benefit plans a, b, f, hf, g, & n - asp | home · 800 crescent centre dr. suite 200 franklin,...

800 Crescent Centre Dr. Suite 200

Franklin, TN 37067800 264.4000

aetnaseniorproducts.com

Outline of CoverageMedicare Supplement Insurance

Underwritten by

Continental Life Insurance Company of Brentwood, Tennessee

An Aetna Company

Rates Effective:

BENEFIT PLANS A, B, F, HF, G, & N

Pennsylvania

CLIMS03889PA ©2018 Aetna Inc. 02/2018 A

CLI

MS0

3889

PA

02

/20

18

A

1

CONT

INEN

TAL

LIFE

INSU

RANC

E CO

MPA

NY O

F BR

ENTW

OO

D, T

ENNE

SSEE

O

UTLI

NE O

F M

EDIC

ARE

SUPP

LEM

ENT

COVE

RAG

E CO

VER

PAG

E

BENE

FIT

PLAN

S AV

AILA

BLE:

A, B

, F, H

IGH

DEDU

CTIB

LE F

, G, N

Th

ese

char

ts s

how

the

bene

fits

incl

uded

in e

ach

of th

e st

anda

rd M

edic

are

supp

lem

ent p

lans

. Eve

ry c

ompa

ny m

ust m

ake

avai

labl

e Pl

an “A

” and

“B

” and

“C” o

r “F”

. Som

e pl

ans

may

not

be

avai

labl

e in

you

r sta

te.

See

Out

lines

of C

over

age

sect

ions

for d

etai

ls a

bout

ALL

PLA

NS

Bas

ic B

enef

its:

Hos

pita

lizat

ion:

Par

t A c

oins

uran

ce p

lus

cove

rage

for 3

65 a

dditi

onal

day

s af

ter M

edic

are

bene

fits

end.

M

edic

al E

xpen

ses:

Par

t B c

oins

uran

ce (g

ener

ally

20%

of M

edic

are-

Appr

oved

exp

ense

s) o

r, co

-pay

men

ts fo

r hos

pita

l out

patie

nt s

ervi

ces.

Pla

ns

K, L

, and

N re

quire

insu

reds

to p

ay a

por

tion

of c

oins

uran

ce o

r cop

aym

ents

Bl

ood:

Firs

t thr

ee p

ints

of b

lood

eac

h ye

ar.

Hos

pice

: Par

t A c

oins

uran

ce

A

B

C

D

F/F*

G

K

L

M

N

Basi

c,

incl

udin

g 10

0% P

art B

co

insu

ranc

e

Basi

c,

incl

udin

g 10

0% P

art B

co

insu

ranc

e

Basi

c,

incl

udin

g 10

0% P

art B

co

insu

ranc

e

Basi

c,

incl

udin

g 10

0% P

art B

co

insu

ranc

e

Basi

c,

incl

udin

g 10

0% P

art B

co

insu

ranc

e

Basi

c,

incl

udin

g 10

0% P

art B

co

insu

ranc

e

Hos

pita

lizat

ion

and

prev

entiv

e ca

re p

aid

at

100%

; oth

er

basi

c be

nefit

s pa

id a

t 50%

Hos

pita

lizat

ion

and

prev

entiv

e ca

re p

aid

at

100%

; oth

er

basi

c be

nefit

s pa

id a

t 75%

Basi

c,

incl

udin

g 10

0% P

art B

co

insu

ranc

e

Basi

c, in

clud

ing

100%

Par

t B

coin

sura

nce,

exc

ept u

p to

$20

cop

aym

ent f

or

offic

e vi

sit,

and

up to

$50

cop

aym

ent f

or

ER

Skille

d N

ursi

ng

Faci

lity

Coi

nsur

ance

Skille

d N

ursi

ng

Faci

lity

Coi

nsur

ance

Skille

d N

ursi

ng

Faci

lity

Coi

nsur

ance

Skille

d N

ursi

ng

Faci

lity

Coi

nsur

ance

50%

Ski

lled

Nur

sing

Fa

cilit

y C

oins

uran

ce

75%

Ski

lled

Nur

sing

Fac

ility

Coi

nsur

ance

Skille

d N

ursi

ng

Faci

lity

Coi

nsur

ance

Skille

d N

ursi

ng

Faci

lity

Coi

nsur

ance

Pa

rt A

Ded

uctib

le

Part

A D

educ

tible

Pa

rt A

Ded

uctib

le

Part

A D

educ

tible

Pa

rt A

Ded

uctib

le

50%

Par

t A

Ded

uctib

le

75%

Par

t A

Ded

uctib

le

50%

Par

t A

Ded

uctib

le

Part

A D

educ

tible

Part

B D

educ

tible

Part

B D

educ

tible

Part

B Ex

cess

(1

00%

)

Part

B Ex

cess

(1

00%

)

Fore

ign

Trav

el

Emer

genc

y

Fore

ign

Trav

el

Emer

genc

y

Fore

ign

Trav

el

Emer

genc

y

Fore

ign

Trav

el

Emer

genc

y

Fore

ign

Trav

el

Emer

genc

y

Fore

ign

Trav

el

Emer

genc

y

Out

-of-p

ocke

t lim

it $5

240;

pa

id a

t 100

%

afte

r lim

it re

ache

d

Out

-of-p

ocke

t lim

it $2

620;

pa

id a

t 100

%

afte

r lim

it re

ache

d

*Pla

n F

also

has

an

optio

n ca

lled

a hi

gh d

educ

tible

pla

n F.

Thi

s hi

gh d

educ

tible

pla

n pa

ys t

he s

ame

bene

fits

as P

lan

F af

ter

one

has

paid

a c

alen

dar

year

$22

40

dedu

ctib

le. B

enef

its fr

om h

igh

dedu

ctib

le p

lan

F w

ill no

t beg

in u

ntil

out-o

f-poc

ket e

xpen

ses

exce

ed $

2240

. O

ut-o

f-poc

ket e

xpen

ses

for

this

ded

uctib

le a

re e

xpen

ses

that

w

ould

ord

inar

ily b

e pa

id b

y th

e po

licy.

The

se e

xpen

ses

incl

ude

the

Med

icar

e de

duct

ible

s fo

r Pa

rt A

and

Part

B, b

ut d

o no

t in

clud

e th

e pl

an’s

sep

arat

e fo

reig

n tra

vel

emer

genc

y de

duct

ible

.

CLI

MS0

3889

PA

02

/20

18

A

2

Att

ain

ed

Pre

ferr

ed

Att

ain

ed

Stan

dar

d

Age

Pla

n A

Pla

n B

Pla

n F

Pla

n H

FP

lan

GP

lan

NA

geP

lan

AP

lan

BP

lan

FP

lan

HF

Pla

n G

Pla

n N

Un

de

r 65

1,22

4

1,

319

1,70

2

68

0

1,46

0

1,

092

Un

de

r 65

1,35

9

1,

466

1,89

0

75

6

1,62

3

1,

214

65

1,22

4

1,

319

1,70

2

68

0

1,46

0

1,

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651,

359

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1,

890

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623

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66

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68

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1,46

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116

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1,

890

756

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623

1,24

1

67

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1,

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1,27

0

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1,23

8

1,

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1,72

2

68

9

1,47

8

1,

182

681,

376

1,48

3

1,

913

766

1,

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1,31

4

69

1,26

6

1,

363

1,75

9

70

4

1,51

0

1,

235

691,

406

1,51

4

1,

955

782

1,

677

1,37

3

70

1,30

0

1,

399

1,80

6

72

2

1,54

9

1,

294

701,

444

1,55

5

2,

007

802

1,

721

1,43

8

71

1,33

8

1,

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1,86

0

74

4

1,59

6

1,

333

711,

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1,60

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2,

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1,

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1,48

3

72

1,38

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1,

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1,91

8

76

7

1,64

5

1,

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721,

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1,65

1

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131

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1,

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1,52

9

73

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2

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731,

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5

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1,

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1,57

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1,

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2,05

0

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0

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741,

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1,

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1,63

3

75

1,52

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1,

646

2,12

4

85

0

1,82

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1,

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751,

698

1,82

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2,

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1,88

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758

1,89

4

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443

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097

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2

77

1,63

5

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762

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4

91

0

1,95

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1,

629

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817

1,95

7

2,

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1,01

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2,

167

1,81

0

78

1,68

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1,

819

2,34

7

93

9

2,01

5

1,

683

781,

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1,86

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2,42

4

97

0

2,08

0

1,

738

791,

937

2,08

7

2,

693

1,07

7

2,

312

1,93

2

80

1,79

9

1,

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2,50

1

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000

2,14

6

1,

792

801,

999

2,15

4

2,

779

1,11

1

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384

1,99

2

81

1,85

5

1,

999

2,57

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1,

032

2,21

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83

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124

2,74

1

1,

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2,35

3

1,

965

832,

192

2,36

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3,

046

1,21

8

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614

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3

84

2,03

3

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190

2,82

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2,

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259

2,43

3

3,

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1,25

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2,

694

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2,10

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2,58

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3

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2,35

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532

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4

Mo

dal

Fac

tors

:Se

mi-

An

nu

al:

0.52

00Q

uar

terl

y:0.

2650

Mo

nth

ly:

0.08

33

The

ab

ove

rat

es

do

no

t in

clu

de

th

e $

20 o

ne

-tim

e p

oli

cy f

ee

.

To c

alcu

late

a H

ou

seh

old

dis

cou

nt:

A

nn

ual

pre

miu

m x

mo

dal

fac

tor

= m

od

al p

rem

ium

(ro

un

d t

o n

ear

est

wh

ole

ce

nt)

M

od

al p

rem

ium

x .9

3 =

dis

cou

nte

d p

rem

ium

If a

pp

lyin

g d

uri

ng

Op

en

En

roll

me

nt

or

Gu

aran

tee

d Is

sue

Pe

rio

d, u

se P

refe

rre

d r

ate

s.

Rat

es E

ffec

tive

2/1

/20

18

Fem

ale

Rat

es

Co

nti

ne

nta

l Lif

e In

sura

nce

Co

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any

of

Bre

ntw

oo

d, T

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ne

sse

eA

nn

ual

Pre

miu

ms

For

Use

in

ZIP

Co

des

: 1

50

-15

4 a

nd

15

6

CLI

MS0

3889

PA

02

/20

18

A

3

Att

ain

ed

Pre

ferr

ed

Att

ain

ed

Stan

dar

d

Age

Pla

n A

Pla

n B

Pla

n F

Pla

n H

FP

lan

GP

lan

NA

geP

lan

AP

lan

BP

lan

FP

lan

HF

Pla

n G

Pla

n N

Un

de

r 65

1,40

7

1,

516

1,95

7

78

2

1,67

9

1,

255

Un

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r 65

1,56

3

1,

686

2,17

4

86

9

1,86

6

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7

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516

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7

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174

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661,

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2,22

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84

2,06

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CLIMS03889PA 02/2018 A

8

PREMIUM INFORMATION Continental Life Insurance Company of Brentwood, Tennessee can only raise your premium if we raise the premium for all policies like yours in this state. Premiums for this policy will increase annually due to the increase in your age. Upon attainment of an age requiring a rate increase, the renewal premium for the policy will be the renewal premium then in effect for your attained age. Other policies may be provided with Issue Age rating and do not increase with age. You should compare Issue Age with Attained Age policies.

Premiums payable other than annual will be determined according to the following factors:

Semi-annual: 0.5200 Quarterly: 0.2650 Monthly EFT: 0.0833.

HOUSEHOLD DISCOUNT

In order to be eligible for the Household discount under an Continental Life Insurance Company of Brentwood, Tennessee Medicare supplement plan, you must apply for a Medicare supplement plan at the same time as another Medicare eligible adult or the other Medicare eligible adult must currently be covered by a Company Continental Life Insurance Company of Brentwood, Tennessee Medicare Supplement policy. The Medicare eligible adult must be either (a) your spouse; (b) be someone with whom you are in a civil union partnership; and (c) be someone with whom you have continuously resided for the past 12 months. The household discount will only be applicable if a policy for each applicant is issued. The discounted rate will be 7 percent lower than the individual rates and will apply as long as both policies remain in force.

DISCLOSURES Use this outline to compare benefits and premium 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 your insurance company.

RIGHT TO RETURN POLICY If you find that you are not satisfied with your policy, you may return it to Continental Life Insurance Company of Brentwood, Tennessee P.O. Box 14770, Lexington, KY 40512-4770. 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 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 cover all of your medical costs. Neither Continental Life Insurance Company of Brentwood, Tennessee 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 & 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 any questions about your medical and health history. The company 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.

THE FOLLOWING CHARTS DESCRIBE PLANS A, B, F, HIGH DEDUCTIBLE F, G and N OFFERED BY CONTINENTAL LIFE INSURANCE COMPANY OF BRENTWOOD, TENNESSEE.

CLIMS03889PA 02/2018 A

9

PLAN A

MEDICARE (PART A) – MEDICAL 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 PAYS

YOU PAY

HOSPITALIZATION* Semiprivate room and board, general nursing and miscellaneous services and supplies First 60 days

61st thru 90th day 91st day and after •While using 60 lifetime reserve days •Once lifetime reserve days are used: •Additional 365 days

•Beyond the Additional 365 days

All but $1340

All but $335 a day

All but $670 a day

$0 $0

$0

$335 a day

$670 a day

100% of Medicare Eligible Expenses $0

$1340 (Part A Deductible) $0

$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 21st thru 100th day

101st day and after

All approved amounts All but $167.50 a day

$0

$0 $0

$0

$0 Up to $167.50 a day All costs

BLOOD First 3 pints Additional amounts

$0 100%

3 pints $0

$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

$0

**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.

CLIMS03889PA 02/2018 A

10

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.


PLAN 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 $183 of Medicare-Approved amounts* Remainder of Medicare-Approved amounts

$0

Generally 80%

$0

Generally 20%

$183 (Part B Deductible)

$0

Part B Excess Charges (Above Medicare-Approved amounts)

$0

$0

All costs BLOOD First 3 pints Next $183 of Medicare-Approved amounts* Remainder of Medicare-Approved amounts

$0 $0

80%

All costs $0

20%

$0 $183 (Part B Deductible)

$0

CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES

100%

$0

$0

PARTS A & B


PLAN PAYS

YOU PAY

HOME HEALTH CARE – MEDICARE APPROVED SERVICES •Medically necessary skilled care services and medical supplies

•Durable medical equipment

•First $183of Medicare Approved amounts*

•Remainder of Medicare Approved amounts

100%

$0

80%

$0

$0

20%

$0


$0

CLIMS03889PA 02/2018 A

11

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.


PLAN PAYS

YOU PAY




All but $1340 All but $335 a day

All but $670 a day

$0 $0

$1340 (Part A Deductible) $335 a day

$670 a day


$0 $0

$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

21st thru 100th day

101st day and after

All approved amounts All but $167.50 a day $0

$0 $0

$0

$0 Up to $167.50 a day All costs


$0 100%

3 pints $0

$0 $0




$0

**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 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.

CLIMS03889PA 02/2018 A

12

PLAN B


* 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.


PLAN PAYS

YOU PAY


$0

Generally 80%

$0

Generally 20%


$0


$0

$0


$0 $0

80%

All costs $0

20%


$0


100%

$0

$0

PARTS A & B


PLAN PAYS

YOU PAY


•Durable medical equipment •First $183 of Medicare Approved amounts*


100%

$0

80%

$0

$0

20%

$0


$0

CLIMS03889PA 02/2018 A

13

PLAN F




PLAN PAYS

YOU PAY





All but $670 a day

$0 $0


$670 a day


$0 $0

$0

$0** All costs


21st thru 100th day

101st day and after


$0 Up to $167.50 a day $0

$0 $0

All costs


$0 100%

3 pints $0

$0 $0




$0


CLIMS03889PA 02/2018 A

14

PLAN F




PLAN PAYS

YOU PAY


$0

Generally 80%


Generally 20%

$0

$0 Part B Excess Charges (Above Medicare-Approved amounts)

$0

100%

$0 BLOOD First 3 pints Next $183 of Medicare-Approved amounts* Remainder of Medicare-Approved amounts

$0 $0

80%

All costs $183 (Part B Deductible)

20%

$0 $0

$0 CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES

100%

$0

$0

PARTS A & B


PLAN PAYS

YOU PAY




100%

$0

80%

$0


20%

$0

$0

$0

CLIMS03889PA 02/2018 A

15

PLAN F

OTHER BENEFITS – NOT COVERED BY MEDICARE


PLAN 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 Remainder of charges

$0 $0

$0 80% to a lifetime maximum benefit of $50,000

$250 20% and amounts over the $50,000 lifetime maximum

CLIMS03889PA 02/2018 A

16

HIGH DEDUCTIBLE PLAN F



***This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2240 deductible. Benefits from high deductible plan F will not begin until out-of-pocket expenses are $2240. 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.

SERVICES

MEDICARE PAYS

AFTER YOU PAY $2240

DEDUCTIBLE*** PLAN PAYS

IN ADDITION TO $2240

DEDUCTIBLE*** YOU PAY





All but $670 a day

$0 $0


$670 a day


$0 $0

$0

$0** All costs


21st thru 100th day

101st day and after


$0 Up to $167.50 a day $0

$0 $0

All costs


$0 100%

3 pints $0

$0 $0

CLIMS03889PA 02/2018 A

17




$0


CLIMS03889PA 02/2018 A

18




***This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2240 deductible. Benefits from high deductible plan F will not begin until out-of-pocket expenses are $2240. 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.

SERVICES

MEDICARE PAYS

AFTER YOU PAY $2240





$0

Generally 80%


Generally 20%

$0

$0 Part B Excess Charges (Above Medicare-Approved amounts)

$0

100%


$0 $0

80%

All costs $183 (Part B Deductible)

20%

$0 $0

$0 CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES

100%

$0

$0

CLIMS03889PA 02/2018 A

19


PARTS A & B

SERVICES

MEDICARE PAYS

AFTER YOU PAY $2240







100%

$0

80%

$0


20%

$0

$0

$0


SERVICES

MEDICARE PAYS

AFTER YOU PAY $2240

DEDUCTIBLE** PLAN PAYS


DEDUCTIBLE** YOU PAY


$0 $0



CLIMS03889PA 02/2018 A

20

PLAN G




PLAN PAYS

YOU PAY





All but $670 a day

$0 $0


$670 a day


$0 $0

$0

$0** All costs


21st thru 100th day 101st day and after


$0 Up to $167.50 a day $0

$0 $0 All costs


$0 100%

3 pints $0

$0 $0

HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness services



$0


CLIMS03889PA 02/2018 A

21

PLAN G




PLAN PAYS

YOU PAY


$0

Generally 80%

$0

Generally 20%


$0


$0

100%


$0 $0

80%

All costs $0

20%


$0


100%

$0

$0

PARTS A & B


PLAN PAYS

YOU PAY

HOME HEALTH CARE – MEDICARE APPROVED SERVICES

Medically necessary skilled care services and medical supplies 100% $0 $0 Durable medical equipment First $183 of Medicare Approved amounts*

$0 $0 $183 (Part B Deductible)

Remainder of Medicare Approved amounts 80% 20% $0

CLIMS03889PA 02/2018 A

22

PLAN G



PLAN PAYS

YOU PAY


$0 $0



CLIMS03889PA 02/2018 A

23

PLAN N




PLAN PAYS

YOU PAY





All but $670 a day

$0 $0


$670 a day


$0 $0

$0

$0** All costs


21st thru 100th day

101st day and after


$0 Up to $167.50 a day $0

$0 $0

All costs


$0 100%

3 pints $0

$0 $0

HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness services


Medicare co-payment/ coinsurance

$0


CLIMS03889PA 02/2018 A

24

PLAN N




PLAN PAYS

YOU PAY


$0

Generally 80%

$0

Balance, other than up to $20 per office visit and up to $50 per emergency room visit. The co-payment of up to $50 is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense.

$183 (Part B Deductible) Up to $20 per office visit and up to $50 per emergency room visit. The copayment of up to $50 is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense.


$0

0%


$0 $0

80%

All costs $0

20%


$0


100%

$0

$0

CLIMS03889PA 02/2018 A

25

PLAN N

PARTS A & B


PLAN PAYS

YOU PAY

HOME HEALTH CARE – MEDICARE APPROVED SERVICES •Medically necessary skilled care services and medical supplies •Durable medical equipment •First $183 of Medicare Approved amounts* •Remainder of Medicare Approved amounts

100% $0

80%

$0 $0

20%

$0


$0



PLAN 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

Remainder of charges

$0

$0

$0

80% to a lifetime maximum benefit of $50,000

$250

20% and amounts over the $50,000 lifetime maximum

benefit plans a, b, f, hf, g, & n - asp | home · 800 crescent centre dr. suite 200 franklin,...

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