and board, general nursingand miscellaneous services and supplies.First 60 daysAll but 1,556 1,556 (Part Adeductible) 061st thru 90th dayAll but 389 a day 389 a day 091st day and after: While using 60 lifetime reserve daysAll but 778 a day 778 a day 0 Once lifetime reserve days are used:- Additional 365 days 0100% ofMedicareeligibleexpenses 02 0 0All costsFirst 20 daysAll approvedamounts 0 021st thru 100th dayAll but 194.50a dayUp to 194.50a day 0101st day and after 0 0All costsBloodFirst 3 pints 03 pints 0Additional amounts100% 0 0Hospice CareYou must meet Medicare’s requirements,including a doctor’s certification ofterminal illness.All but verylimitedcopayment/coinsurance foroutpatient drugsand inpatientrespite careMedicarecopayment/coinsurance 0- Beyond the additional 365 daysSkilled Nursing Facility Care1You must meet Medicare’s requirements,including having been in a hospital for at least 3days and entered a Medicare-approved facilitywithin 30 days after leaving the hospital.Questions? 1-888-328-4542 (TTY 711) HorizonBlue.com/Medicare

Medicare (Part B) Medical Services Per Calendar YearServiceMedicare PaysPlan PaysYou PayMedical ExpensesIN OR OUT OF THE HOSPITAL ANDOUTPATIENT HOSPITAL TREATMENT, such asphysicians’ services, inpatient and outpatientmedical and surgical services and supplies,physical and speech therapy, diagnostic tests,durable medical equipment.First 233 of Medicare-approved amounts3 0 0 233 (Part Bdeductible)Remainder of Medicare-approved amountsGenerally 80%Generally 20% 0Part B Excess ChargesAbove Medicare-approved amounts 0 0All costsBloodFirst 3 pints 0All costs 0 0 0 233 (Part Bdeductible)Remainder of Medicare-approved amounts80%20% 0Clinical Laboratory ServicesTESTS FOR DIAGNOSTIC SERVICES100% 0 0Next 233 of Medicare-approved amounts3Parts A & BHome Health CareMEDICARE-APPROVED SERVICESMedically necessary skilled care servicesand medical supplies100% 0 0Durable medical equipment First 233 of Medicare-approved amounts3 0 0 233 (Part Bdeductible) Remainder Medicare-approved amounts80%20% 0Other Benefits Not Covered by MedicareForeign Travel Not Covered by MedicareMedically necessary emergency care servicesbeginning during the first 60 days of each tripoutside the USA.First 250 each calendar year 0 0 250Remainder of charges 080% to a lifetimemaximumbenefit of 50,00020% andamounts overthe 50,000lifetimemaximum

PLAN F BENEFIT SUMMARYMedicare (Part A) Hospital Services Per Benefit PeriodServiceMedicare PaysPlan PaysYou PayHospitalization1Semi-private room and board, general nursingand miscellaneous services and supplies.First 60 daysAll but 1,556 1,556 (Part Adeductible) 061st thru 90th dayAll but 389 a day 389 a day 091st day and after: While using 60 lifetime reserve daysAll but 778 a day 778 a day 0 Once lifetime reserve days are used:- Additional 365 days 0100% ofMedicareeligibleexpenses 02 0 0All costsAll approvedamounts 0 021st thru 100th dayAll but 194.50a dayUp to 194.50a day 0101st day and after 0 0All costsBloodFirst 3 pints 03 pints 0Additional amounts100% 0 0Hospice CareYou must meet Medicare’s requirements,including a doctor’s certification ofterminal illness.All but verylimitedcopayment/coinsurance foroutpatient drugsand inpatientrespite careMedicarecopayment/coinsurance 0- Beyond the additional 365 daysSkilled Nursing Facility Care1You must meet Medicare’s requirements,including having been in a hospital for at least 3days and entered a Medicare-approved facilitywithin 30 days after leaving the hospital.First 20 daysQuestions? 1-888-328-4542 (TTY 711) HorizonBlue.com/Medicare

Medicare (Part B) Medical Services Per Calendar YearServiceMedicare PaysPlan PaysYou PayMedical ExpensesIN OR OUT OF THE HOSPITAL ANDOUTPATIENT HOSPITAL TREATMENT, such asphysicians’ services, inpatient and outpatientmedical and surgical services and supplies,physical and speech therapy, diagnostic tests,durable medical equipment.First 233 of Medicare-approved amounts3 0 233 (Part Bdeductible) 0Remainder of Medicare-approved amountsGenerally 80%Generally 20% 0Part B Excess ChargesAbove Medicare-approved amounts 0All costs 0BloodFirst 3 pints 0All costs 0 0 233 (Part Bdeductible) 0Remainder of Medicare-approved amounts80%20% 0Clinical Laboratory ServicesTESTS FOR DIAGNOSTIC SERVICES100% 0 0Next 233 of Medicare-approved amounts3Parts A & BHome Health CareMEDICARE-APPROVED SERVICESMedically necessary skilled care servicesand medical supplies100% 0 0Durable medical equipment First 233 of Medicare-approved amounts3 0 233 (Part Bdeductible) 0 Remainder Medicare-approved amounts80%20% 0Other Benefits Not Covered by MedicareForeign Travel Not Covered by MedicareMedically necessary emergency care servicesbeginning during the first 60 days of each tripoutside the USA.First 250 each calendar year 0 0 250Remainder of charges 080% to a lifetimemaximumbenefit of 50,00020% andamounts overthe 50,000lifetimemaximum

PLAN G BENEFIT SUMMARYMedicare (Part A) Hospital Services Per Benefit PeriodServiceMedicare PaysPlan PaysYou PayHospitalization1Semi-private room and board, general nursingand miscellaneous services and supplies.First 60 daysAll but 1,556 1,556 (PartA deductible) 061st thru 90th dayAll but 389 a day 389 a day 091st day and after: While using 60 lifetime reserve daysAll but 778 a day 778 a day 0 Once lifetime reserve days are used:- Additional 365 days 0100% ofMedicareeligibleexpenses 02 0 0All costsFirst 20 daysAll approvedamounts 0 021st thru 100th dayAll but 194.50a dayUp to 194.50a day 0101st day and after 0 0All costsBloodFirst 3 pints 03 pints 0Additional amounts100% 0 0Hospice CareYou must meet Medicare’s requirements,including a doctor’s certification ofterminal illness.All but verylimitedcopayment/coinsurance foroutpatient drugsand inpatientrespite careMedicarecopayment/coinsurance 0- Beyond the additional 365 daysSkilled Nursing Facility Care1You must meet Medicare’s requirements,including having been in a hospital for at least 3days and entered a Medicare-approved facilitywithin 30 days after leaving the hospital.Questions? 1-888-328-4542 (TTY 711) HorizonBlue.com/Medicare

Medicare (Part B) Medical Services Per Calendar YearServiceMedicare PaysPlan PaysYou PayMedical ExpensesIN OR OUT OF THE HOSPITAL ANDOUTPATIENT HOSPITAL TREATMENT, such asphysicians’ services, inpatient and outpatientmedical and surgical services and supplies,physical and speech therapy, diagnostic tests,durable medical equipment.First 233 of Medicare-approved amounts3 0 0 233 (Part Bdeductible)Remainder of Medicare-approved amountsGenerally 80%Generally 20% 0Part B Excess ChargesAbove Medicare-approved amounts 0100% 0BloodFirst 3 pints 0All costs 0 0 0 233 (Part Bdeductible)Remainder of Medicare-approved amounts80%20% 0Clinical Laboratory ServicesTESTS FOR DIAGNOSTIC SERVICES100% 0 0Next 233 of Medicare-approved amounts3Parts A & BHome Health CareMEDICARE-APPROVED SERVICESMedically necessary skilled care servicesand medical supplies100% 0 0Durable medical equipment First 233 of Medicare-approved amounts3 0 0 233 (Part Bdeductible) Remainder Medicare-approved amounts80%20% 0Other Benefits Not Covered by MedicareForeign Travel Not Covered by MedicareMedically necessary emergency care servicesbeginning during the first 60 days of each tripoutside the USA.First 250 each calendar year 0 0 250Remainder of charges 080% to a lifetimemaximum benefitof 50,00020% andamounts overthe 50,000lifetimemaximum

PLAN K BENEFIT SUMMARYMedicare (Part A) Hospital Services Per Benefit PeriodServiceHospitalization1Semi-private room and board, general nursingand miscellaneous services and supplies.First 60 daysMedicare PaysPlan PaysYou PayAll but 1,556 778(50% of Part Adeductible) 778(50% of Part Adeductible)61st thru 90th dayAll but 389 a day 389 a day 091st day and after: While using 60 lifetime reserve daysAll but 778 a day 778 a day 0 Once lifetime reserve days are used:- Additional 365 days 0100% ofMedicareeligibleexpenses 02 0 0All costsFirst 20 daysAll approvedamounts 0 021st thru 100th dayAll but 194.50a dayUp to 97.25a dayUp to 97.25a day101st day and after 0 0All costsBloodFirst 3 pints 050%50%Additional amounts100% 0 0Hospice CareYou must meet Medicare’s requirements,including a doctor’s certification ofterminal illness.All but verylimitedcopayment/coinsurance foroutpatient drugsand inpatientrespite care50% ofcopayment/coinsurance50% of Medicarecopayment/coinsurance- Beyond the additional 365 daysSkilled Nursing Facility Care1You must meet Medicare’s requirements,including having been in a hospital for at least 3days and entered a Medicare-approved facilitywithin 30 days after leaving the hospital.Questions? 1-888-328-4542 (TTY 711) HorizonBlue.com/Medicare

Medicare (Part B) Medical Services Per Calendar YearServiceMedicare PaysPlan PaysYou PayMedical ExpensesIN OR OUT OF THE HOSPITAL ANDOUTPATIENT HOSPITAL TREATMENT, such asphysicians’ services, inpatient and outpatientmedical and surgical services and supplies,physical and speech therapy, diagnostic tests,durable medical equipment.First 233 of Medicare-approved amounts3 0 0 233 (Part Bdeductible)Preventative Benefits for Medicarecovered servicesGenerally 75% ormore of MedicareapprovedamountsRemainderof MedicareapprovedamountsAll costs aboveMedicareapprovedamountsRemainder of Medicare-approved amountsGenerally 80%Generally 10%Generally 10% 0 0All costs (andthey do notcount towardannual out-ofpocket limitof 6,620)4 050%50% 0 0 233 (Part Bdeductible)Remainder of Medicare-approved amountsGenerally 80%Generally 10%Generally 10%Clinical Laboratory ServicesTESTS FOR DIAGNOSTIC SERVICES100% 0 0Part B Excess ChargesAbove Medicare-approved amountsBloodFirst 3 pintsNext 233 of Medicare-approved amounts3Parts A & BHome Health CareMEDICARE-APPROVED SERVICESMedically necessary skilled care servicesand medical supplies100% 0 0Durable medical equipment First 233 of Medicare-approved amounts3 0 0 233 (Part Bdeductible) Remainder Medicare-approved amounts80%20% 0

PLAN N BENEFIT SUMMARYMedicare (Part A) Hospital Services Per Benefit PeriodServiceMedicare PaysPlan PaysYou PayHospitalization1Semi-private room and board, general nursingand miscellaneous services and supplies.First 60 daysAll but 1,556 1,556 (Part Adeductible) 061st thru 90th dayAll but 389 a day 389 a day 091st day and after: While using 60 lifetime reserve daysAll but 778 a day 778 a day 0 Once lifetime reserve days are used:- Additional 365 days 0100% ofMedicareeligibleexpenses 02 0 0All costsFirst 20 daysAll approvedamounts 0 021st thru 100th dayAll but 194.50a dayUp to 194.50a day 0101st day and after 0 0All costsBloodFirst 3 pints 03 pints 0Additional amounts100% 0 0Hospice CareYou must meet Medicare’s requirements,including a doctor’s certification ofterminal illness.All but verylimitedcopayment/coinsurance foroutpatient drugsand inpatientrespite careMedicarecopayment/coinsurance 0- Beyond the additional 365 daysSkilled Nursing Facility Care1You must meet Medicare’s requirements,including having been in a hospital for at least 3days and entered a Medicare-approved facilitywithin 30 days after leaving the hospital.Questions? 1-888-328-4542 (TTY 711) HorizonBlue.com/Medicare

Medicare (Part B) Medical Services Per Calendar YearServiceMedicare PaysPlan PaysYou PayMedical ExpensesIN OR OUT OF THE HOSPITAL ANDOUTPATIENT HOSPITAL TREATMENT, such asphysicians’ services, inpatient and outpatientmedical and surgical services and supplies,physical and speech therapy, diagnostic tests,durable medical equipment. 233 (Part Bdeductible)First 233 of Medicare-approved amounts3 0 0Remainder of Medicare-approved amountsGenerally 80%Balance, otherthan up to 20per office visitand up to 50per emergencyroom visit. Thecopayment of upto 50 is waivedif the insured isadmitted to anyhospital, and theemergencyvisit is coveredas a MedicarePart A expense.Up to 20per office peremergencyroom visit. Thecopayment of upto 50 is waivedif the insured isadmitted to anyhospital, and theemergency visitis covered as aMedicare Part Aexpense.Part B Excess ChargesAbove Medicare-approved amounts 0 0All costsBloodFirst 3 pints 0100% 0 0 0 233 (Part Bdeductible)Remainder of Medicare-approved amounts80%20% 0Clinical Laboratory ServicesTESTS FOR DIAGNOSTIC SERVICES100% 0 0Next 233 of Medicare-approved amounts3(Continued)

Medicare (Part B) Medical Services Per Calendar YearParts A & BHome Health CareMEDICARE-APPROVED SERVICESMedically necessary skilled care servicesand medical supplies100% 0 0Durable medical equipment First 233 of Medicare-approved amounts3 0 0 233 (Part Bdeductible) Remainder Medicare-approved amounts80%20% 0Other Benefits Not Covered by MedicareForeign Travel Not Covered by MedicareMedically necessary emergency care servicesbeginning during the first 60 days of each tripoutside the USA.First 250 each calendar year 0 0 250Remainder of charges 080% to a lifetimemaximumbenefit of 50,00020% andamounts overthe 50,000lifetimemaximumQuestions? 1-888-328-4542 (TTY 711) HorizonBlue.com/Medicare

Important NotesAll deductibles and coinsurance are 2022 amounts.1A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out ofthe hospital and have not received skilled care in any other facility for 60 days in a row.2When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whateveramount 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 amountMedicare would have paid.3Once you have been billed 233 of Medicare-approved amounts for covered services, your Part B deductible will have beenmet for the calendar year.4You will pay half the cost-sharing of some covered services until you reach the annual out-of-pocket limit

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.