great southern life medicare supplement · 1. you do not need more than one medicare supplement...

For Use in Ohio 18-247-8-OH (06/19)

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

Included in this packet:î Application for Medicare Supplement Insuranceî Health Information Authorizationî Medicare Supplement Replacement Noticeî Bank Draft Authorization for Medicare Supplementî Important Consumer Noticesî Guaranteed Issue Eligibility Disclosureî Ohio Solicitation Formî Producer Statementî Premium Worksheetî Outline of Coverageî Rate Guideî Fax Transmittal

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

applicant at the point of sale for all states.

Home Office: Dallas, Texas • Medicare Supplement Administrative Office: PO BOX 10812, Clearwater, FL 33757-8812

MedicareApplication Packet

Great Southern Life

Supplement

Home Office: Dallas, Texas • Medicare Supplement Administrative Office: PO Box 10812, Clearwater, FL 33757-8812 18-247-11

Fax applications and New Business documents ONLY to: 855.864.8526

Important:

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

Forms Sequence:

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

PLEASE PRINT LEGIBLY

Agent Name Agent Code

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

Applicant Name Plan Applied For

Initial Premium Amount to be drafted or charged

(include policy fee)

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

Medicare Supplement Application Transmittal Form 18-247-11

Home Office: Dallas, Texas • Medicare Supplement Administrative Office: PO Box 10812, Clearwater, FL 33757-8812 GOH5510 Page 1 of 5 For Use in Ohio

New Business Coverage Change Reinstatement

Part I – Personal Information

Title: Mr. Mrs. Miss Ms. Other______________

Last Name First Name MI Gender

Male Female Street Address

City State ZIP

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

______ft. ______in.

Weight

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

____________________________ (mm/dd/yyyy) Daytime Phone Evening Phone Mobile Phone

Email Address

Part II – Plan Selection

A F G N F - High Deductible

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

Part III – Eligibility State law allows a 6-month open enrollment period beginning with the first day of the first month in which you are both: (1) age 65 or older; and (2) enrolled in Medicare Part B. If you are a qualified open enrollee, you may apply for and receive any Medicare Supplement Plan available from us.

1. Are you covered under Medicare Part A? ........................................................................................................................... Yes No a. If Yes, what is your Part A start date? _______/_______/_______ b. If No, what is your eligibility date? _______/_______/_______

2. Did you enroll in Medicare Part B in the last 6 months? ................................................................................................. Yes No

a. If Yes, what is your Part B start date? _______/_______/_______ 3. Have you enrolled in Medicare Part B more than once? ................................................................................................ Yes No 4. Did you turn 65 in the last 6 months? ................................................................................................................................... Yes No

Application for Medicare Supplement Insurance GOH5510


GOH5510

Part IV – Medicare & Insurance Information

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

PLEASE ANSWER ALL QUESTIONS

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

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

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

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

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

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

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

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

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

If so, with what company? _______________________________________________________________________________________

Policy Number: _________________________________________________________________________________________________

Telephone Number: _________________________ What plan do you have? ___________________________________________

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

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

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

a. If so, with what company? _______________________________________________________________________________________

Policy or Certificate Number: ____________________________________________________________________________________

Telephone Number: ______________________ What plan do you have? ______________________________________________

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

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

a. If so, with what company? _______________________________________________________________________________________

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

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

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


GOH5510

Part V – General Information 1. You do not need more than one Medicare Supplement policy or certificate. 2. If you purchase this policy, you may want to evaluate your existing health coverage and decide if you need multiple

coverages. 3. You may be eligible for benefits under Medicaid and may not need a Medicare Supplement policy or certificate. 4. If, after purchasing this policy, you become eligible for Medicaid, the benefits and premiums under your Medicare

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

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

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

Part VI – Premium Payment & Administration Initial Premium: $ ___________ One-Time Policy Fee: $ 25.00 Total Initial Premium: $ ___________

Premium Mode/Method: Monthly Bank Draft Annual Direct Bill

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

NOTICE TO APPLICANT: Please answer all of the following questions. Please verify the accuracy and completeness of the medical information on this application. Incomplete or false information on this application could jeopardize future claims.

If you answer YES to any of the following questions 1-13, you are not eligible for coverage. 1. Are you currently or within the past 6 months been: a. Hospitalized, bedridden, confined to a wheelchair, or require the use of a motorized mobility aid? ........ Yes No b. Residing in a nursing home or assisted living facility, or other professional care facility? ........................... Yes No c. Receiving home health care?......................................................................................................................................... Yes No d. Receiving assistance with Activities of Daily Living including eating, bathing, toileting, or dressing? ..... Yes No e. Diagnosed with a Terminal Illness? .............................................................................................................................. Yes No


GOH5510

Part VII – Medical Questions (continued) 2. Do you currently receive care or treatment that requires administration of medications or physical therapy in a medical facility or by a licensed member of the medical profession, including but not limited to: joint injections to alleviate pain, infusions or for pain to joints, spine or other areas of the body, biologics, infusions, or treatments for chronic illness that must be administered by a licensed practitioner (excluding b12 injections)? ...................................................................................................................................................... Yes No 3. Do you currently have an implanted cardiac defibrillator?.............................................................................................. Yes No 4. Have you ever been diagnosed with, advised, or treated by a member of the medical profession for: a. Pulmonary Hypertension (excluding common high blood pressure), Emphysema, chronic obstructive

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

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

c. Alzheimer’s disease, senile dementia, or any other cognitive or memory disorder? ...................................... Yes No d. Chronic kidney disease, kidney failure, renal insufficiency, or kidney disease requiring dialysis? ............ Yes No 5. Have you ever been advised by a licensed member of the medical profession: a. that surgery, including cataract surgery, may be required within the next 12 months? ................................. Yes No b. to have surgery, medical tests (excluding HIV/AIDS), treatment, or therapy (including physical

therapy) that has not yet been performed, or are you currently receiving therapy or treatment or awaiting test results? ......................................................................................................................................................... Yes No

c. to have an organ transplant or have you ever had an organ transplant? .......................................................... Yes No 6. Have you ever tested positive for exposure to the HIV infection or been diagnosed as having Acquired

Immune Deficiency Syndrome (AIDS) or AIDS related complex (ARC)? .................................................................. Yes No 7. Have you ever had an amputation Not caused by an injury or accident? ................................................................. Yes No 8. Have you ever been diagnosed with, received care or treatment for, or been advised by a licensed

member of the medical profession to seek treatment for Diabetes in any form or been advised to take medication of any kind to reduce or control your blood sugar in addition to:

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

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

Heart Rhythm Disturbances, or Retinopathy? ........................................................................................................... Yes No c. Ever being diagnosed by a licensed member of the medical profession with Hypertension (High Blood Pressure) which has required hospitalization; or has, within the past 12 months, required you to take more than three (3) medications for hypertension or been diagnosed as not well controlled by a licensed member of the medical profession? ....................................................................... Yes No 9. Within the past 2 years, have you been diagnosed with, advised, or treated by a licensed member of the

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

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

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

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

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


GOH5510

Part VII – Medical Questions (continued) 12. Within the past 2 years, have you been diagnosed with, advised, or treated by a licensed member

of the medical profession for: a. Heart attack? ........................................................................................................................................................................ Yes No b. Stroke or TIA (Transient Ischemic Attack or “Mini Stroke”)? ................................................................................. Yes No c. Bypass or Stent placement in any artery? .................................................................................................................. Yes No d. Initial installation of a Pacemaker? ................................................................................................................................ Yes No e. Initial diagnosis of Atrial Fibrillation or undergone Ablation procedure? ............................................................ Yes No f. Heart Valve Surgery for repair or replacement? ........................................................................................................ Yes No g. Pulmonary Embolism? ...................................................................................................................................................... Yes No h. Congestive Heart Failure, enlarged heart, or Cardiomyopathy? .......................................................................... Yes No 13. Within the past 2 years, have you received an initial diagnosis by a licensed member of the medical

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

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

Company Type of Policy Effective Date In Force Yes No Yes No Yes No

Part IX – Agreement & Acknowledgment I wish to apply for Medicare supplement insurance coverage. I acknowledge that I have received or been given access to review: (a) an Outline of Coverage for the coverage applied for, and (b) a “Guide to Health Insurance for People with Medicare.” I AUTHORIZE Great Southern Life Insurance Company (the Company) to act on electronic and/or telephonic information from all parties specified in this application. This authorization may be revoked by sending written notice to Great Southern at its Medicare Supplement Administrative Office address. The absence of this authorization constitutes a rejection of this authorization. I FULLY UNDERSTAND the questions contained in this Application. To the best of my knowledge and belief, the answers I provided are true and complete. I understand the Company may conduct a telephone interview with me regarding the answers. I understand and agree the coverage applied for will not take effect until issued by the Company, and that the agent is not authorized to extend, waive or change any terms, conditions or provisions of the coverage. Caution: If your answers on this Application are incorrect or untrue, the Company has the right to deny benefits or rescind your coverage. Any person who, with the intent to defraud or knowing that he or she is facilitating a fraud against an insurer, submits and application or files a claim containing a false or deceptive statement is guilty of insurance fraud. _________________________________________________________ Send policy to: Applicant Producer Signed at (City and State) _________________________________________________________ _____________________________________ Applicant’s Signature Date _________________________________________________________ _____________________________________ Producer’s Signature Producer Number _________________________________________________________ Producer’s Phone

Home Office: Dallas, Texas • Medicare Supplement Administrative Office: PO Box 10812, Clearwater, FL 33757-8812 GAA8555 (05/18)

This Authorization complies with the HIPAA Privacy Rule You agree to provide your personal health information to Americo Financial Life and Annuity Insurance Company and/or Great Southern Life Insurance Company (“the Companies”) and its agents, and to allow the Companies to access your protected health information from other sources so that it and its affiliates may evaluate your insurability and make a coverage or issuance determination. Information regarding your insurability will be treated as confidential. The Companies are members of MIB, Inc. (MIB). The Companies, or its reinsurers, may make a brief report to MIB, which operates an information exchange on behalf of its members. If you apply to another member company for life or health insurance coverage, or a claim for benefits is submitted to such a company, MIB may supply such company with the information in its file. The Companies or its reinsurers may also release your protected health information to other insurance companies to whom you may apply for life or health insurance, or to whom a claim for benefits may be submitted. It is the Companies’ practice to prohibit third parties who lawfully receive nonpublic health information from redisclosing or reusing the disclosed information. You may request to see the information kept in your MIB file. You may also contact MIB and seek correction of any errors in your file. Your authorization permits any insurance or reinsurance company, health plan, licensed medical physician, health care professional, hospital, clinic, laboratory, pharmacy, pharmacy benefit manager, records custodians, other medical or medical related facility, or other health care provider that has provided services, treatment or payment to you or on your behalf, within the past 10 years (“Your Providers”), or any clearing house, consumer reporting agency, or MIB, to disclose your entire medical record and any other protected health information, concerning you to Americo Financial Life and Annuity Insurance Company and/or Great Southern Life Insurance Company or its reinsurers, employees and representatives. This includes information on the diagnosis or treatment of Human Immunodeficiency Virus (HIV) infection and sexually transmitted diseases. This includes information on the diagnosis and treatment of mental illness and the use of alcohol, drugs, and nicotine products, but excludes psychotherapy notes and excludes information related to genetic tests or genetic services (except to pay a claim related to such tests or services). By your signature below, you acknowledge that any agreements you have made to restrict your protected health information does not apply to this Authorization and you instruct any physician, health care professional, hospital, clinic, medical facility, or other health care provider to release and disclose your entire medial record without restriction. Your protected health information is to be disclosed under this Authorization so that the Companies may: (1) underwrite your application for coverage, make eligibility, risk rating, policy issuance and enrollment determinations; (2) obtain reinsurance; (3) administer claims and determine or fulfill their responsibility for coverage and provision for benefits; (4) administer coverage; (5) conduct other legally permissible activities that relate to any coverage you have applied for with Great Southern Life; and (6) market other of the Companies’ insurance products to you. By your execution of this Authorization, you agree that the Companies’ may disclose your protected health information and the details of your medical history used in the underwriting, declination or approval of your application for coverage and may disclose specific information to the sales agent listed on this application. This Authorization shall remain in force for 30 months following the date of your signature below, and a copy of this Authorization is as valid as the original. This Authorization may be revoked by sending a written request for revocation to Americo Life, Inc. at PO Box 410288, Kansas City, MO 64141-0288, Attention: Legal Department; however, a revocation is not effective to the extent that any of Your Providers has relied on this Authorization or to the extent that the Companies have a legal right to contest a claim under an insurance policy or to contest the policy itself. Any information that is disclosed pursuant to this Authorization may be redisclosed and is no longer covered by federal rules governing privacy and confidentially of health information. Your Providers may not refuse to provide treatment or payment for health care services if you refuse to sign this Authorization. If you refuse to sign this Authorization to release your complete medical record, the Companies may not be able to process your application, or if coverage has been issued may not be able to make any benefit payments.

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

_______________________________________________________________ ___________________________________ Signature of Applicant or Personal Representative Date

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

Health Information Authorization GAA8555 (05/18)

Home Office: Dallas, Texas • Medicare Supplement Administrative Office: PO Box 10812, Clearwater, FL 33757-8812 GOH8550 Submit with Application For Use in Ohio

Medicare Supplement Replacement Notice GOH8550

NOTICE TO APPLICANT REGARDING REPLACEMENT OF MEDICARE SUPPLEMENT INSURANCE OR MEDICARE ADVANTAGE

SAVE THIS NOTICE ! IT MAY BE IMPORTANT TO YOU IN THE FUTURE. According to your application, you intend to terminate existing Medicare supplement or Medicare Advantage insurance and replace it with a policy to be issued by Great Southern Life Insurance Company. Your new policy will provide thirty (30) days within which you may decide, without cost, whether you desire to keep the policy.

You should review this new coverage carefully. Compare it with all accident and sickness coverage you now have. If after due consideration, you find that purchase of this Medicare supplement coverage is a wise decision, you should terminate your present Medicare supplement or Medicare Advantage coverage. You should evaluate the need for other accident and sickness coverage you have that may duplicate this policy

Statement to Applicant by Issuer - ______________________________________________________________________ Agent, Broker, or other Representative

I have reviewed your current medical or health insurance coverage. To the best of my knowledge, this Medicare supplement policy will not duplicate your existing Medicare supplement or, if applicable, Medicare Advantage coverage because you intend to terminate your existing Medicare supplement coverage or leave your Medicare Advantage plan. The replacement policy is being purchased for the following reason: (check one):

Additional benefits. No change in benefits, but lower premiums. Fewer benefits and lower premiums. My plan has outpatient prescription drug coverage and I am enrolling in Part D. Disenrollment from a Medicare Advantage plan. Please explain reason for disenrollment Other (please specify): _____________________________________________________________________________

1. Note: If the issuer of the Medicare supplement policy being applied for does not, or is otherwise prohibited from imposing preexisting condition limitations, please skip to statement 2 below. Health conditions which you may presently have (preexisting conditions) may not be immediately or fully covered under the new policy. This could result in denial or delay of a claim for benefits under the new policy, whereas a similar claim might have been payable under your present policy.

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

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

Do not cancel your present policy until you have received your new policy and are sure that you want to keep it. _______________________________________________________________ Signature of Agent, Broker, or Other Representative _______________________________________________________________ _____________________________ Applicant’s Signature Date

Home Office: Dallas, Texas • Medicare Supplement Administrative Office: PO Box 10812, Clearwater, FL 33757-8812 GOH8550 Leave with Applicant For Use in Ohio

Medicare Supplement Replacement Notice GOH8550

NOTICE TO APPLICANT REGARDING REPLACEMENT OF MEDICARE SUPPLEMENT INSURANCE OR MEDICARE ADVANTAGE

SAVE THIS NOTICE ! IT MAY BE IMPORTANT TO YOU IN THE FUTURE. According to your application, you intend to terminate existing Medicare supplement or Medicare Advantage insurance and replace it with a policy to be issued by Great Southern Life Insurance Company. Your new policy will provide thirty (30) days within which you may decide, without cost, whether you desire to keep the policy.

You should review this new coverage carefully. Compare it with all accident and sickness coverage you now have. If after due consideration, you find that purchase of this Medicare supplement coverage is a wise decision, you should terminate your present Medicare supplement or Medicare Advantage coverage. You should evaluate the need for other accident and sickness coverage you have that may duplicate this policy

Statement to Applicant by Issuer - ______________________________________________________________________ Agent, Broker, or other Representative

I have reviewed your current medical or health insurance coverage. To the best of my knowledge, this Medicare supplement policy will not duplicate your existing Medicare supplement or, if applicable, Medicare Advantage coverage because you intend to terminate your existing Medicare supplement coverage or leave your Medicare Advantage plan. The replacement policy is being purchased for the following reason: (check one):

Additional benefits. No change in benefits, but lower premiums. Fewer benefits and lower premiums. My plan has outpatient prescription drug coverage and I am enrolling in Part D. Disenrollment from a Medicare Advantage plan. Please explain reason for disenrollment Other (please specify): _____________________________________________________________________________

1. Note: If the issuer of the Medicare supplement policy being applied for does not, or is otherwise prohibited from imposing preexisting condition limitations, please skip to statement 2 below. Health conditions which you may presently have (preexisting conditions) may not be immediately or fully covered under the new policy. This could result in denial or delay of a claim for benefits under the new policy, whereas a similar claim might have been payable under your present policy.

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

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

Do not cancel your present policy until you have received your new policy and are sure that you want to keep it. _______________________________________________________________ Signature of Agent, Broker, or Other Representative _______________________________________________________________ _____________________________ Applicant’s Signature Date

Home Office: Dallas, Texas • Medicare Supplement Administrative Office: PO Box 10812, Clearwater, FL 33757-8812 18-247-10 (11/18)

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

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

Subsequent Premium Payments (choose one)

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

4th Wednesday of the Month

Note: If one of the dates above falls on a weekend or holiday, deduction will be on prior business day. Other, please specify a day of the month from 1 to 28 ___________ (Note: if this date falls on a weekend or holiday,

deduction will be on next business day that falls between the 1st and 28th)

Part II – Select one of the following payment options Checking Savings Branch/Bank Name: __________________________________________________________

Routing Number

Account Number

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

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

Bank Draft Authorization for Medicare Supplement 18-247-10 (11/18)

Home Office: Dallas, Texas • Medicare Supplement Administrative Office: PO Box 10812, Clearwater, FL 33757-8812 GAA8394-MS (01/17) Leave with Applicant

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

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

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

Important Consumer Notices GAA8394-MS (01/17)

Home Office: Dallas, Texas • Medicare Supplement Administrative Office: PO Box 10812, Clearwater, FL 33757-8812 GAA8564 Leave with Applicant

The following are definitions of the categories of individuals who are eligible for Guaranteed Issue under the Balanced Budget Act of 1997: Enrolled under an employee welfare benefit plan that provides health benefits that supplement the benefits under Medicare; and

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

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

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

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

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

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

Documentation of these events must be submitted with the Application.

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

Disclosure Guaranteed Issue Eligibility GAA8564

Home Office: Dallas, Texas • Medicare Supplement Administrative Office: PO Box 10812, Clearwater, FL 33757-8812 GOH8552 Complete and Submit with Application For Use in Ohio

Ohio Solicitation Form GOH8552

I, The Insurance Agent or Broker Certify: That, I am an insurance agent or broker.

That, I am making the solicitation or sale on behalf of Great Southern Life Insurance Company.

That, I have no connection or affiliation with, and are not in any way sponsored by, the federal or state government, the social security administration, the Centers for Medicare and Medicaid services, or the Department of Health and Human Services.

Agent Name Agent Phone No.

Address of Agent

Name of Agency Phone Number

Address of Agency

I, The Applicant, understand that I have the right to: Verify the information above by contacting the Ohio Department of Insurance:

Ohio Department of Insurance 50 W. Town Street, 3rd Floor-Suite 300 Columbus, OH 43215

Contact the agent or broker making the solicitation or sale at both an address and telephone number provided by the agent or broker;

Contact the insurance company, insurance companies or the insurance company administrative office on behalf of which the solicitation or sale was made at an address and telephone number provided by the agent or broker;

Pay my premium(s) directly to the insurance company's designated administrator, if I purchase a Medicare supplemental insurance policy.

Great Southern Life Insurance Company Medicare Supplement Administrative Office PO Box 10812, Clearwater, FL 33757-8812

I, The Applicant, acknowledge the receipt of this form.

__________________________________________________ Applicant’s Signature

Home Office: Dallas, Texas • Medicare Supplement Administrative Office: PO Box 10812, Clearwater, FL 33757-8812 GOH8552 Complete and Leave with Applicant For Use in Ohio

Ohio Solicitation Form GOH8552

I, The Insurance Agent or Broker Certify: That, I am an insurance agent or broker.

That, I am making the solicitation or sale on behalf of Great Southern Life Insurance Company.

That, I have no connection or affiliation with, and are not in any way sponsored by, the federal or state government, the social security administration, the Centers for Medicare and Medicaid services, or the Department of Health and Human Services.

Agent Name Agent Phone No.

Address of Agent

Name of Agency Phone Number

Address of Agency

I, The Applicant, understand that I have the right to: Verify the information above by contacting the Ohio Department of Insurance:

Ohio Department of Insurance 50 W. Town Street, 3rd Floor-Suite 300 Columbus, OH 43215

Contact the agent or broker making the solicitation or sale at both an address and telephone number provided by the agent or broker;

Contact the insurance company, insurance companies or the insurance company administrative office on behalf of which the solicitation or sale was made at an address and telephone number provided by the agent or broker;

Pay my premium(s) directly to the insurance company's designated administrator, if I purchase a Medicare supplemental insurance policy.

Great Southern Life Insurance Company Medicare Supplement Administrative Office PO Box 10812, Clearwater, FL 33757-8812

I, The Applicant, acknowledge the receipt of this form.

__________________________________________________ Applicant’s Signature

Home Office: Dallas, Texas • Medicare Supplement Administrative Office: PO Box 10812, Clearwater, FL 33757-8812 GAA5510-AS

All questions must be completed

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

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

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

Name:________________________________________________ Relationship to Applicant:___________________________________

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

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

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

If Yes, provide relationship:____________________________________________________ Replacement Information

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

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

Print Producer’s Name Producer’s Signature

Agent Number

% Commission

Split X

X

Producer Statement GAA5510-AS

Home Office: Dallas, Texas • Medicare Supplement Administrative Office: PO Box 10812, Clearwater, FL 33757-8812 18-247-9-BB For Agent Use Only

Medicare Supplement Premium Worksheet 18-247-9-BB

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

Applicant 1 Applicant 2

Premium Calculation Example Information shown below

is for calculation purposes only.

1. Medicare Supplement Insurance Plan Plan F

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

3. Applicant’s ZIP Code 07104

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

$196.78

5. Rate Adjustment If the applicant is in open enrollment or guaranteed issue period, skip to Step 6. Locate height and weight on the next page.

If weight is in the Standard column, enter the amount from Step 4.

If weight is in the Class I column, multiply the amount from Step 4 by: 1.15.

$196.78 X 1.15 = $226.30

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

6. Payment Options The monthly payment is the last premium entered (Step 4 or 5). To determine annual premium, multiply by 12.

$226.30 monthly payment $2,715.60 annual payment

Home Office: Dallas, Texas • Medicare Supplement Administrative Office: PO Box 10812, Clearwater, FL 33757-8812 18-247-9-BB For Agent Use Only

Medicare Supplement Premium Worksheet 18-247-9-BB

Eligibility: Find the applicant’s height in the left-hand column and look across the row to find the applicant’s weight. If the weight is in the Decline column, the applicant is not eligible for coverage at this time. Rate Adjustment: The column heading above the applicant’s weight will indicate your appropriate rate adjustment, if any (risk class).

Decline Class I Standard Class I Decline

Height Weight Weight Weight Weight Weight 4' 6'' < 63 63 – 70 71 – 128 129 – 170 171 + 4' 7'' < 65 65 – 73 74 – 133 134 – 176 177 + 4' 8'' < 67 67 – 75 76 – 138 139 – 182 183 + 4' 9'' < 70 70 – 78 79 – 143 144 – 189 190 +

4' 10'' < 72 72 – 81 82 – 148 149 – 196 197 + 4' 11'' < 75 75 – 84 85 – 153 154 – 202 203 + 5' 0'' < 77 77 – 87 88 – 158 159 – 209 210 + 5' 1'' < 80 80 – 89 90 – 164 165 – 216 217 + 5' 2'' < 83 83 – 92 93 – 169 170 – 224 225 + 5' 3'' < 85 85 – 95 96 – 175 176 – 231 232 + 5' 4'' < 88 88 – 99 100 – 180 181 – 238 239 + 5' 5'' < 91 91 – 102 103 – 186 187 – 246 247 + 5' 6'' < 93 93 – 105 106 – 192 193 – 254 255 + 5' 7'' < 96 96 – 108 109 – 197 198 – 261 262 + 5' 8'' < 99 99 – 111 112 – 203 204 – 269 270 + 5' 9'' < 102 102 – 115 116 – 209 210 – 277 278 +

5' 10'' < 105 105 – 118 119 – 216 217 – 285 286 + 5' 11'' < 108 108 – 121 122 – 222 223 – 293 294 + 6' 0'' < 111 111 – 125 126 – 228 229 – 302 303 + 6' 1'' < 114 114 – 128 129 – 234 235 – 310 311 + 6' 2'' < 117 117 – 132 133 – 241 242 – 319 320 + 6' 3'' < 121 121 – 136 137 – 248 249 – 328 329 + 6' 4'' < 124 124 – 139 140 – 254 255 – 336 337 + 6' 5'' < 127 127 – 143 144 – 261 262 – 345 346 + 6' 6'' < 130 130 – 147 148 – 268 269 – 354 355 + 6' 7'' < 134 134 – 150 151 – 275 276 – 363 364 + 6' 8'' < 137 137 – 154 155 – 282 283 – 373 374 + 6' 9'' < 140 140 – 158 159 – 289 290 – 382 383 +

6' 10'' < 144 144 – 162 163 – 296 297 – 392 393 + 6' 11'' < 147 147 – 166 167 – 303 304 – 401 402 + 7' 0'' < 151 151 – 170 171 – 311 312 – 411 412 + 7' 1'' < 155 155 – 174 175 – 318 319 – 421 422 + 7' 2'' < 158 158 – 178 179 – 326 327 – 431 432 + 7' 3'' < 162 162 – 183 184 – 333 334 – 441 442 + 7' 4'' < 166 166 – 187 188 – 341 342 – 451 452 +

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7.55

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7.53

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026

5.65

9822

9.34

263.7

478

.8590

.6831

8.58

366.3

626

6.09

306.0

023

4.46

269.6

399

232.7

826

7.69

79.40

91.31

323.3

637

1.86

270.0

831

0.59

237.9

827

3.68

2 of 2

0

For A

nnua

l Pre

mium

mod

e, mu

ltiply

month

ly ra

tes by

12. F

or C

lass 1

rates

mult

iply b

y 1.15

. GO

H500

-OC

Effec

tive:

06/01

/2019

RATE

S

Mont

hly R

ates

by P

lan –

Ohio

Zi

p Co

des:

All Z

ip C

odes

that

star

t with

430-

435,

437-

439,

446-

449,

455-

459

Toba

cco

Rate

s At

tain

ed

Age

Plan

AHD

Plan

FPl

an F

Plan

GPl

an N

Fem

aleMa

leFe

male

Male

Fem

aleMa

leFe

male

Male

Fem

aleMa

le65

123.8

714

2.45

42.49

48.86

147.4

916

9.62

117.4

113

5.02

99.96

114.9

566

123.8

714

2.45

42.49

48.86

147.4

916

9.62

117.4

113

5.02

99.96

114.9

567

123.8

714

2.45

42.49

48.86

147.4

916

9.62

117.4

113

5.02

99.96

114.9

568

123.8

714

2.45

42.49

48.86

147.4

916

9.62

117.4

113

5.02

99.96

114.9

569

126.2

614

5.20

43.86

50.43

150.1

317

2.65

120.0

713

8.08

102.0

711

7.38

7013

0.97

150.6

246

.0152

.9115

5.34

178.6

412

4.73

143.4

410

5.95

121.8

471

134.8

915

5.13

47.64

54.79

160.3

618

4.42

129.2

314

8.61

109.8

112

6.28

7213

8.81

159.6

349

.2756

.6716

5.38

190.1

913

3.72

153.7

811

3.68

130.7

373

143.1

616

4.63

51.06

58.72

170.9

119

6.55

138.6

315

9.43

117.8

913

5.58

7414

7.53

169.6

652

.8660

.7817

6.47

202.9

414

3.57

165.1

112

2.13

140.4

575

153.1

417

6.11

54.93

63.17

183.5

221

1.05

149.7

217

2.18

127.4

114

6.52

7615

7.17

180.7

556

.6365

.1218

9.57

218.0

015

4.95

178.1

913

2.05

151.8

677

161.2

918

5.48

58.35

67.10

195.7

422

5.11

160.2

918

4.33

136.8

015

7.32

7816

5.65

190.4

960

.0969

.1020

2.25

232.5

816

5.90

190.7

814

1.79

163.0

679

170.2

619

5.80

61.86

71.14

209.1

024

0.47

171.8

119

7.58

147.0

316

9.09

8017

4.98

201.2

363

.6573

.2021

6.11

248.5

317

7.86

204.5

415

2.40

175.2

681

180.3

720

7.42

65.48

75.30

224.7

825

8.49

185.2

721

3.06

159.1

418

3.01

8218

5.91

213.7

967

.3377

.4423

3.71

268.7

719

2.92

221.8

616

6.10

191.0

183

191.4

122

0.12

69.22

79.60

242.7

027

9.10

200.6

223

0.72

173.1

119

9.08

8419

7.07

226.6

371

.1281

.7925

1.96

289.7

520

8.56

239.8

518

0.35

207.4

085

202.8

823

3.31

72.98

83.93

261.5

030

0.73

216.7

524

9.26

187.8

221

5.99

8620

8.00

239.2

074

.5785

.7527

0.14

310.6

622

4.12

257.7

419

4.55

223.7

387

213.2

524

5.24

76.16

87.59

279.0

232

0.87

231.7

026

6.45

201.4

823

1.70

8821

8.63

251.4

377

.7889

.4528

8.16

331.3

823

9.50

275.4

220

8.61

239.9

189

224.1

425

7.76

79.42

91.33

297.5

534

2.19

247.5

328

4.66

215.9

624

8.36

9022

9.79

264.2

681

.0893

.2430

7.22

353.3

025

5.78

294.1

522

3.52

257.0

591

234.8

527

0.07

82.59

94.97

316.4

436

3.91

263.6

330

3.18

230.7

826

5.40

9223

9.07

274.9

384

.1196

.7332

4.63

373.3

327

0.64

311.2

323

7.31

272.9

193

243.3

827

9.88

85.66

98.51

333.0

238

2.97

277.8

031

9.47

244.0

028

0.60

9424

7.76

284.9

287

.2210

0.30

341.5

939

2.83

285.1

332

7.90

250.8

428

8.47

9525

2.21

290.0

588

.8010

2.12

350.3

640

2.91

292.6

333

6.53

257.8

529

6.53

9625

6.00

294.4

089

.4210

2.83

355.6

140

8.96

297.0

234

1.58

261.7

230

0.98

9725

9.84

298.8

190

.0510

3.55

360.9

541

5.09

301.4

834

6.70

265.6

530

5.49

9826

3.74

303.3

090

.6810

4.28

366.3

642

1.32

306.0

035

1.90

269.6

331

0.08

9926

7.69

307.8

591

.3110

5.01

371.8

642

7.64

310.5

935

7.18

273.6

831

4.73

3 of 2

0

For A

nnua

l Pre

mium

mod

e, mu

ltiply

month

ly ra

tes by

12. F

or C

lass 1

rates

mult

iply b

y 1.15

. GO

H500

-OC

Effec

tive:

06/01

/2019

RATE

S

Mont

hly R

ates

by P

lan –

Ohio

Zi

p Co

des:

All Z

ip C

odes

that

star

t with

436,

440-

445

Non-

Toba

cco

Rate

s At

tain

ed

Age

Plan

AHD

Plan

FPl

an F

Plan

GPl

an N

Fem

aleMa

leFe

male

Male

Fem

aleMa

leFe

male

Male

Fem

aleMa

le65

120.3

213

8.36

41.27

47.46

143.2

616

4.75

114.0

413

1.15

97.09

111.6

566

120.3

213

8.36

41.27

47.46

143.2

616

4.75

114.0

413

1.15

97.09

111.6

567

120.3

213

8.36

41.27

47.46

143.2

616

4.75

114.0

413

1.15

97.09

111.6

568

120.3

213

8.36

41.27

47.46

143.2

616

4.75

114.0

413

1.15

97.09

111.6

569

122.6

414

1.04

42.60

48.99

145.8

316

7.70

116.6

313

4.12

99.14

114.0

170

127.2

214

6.30

44.69

51.39

150.8

917

3.52

121.1

613

9.33

102.9

111

8.34

7113

1.02

150.6

846

.2753

.2215

5.76

179.1

312

5.52

144.3

510

6.66

122.6

672

134.8

315

5.05

47.86

55.04

160.6

418

4.73

129.8

914

9.37

110.4

212

6.98

7313

9.05

159.9

149

.6057

.0316

6.01

190.9

113

4.66

154.8

611

4.51

131.6

974

143.3

016

4.79

51.34

59.04

171.4

119

7.12

139.4

516

0.37

118.6

313

6.43

7514

8.75

171.0

653

.3661

.3617

8.26

204.9

914

5.43

167.2

412

3.75

142.3

276

152.6

717

5.57

55.01

63.26

184.1

321

1.75

150.5

017

3.08

128.2

714

7.51

7715

6.66

180.1

656

.6865

.1819

0.13

218.6

515

5.69

179.0

413

2.88

152.8

178

160.9

018

5.03

58.37

67.12

196.4

522

5.91

161.1

418

5.31

137.7

215

8.38

7916

5.38

190.1

960

.0869

.1020

3.10

233.5

716

6.88

191.9

114

2.82

164.2

480

169.9

719

5.46

61.82

71.10

209.9

224

1.40

172.7

619

8.67

148.0

317

0.24

8117

5.20

201.4

863

.6073

.1421

8.33

251.0

817

9.96

206.9

515

4.57

177.7

682

180.5

820

7.66

65.40

75.21

227.0

126

1.06

187.3

921

5.50

161.3

318

5.53

8318

5.92

213.8

167

.2377

.3223

5.74

271.1

019

4.87

224.1

016

8.15

193.3

784

191.4

222

0.13

69.08

79.45

244.7

328

1.44

202.5

823

2.97

175.1

820

1.46

8519

7.06

226.6

270

.8981

.5225

4.00

292.1

021

0.54

242.1

118

2.43

209.7

986

202.0

423

2.34

72.43

83.29

262.3

930

1.75

217.6

925

0.34

188.9

721

7.31

8720

7.14

238.2

173

.9885

.0827

1.02

311.6

722

5.05

258.8

119

5.70

225.0

588

212.3

624

4.22

75.55

86.89

279.8

932

1.88

232.6

326

7.53

202.6

323

3.03

8921

7.71

250.3

777

.1488

.7128

9.02

332.3

724

0.43

276.4

920

9.77

241.2

390

223.2

025

6.68

78.75

90.56

298.4

134

3.17

248.4

528

5.72

217.1

224

9.68

9122

8.11

262.3

380

.2292

.2530

7.37

353.4

725

6.07

294.4

922

4.16

257.7

992

232.2

226

7.05

81.70

93.96

315.3

336

2.62

262.8

830

2.31

230.5

126

5.08

9323

6.40

271.8

683

.2095

.6832

3.47

371.9

926

9.84

310.3

123

7.00

272.5

594

240.6

527

6.75

84.72

97.43

331.8

038

1.56

276.9

631

8.50

243.6

528

0.20

9524

4.98

281.7

386

.2599

.1934

0.31

391.3

628

4.24

326.8

825

0.46

288.0

396

248.6

628

5.96

86.86

99.88

345.4

239

7.23

288.5

033

1.78

254.2

129

2.35

9725

2.39

290.2

487

.4610

0.58

350.6

040

3.19

292.8

333

6.76

258.0

329

6.73

9825

6.17

294.6

088

.0810

1.29

355.8

640

9.24

297.2

234

1.81

261.9

030

1.18

9926

0.02

299.0

288

.6910

2.00

361.2

041

5.37

301.6

834

6.94

265.8

330

5.70

4 of 2

0

For A

nnua

l Pre

mium

mod

e, mu

ltiply

month

ly ra

tes by

12. F

or C

lass 1

rates

mult

iply b

y 1.15

. GO

H500

-OC

Effec

tive:

06/01

/2019

RATE

S

Mont

hly R

ates

by P

lan –

Ohio

Zi

p Co

des:

All Z

ip C

odes

that

star

t with

436,

440-

445

Toba

cco

Rate

s At

tain

ed

Age

Plan

AHD

Plan

FPl

an F

Plan

GPl

an N

Fem

aleMa

leFe

male

Male

Fem

aleMa

leFe

male

Male

Fem

aleMa

le65

138.3

615

9.12

47.46

54.58

164.7

518

9.47

131.1

515

0.82

111.6

512

8.40

6613

8.36

159.1

247

.4654

.5816

4.75

189.4

713

1.15

150.8

211

1.65

128.4

067

138.3

615

9.12

47.46

54.58

164.7

518

9.47

131.1

515

0.82

111.6

512

8.40

6813

8.36

159.1

247

.4654

.5816

4.75

189.4

713

1.15

150.8

211

1.65

128.4

069

141.0

416

2.19

48.99

56.34

167.7

019

2.86

134.1

215

4.24

114.0

113

1.11

7014

6.30

168.2

551

.3959

.1017

3.52

199.5

513

9.33

160.2

311

8.34

136.1

071

150.6

817

3.28

53.22

61.20

179.1

320

6.00

144.3

516

6.00

122.6

614

1.06

7215

5.05

178.3

155

.0463

.3018

4.73

212.4

414

9.37

171.7

812

6.98

146.0

273

159.9

118

3.90

57.03

65.59

190.9

121

9.55

154.8

617

8.08

131.6

915

1.44

7416

4.79

189.5

159

.0467

.9019

7.12

226.6

916

0.37

184.4

313

6.43

156.8

975

171.0

619

6.72

61.36

70.57

204.9

923

5.74

167.2

419

2.33

142.3

216

3.67

7617

5.57

201.9

063

.2672

.7421

1.75

243.5

117

3.08

199.0

414

7.51

169.6

377

180.1

620

7.19

65.18

74.95

218.6

525

1.45

179.0

420

5.90

152.8

117

5.73

7818

5.03

212.7

967

.1277

.1922

5.91

259.8

018

5.31

213.1

115

8.38

182.1

479

190.1

921

8.72

69.10

79.46

233.5

726

8.61

191.9

122

0.70

164.2

418

8.87

8019

5.46

224.7

871

.1081

.7624

1.40

277.6

119

8.67

228.4

717

0.24

195.7

781

201.4

823

1.70

73.14

84.11

251.0

828

8.74

206.9

523

7.99

177.7

620

4.42

8220

7.66

238.8

175

.2186

.5026

1.06

300.2

221

5.50

247.8

218

5.53

213.3

683

213.8

124

5.88

77.32

88.91

271.1

031

1.77

224.1

025

7.72

193.3

722

2.37

8422

0.13

253.1

579

.4591

.3628

1.44

323.6

623

2.97

267.9

220

1.46

231.6

785

226.6

226

0.61

81.52

93.75

292.1

033

5.92

242.1

127

8.43

209.7

924

1.26

8623

2.34

267.1

983

.2995

.7830

1.75

347.0

125

0.34

287.9

021

7.31

249.9

187

238.2

127

3.94

85.08

97.84

311.6

735

8.42

258.8

129

7.63

225.0

525

8.81

8824

4.22

280.8

586

.8999

.9232

1.88

370.1

626

7.53

307.6

523

3.03

267.9

889

250.3

728

7.93

88.71

102.0

233

2.37

382.2

327

6.49

317.9

724

1.23

277.4

290

256.6

829

5.18

90.56

104.1

534

3.17

394.6

528

5.72

328.5

724

9.68

287.1

391

262.3

330

1.68

92.25

106.0

935

3.47

406.4

929

4.49

338.6

625

7.79

296.4

692

267.0

530

7.11

93.96

108.0

536

2.62

417.0

230

2.31

347.6

526

5.08

304.8

593

271.8

631

2.63

95.68

110.0

337

1.99

427.7

931

0.31

356.8

627

2.55

313.4

494

276.7

531

8.26

97.43

112.0

438

1.56

438.8

031

8.50

366.2

728

0.20

322.2

395

281.7

332

3.99

99.19

114.0

739

1.36

450.0

632

6.88

375.9

128

8.03

331.2

396

285.9

632

8.85

99.88

114.8

739

7.23

456.8

133

1.78

381.5

529

2.35

336.2

097

290.2

433

3.78

100.5

811

5.67

403.1

946

3.67

336.7

638

7.27

296.7

334

1.24

9829

4.60

338.7

910

1.29

116.4

840

9.24

470.6

234

1.81

393.0

830

1.18

346.3

699

299.0

234

3.87

102.0

011

7.30

415.3

747

7.68

346.9

439

8.98

305.7

035

1.56

5 of 2

0

For A

nnua

l Pre

mium

mod

e, mu

ltiply

month

ly ra

tes by

12. F

or C

lass 1

rates

mult

iply b

y 1.15

. GO

H500

-OC

Effec

tive:

06/01

/2019

RATE

S

Mont

hly R

ates

by P

lan –

Ohio

Zi

p Co

des:

All Z

ip C

odes

that

star

t with

450-

454

Non-

Toba

cco

Rate

s At

tain

ed

Age

Plan

AHD

Plan

FPl

an F

Plan

GPl

an N

Fem

aleMa

leFe

male

Male

Fem

aleMa

leFe

male

Male

Fem

aleMa

le65

114.5

913

1.77

39.30

45.20

136.4

415

6.91

108.6

112

4.91

92.47

106.3

466

114.5

913

1.77

39.30

45.20

136.4

415

6.91

108.6

112

4.91

92.47

106.3

467

114.5

913

1.77

39.30

45.20

136.4

415

6.91

108.6

112

4.91

92.47

106.3

468

114.5

913

1.77

39.30

45.20

136.4

415

6.91

108.6

112

4.91

92.47

106.3

469

116.8

013

4.32

40.57

46.66

138.8

815

9.72

111.0

712

7.73

94.42

108.5

870

121.1

613

9.33

42.56

48.95

143.7

016

5.26

115.3

913

2.70

98.01

112.7

171

124.7

914

3.50

44.07

50.68

148.3

517

0.60

119.5

513

7.48

101.5

811

6.82

7212

8.41

147.6

745

.5852

.4215

2.99

175.9

412

3.70

142.2

610

5.16

120.9

373

132.4

315

2.30

47.23

54.32

158.1

018

1.82

128.2

414

7.48

109.0

612

5.42

7413

6.47

156.9

548

.9056

.2316

3.25

187.7

413

2.81

152.7

311

2.98

129.9

375

141.6

616

2.91

50.82

58.44

169.7

719

5.23

138.5

015

9.28

117.8

613

5.54

7614

5.40

167.2

152

.3960

.2417

5.36

201.6

714

3.34

164.8

412

2.16

140.4

877

149.2

017

1.58

53.98

62.07

181.0

820

8.24

148.2

717

0.52

126.5

514

5.53

7815

3.24

176.2

255

.5963

.9318

7.09

215.1

615

3.47

176.4

913

1.16

150.8

479

157.5

118

1.13

57.22

65.81

193.4

322

2.45

158.9

318

2.77

136.0

215

6.42

8016

1.87

186.1

558

.8867

.7119

9.92

229.9

116

4.53

189.2

114

0.98

162.1

381

166.8

519

1.88

60.57

69.66

207.9

323

9.12

171.3

919

7.09

147.2

116

9.30

8217

1.98

197.7

762

.2971

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6.20

248.6

317

8.47

205.2

315

3.65

176.7

083

177.0

720

3.63

64.03

73.63

224.5

125

8.19

185.5

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3.43

160.1

418

4.16

8418

2.30

209.6

565

.7975

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3.08

268.0

419

2.94

221.8

816

6.84

191.8

685

187.6

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5.83

67.51

77.64

241.9

127

8.19

200.5

123

0.59

173.7

419

9.80

8619

2.42

221.2

868

.9879

.3224

9.90

287.3

820

7.32

238.4

217

9.97

206.9

787

197.2

722

6.86

70.46

81.03

258.1

129

6.83

214.3

424

6.49

186.3

821

4.34

8820

2.25

232.5

971

.9582

.7526

6.56

306.5

522

1.55

254.7

919

2.98

221.9

389

207.3

523

8.45

73.47

84.49

275.2

631

6.55

228.9

826

3.33

199.7

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9.75

9021

2.57

244.4

675

.0086

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4.20

326.8

323

6.62

272.1

120

6.78

237.7

991

217.2

524

9.84

76.40

87.86

292.7

333

6.64

243.8

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213.4

924

5.51

9222

1.16

254.3

377

.8189

.4830

0.31

345.3

625

0.36

287.9

121

9.53

252.4

693

225.1

425

8.91

79.24

91.12

308.0

635

4.27

256.9

929

5.53

225.7

225

9.57

9422

9.19

263.5

780

.6892

.7931

6.00

363.3

926

3.77

303.3

323

2.05

266.8

695

233.3

226

8.31

82.14

94.47

324.1

137

2.72

270.7

131

1.31

238.5

327

4.31

9623

6.82

272.3

482

.7295

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8.97

378.3

127

4.77

315.9

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278.4

397

240.3

727

6.42

83.30

95.79

333.9

038

3.99

278.8

932

0.72

245.7

428

2.60

9824

3.97

280.5

783

.8896

.4633

8.91

389.7

528

3.07

325.5

324

9.43

286.8

499

247.6

328

4.78

84.47

97.14

344.0

039

5.59

287.3

233

0.41

253.1

729

1.14

6 of 2

0

For A

nnua

l Pre

mium

mod

e, mu

ltiply

month

ly ra

tes by

12. F

or C

lass 1

rates

mult

iply b

y 1.15

. GO

H500

-OC

Effec

tive:

06/01

/2019

RATE

S

Mont

hly R

ates

by P

lan –

Ohio

Zi

p Co

des:

All Z

ip C

odes

that

star

t with

450-

454

Toba

cco

Rate

s At

tain

ed

Age

Plan

AHD

Plan

FPl

an F

Plan

GPl

an N

Fem

aleMa

leFe

male

Male

Fem

aleMa

leFe

male

Male

Fem

aleMa

le65

131.7

715

1.54

45.20

51.98

156.9

118

0.44

124.9

114

3.64

106.3

412

2.29

6613

1.77

151.5

445

.2051

.9815

6.91

180.4

412

4.91

143.6

410

6.34

122.2

967

131.7

715

1.54

45.20

51.98

156.9

118

0.44

124.9

114

3.64

106.3

412

2.29

6813

1.77

151.5

445

.2051

.9815

6.91

180.4

412

4.91

143.6

410

6.34

122.2

969

134.3

215

4.47

46.66

53.65

159.7

218

3.67

127.7

314

6.89

108.5

812

4.87

7013

9.33

160.2

348

.9556

.2916

5.26

190.0

513

2.70

152.6

011

2.71

129.6

171

143.5

016

5.03

50.68

58.28

170.6

019

6.19

137.4

815

8.10

116.8

213

4.34

7214

7.67

169.8

252

.4260

.2817

5.94

202.3

314

2.26

163.6

012

0.93

139.0

773

152.3

017

5.14

54.32

62.47

181.8

220

9.09

147.4

816

9.60

125.4

214

4.23

7415

6.95

180.4

956

.2364

.6618

7.74

215.9

015

2.73

175.6

412

9.93

149.4

275

162.9

118

7.35

58.44

67.21

195.2

322

4.52

159.2

818

3.17

135.5

415

5.87

7616

7.21

192.2

960

.2469

.2820

1.67

231.9

216

4.84

189.5

614

0.48

161.5

677

171.5

819

7.32

62.07

71.38

208.2

423

9.47

170.5

219

6.09

145.5

316

7.36

7817

6.22

202.6

563

.9373

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5.16

247.4

317

6.49

202.9

615

0.84

173.4

679

181.1

320

8.30

65.81

75.68

222.4

525

5.81

182.7

721

0.19

156.4

217

9.88

8018

6.15

214.0

867

.7177

.8722

9.91

264.3

918

9.21

217.5

916

2.13

186.4

581

191.8

822

0.66

69.66

80.11

239.1

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4.99

197.0

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6.66

169.3

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4.69

8219

7.77

227.4

471

.6382

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8.63

285.9

320

5.23

236.0

217

6.70

203.2

083

203.6

323

4.17

73.63

84.68

258.1

929

6.92

213.4

324

5.44

184.1

621

1.79

8420

9.65

241.0

975

.6687

.0126

8.04

308.2

522

1.88

255.1

619

1.86

220.6

485

215.8

324

8.20

77.64

89.29

278.1

931

9.92

230.5

926

5.17

199.8

022

9.78

8622

1.28

254.4

779

.3291

.2228

7.38

330.4

923

8.42

274.1

920

6.97

238.0

187

226.8

626

0.89

81.03

93.18

296.8

334

1.35

246.4

928

3.46

214.3

424

6.49

8823

2.59

267.4

782

.7595

.1630

6.55

352.5

325

4.79

293.0

022

1.93

255.2

289

238.4

527

4.22

84.49

97.16

316.5

536

4.03

263.3

330

2.82

229.7

526

4.21

9024

4.46

281.1

286

.2599

.1932

6.83

375.8

527

2.11

312.9

323

7.79

273.4

691

249.8

428

7.31

87.86

101.0

433

6.64

387.1

328

0.46

322.5

324

5.51

282.3

492

254.3

329

2.48

89.48

102.9

034

5.36

397.1

628

7.91

331.1

025

2.46

290.3

393

258.9

129

7.75

91.12

104.7

935

4.27

407.4

129

5.53

339.8

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9.57

298.5

194

263.5

730

3.11

92.79

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3.39

417.9

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3.33

348.8

326

6.86

306.8

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268.3

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8.56

94.47

108.6

437

2.72

428.6

331

1.31

358.0

127

4.31

315.4

696

272.3

431

3.19

95.13

109.4

037

8.31

435.0

631

5.98

363.3

827

8.43

320.1

997

276.4

231

7.89

95.79

110.1

638

3.99

441.5

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0.72

368.8

328

2.60

324.9

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280.5

732

2.66

96.46

110.9

338

9.75

448.2

132

5.53

374.3

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6.84

329.8

799

284.7

832

7.50

97.14

111.7

139

5.59

454.9

333

0.41

379.9

829

1.14

334.8

1

7 of 2

0

GREA

T SO

UTHE

RN L

IFE

INSU

RANC

E CO

MPAN

Y Ou

tline

of C

over

age

Medi

care

Sup

plem

ent B

enef

it Pl

ans A

, F, H

igh

Dedu

ctib

le F,

G, a

nd N

.

GO

H50

0-O

C

Effe

ctiv

e: 0

6/01

/201

9

PREM

IUM

INFO

RMAT

ION.

Gr

eat S

outhe

rn Li

fe Ins

uran

ce C

ompa

ny ca

n only

raise

your

prem

ium if

we ra

ise th

e pre

mium

for a

ll poli

cies l

ike yo

urs i

n this

state

.

DISC

LOSU

RES.

Us

e this

outlin

e to c

ompa

re be

nefits

and p

remi

ums a

mong

polic

ies.

READ

YOU

R PO

LICY

VER

Y CA

REFU

LLY.

Th

is is

only

an o

utline

des

cribin

g yo

ur p

olicy

’s mo

st im

porta

nt fea

tures

. The

poli

cy is

your

insu

ranc

e co

ntrac

t. Yo

u mu

st re

ad th

e po

licy i

tself t

o un

derst

and

all o

f the

righ

ts an

d duti

es of

both

you a

nd us

.

RIGH

T TO

RET

URN

POLI

CY.

If you

find t

hat y

ou ar

e not

satis

fied w

ith yo

ur po

licy,

you m

ay re

turn i

t to us

at ou

r Med

icare

Sup

pleme

nt Ad

minis

trativ

e Offic

es: P

O Bo

x 108

12, C

learw

ater,

FL 33

757-

8812

. If y

ou se

nd th

e poli

cy ba

ck to

us w

ithin

30 da

ys af

ter yo

u rec

eive i

t, we w

ill tre

at the

polic

y as i

f it ha

d nev

er be

en is

sued

and r

eturn

all o

f you

r pay

ments

.

POLI

CY R

EPLA

CEME

NT.

If you

are r

eplac

ing an

other

healt

h ins

uran

ce po

licy,

do N

OT ca

ncel

it unti

l you

have

actua

lly re

ceive

d you

r new

polic

y and

are s

ure y

ou w

ant to

keep

it.

NOTI

CE.

The p

olicy

may

not fu

lly co

ver a

ll of y

our m

edica

l cos

ts.

Neith

er G

reat

South

ern L

ife In

sura

nce C

ompa

ny no

r our

agen

ts ar

e con

necte

d with

Med

icare

.

This

outlin

e doe

s not

give a

ll the

detai

ls of

Medic

are c

over

age.

Conta

ct yo

ur lo

cal S

ocial

Sec

urity

offic

e or c

onsu

lt “Me

dicar

e & Y

ou” f

or m

ore d

etails

.

COMP

LETE

ANS

WER

S AR

E VE

RY IM

PORT

ANT.

W

hen

you

fill o

ut the

app

licati

on fo

r the

new

poli

cy, b

e su

re to

ans

wer t

ruthf

ully a

nd co

mplet

ely a

ll que

stion

s abo

ut yo

ur m

edica

l and

hea

lth h

istor

y. W

e ma

y can

cel y

our

polic

y and

refus

e to p

ay an

y clai

ms if

you l

eave

out o

r fals

ify im

porta

nt me

dical

infor

matio

n.

Revie

w th

e app

licat

ion

care

fully

bef

ore y

ou si

gn it

. Be c

erta

in th

at al

l info

rmat

ion

has b

een

prop

erly

reco

rded

.

PLEA

SE R

EFER

TO

YOUR

POL

ICY

FOR

DETA

ILS.

8 of 2

0

GREA

T SO

UTHE

RN L

IFE

INSU

RANC

E CO

MPAN

Y Ou

tline

of C

over

age

Medi

care

Sup

plem

ent B

enef

it Pl

ans A

, F, H

igh

Dedu

ctib

le F,

G, a

nd N

.

GO

H50

0-O

C

Effe

ctiv

e: 0

6/01

/201

9 Pl

an A

PLAN

A

MEDI

CARE

PAR

T A

– HOS

PITA

L SE

RVIC

ES P

ER B

ENEF

IT P

ERIO

D *A

bene

fit pe

riod b

egins

on th

e firs

t day

you r

eceiv

e ser

vice a

s an i

npati

ent in

a ho

spita

l and

ends

after

you h

ave b

een o

ut of

the ho

spita

l and

have

not r

eceiv

ed sk

illed c

are

in an

y othe

r fac

ility f

or 60

days

in a

row.

Serv

ices

Medi

care

Pay

s Pl

an A

Pay

s Yo

u Pa

y HO

SPIT

ALIZ

ATIO

N*

Semi

priva

te ro

om an

d boa

rd, g

ener

al nu

rsing

and m

iscell

aneo

us

servi

ces a

nd su

pplie

s. Fir

st 60

days

Al

l but

$1,36

4 $0

$1

,364 P

art A

Ded

uctib

le 61

st thr

u 90th d

ay

All b

ut $3

41 a

day

$341

a da

y $0

91

st day

and a

fter

-W

hile u

sing 6

0 life

time r

eser

ve da

ys-

Once

lifeti

me re

serve

days

are u

sed

Ad

dition

al 36

5 day

s

Beyo

nd th

e add

itiona

l 365

days

All b

ut $6

82 a

day

$0

$0

$682

a da

y

100%

of M

edica

re E

ligibl

e Exp

ense

s $0

$0

$0**

All C

osts

SKIL

LED

NURS

ING

FACI

LITY

CAR

E*

You m

ust m

eet M

edica

re’s

requ

ireme

nts, in

cludin

g hav

ing be

en in

a ho

spita

l for a

t leas

t 3 da

ys an

d ente

red a

Med

icare

appr

oved

facil

ity

withi

n 30 d

ays a

fter le

aving

the h

ospit

al.

First

20 da

ys

21st t

hru 1

00th d

ays

101st d

ay an

d afte

r

All a

ppro

ved a

moun

ts Al

l but

$170

.50 a

day

$0

$0

$0

$0

$0

Up to

$170

.50 a

day

All C

osts

BLOO

D Fir

st 3 p

ints

Addit

ional

amou

nts

$0

100%

3 p

ints

$0

$0

$0

HOSP

ICE

CARE

Yo

u mus

t mee

t Med

icare

’s re

quire

ments

, inclu

ding a

docto

r’s

certif

icatio

n of te

rmina

l illne

ss.

All b

ut ve

ry lim

ited

copa

ymen

t/coin

sura

nce

for ou

tpatie

nt dr

ugs a

nd

inpati

ent r

espit

e car

e.

Medic

are c

opay

ment/

coins

uran

ce

$0

**NOT

ICE:

Whe

n you

r Med

icare

Par

t A ho

spita

l ben

efits

are e

xhau

sted,

the in

sure

r stan

ds in

the p

lace o

f Med

icare

and w

ill pa

y wha

tever

amou

nt Me

dicar

e wou

ld ha

ve

paid

for up

to an

addit

ional

365 d

ays a

s pro

vided

in th

e poli

cy’s

“Cor

e Ben

efits.

” Dur

ing th

is tim

e, the

hosp

ital is

proh

ibited

from

billin

g you

for t

he ba

lance

base

d on a

ny

differ

ence

betw

een i

ts bil

led ch

arge

s and

the a

moun

t Med

icare

wou

ld ha

ve pa

id.

9 of 2

0

GREA

T SO

UTHE

RN L

IFE

INSU

RANC

E CO

MPAN

Y Ou

tline

of C

over

age

Medi

care

Sup

plem

ent B

enef

it Pl

ans A

, F, H

igh

Dedu

ctib

le F,

G, a

nd N

.

GO

H50

0-O

C

Effe

ctiv

e: 0

6/01

/201

9 Pl

an A

PLAN

A

MEDI

CARE

PAR

T B

– MED

ICAL

SER

VICE

S PE

R CA

LEND

AR Y

EAR

*Onc

e you

have

been

bille

d $18

5 of M

edica

re E

ligibl

e Exp

ense

s for

cove

red s

ervic

es (w

hich a

re no

ted w

ith an

aster

isk),

your

Med

icare

Par

t B D

educ

tible

will h

ave b

een

met fo

r the

calen

dar y

ear.

Serv

ices

Medi

care

Pay

s Pl

an A

Pay

s Yo

u Pa

y ME

DICA

L EX

PENS

ES

In or

out o

f the h

ospit

al an

d outp

atien

t hos

pital

treatm

ent, s

uch a

s Phy

sician

’s se

rvice

s, inp

atien

t and

outpa

tient

medic

al an

d sur

gical

servi

ces a

nd su

pplie

s, ph

ysica

l and

spee

ch th

erap

y, dia

gnos

tic te

sts, d

urab

le me

dical

equip

ment

First

$185

of M

edica

re ap

prov

ed am

ounts

* Re

maind

er of

Med

icare

appr

oved

amou

nts

$0

Gene

rally

80%

$0

Ge

nera

lly 20

%

$185

Par

t B D

educ

tible

$0

PART

B E

XCES

S CH

ARGE

S (a

bove

Med

icare

appr

oved

amou

nts)

$0

$0

All c

osts

BLOO

D Fir

st 3 p

ints

Next

$185

of M

edica

re ap

prov

ed am

ounts

* Re

maind

er of

Med

icare

appr

oved

amou

nts

$0

$0

80%

All c

osts

$0

20%

$0

$185

Par

t B D

educ

tible

$0

CLIN

ICAL

LAB

ORAT

ORY

SERV

ICES

– Te

sts fo

r diag

nosti

c ser

vices

10

0%

$0

$0

PART

S A

& B

Serv

ices

Medi

care

Pay

s Pl

an A

Pay

s Yo

u Pa

y HO

ME H

EALT

H CA

RE

Medic

are A

ppro

ved S

ervic

es

-Med

ically

nece

ssar

y skil

led ca

re se

rvice

s and

med

ical s

uppli

es-D

urab

le me

dical

equip

ment.

-Firs

t $18

5 of M

edica

re ap

prov

ed am

ounts

*-R

emain

der o

f Med

icare

appr

oved

amou

nts

100%

$0

80%

$0

$0

20%

$0

$185

Par

t B D

educ

tible

$0

10 of

20

GREA

T SO

UTHE

RN L

IFE

INSU

RANC

E CO

MPAN

Y Ou

tline

of C

over

age

Medi

care

Sup

plem

ent B

enef

it Pl

ans A

, F, H

igh

Dedu

ctib

le F,

G, a

nd N

.

GO

H50

0-O

C

Effe

ctiv

e: 0

6/01

/201

9 Pl

an F

and

Hig

h D

educ

tible

Pla

n F

PLAN

F A

ND H

IGH

DEDU

CTIB

LE P

LAN

F ME

DICA

RE P

ART

A – H

OSPI

TAL

SERV

ICES

PER

BEN

EFIT

PER

IOD

*A be

nefit

perio

d beg

ins on

the f

irst d

ay yo

u rec

eive s

ervic

e as a

n inp

atien

t in a

hosp

ital a

nd en

ds af

ter yo

u hav

e bee

n out

of the

hosp

ital a

nd ha

ve no

t rec

eived

skille

d car

ein

any o

ther f

acilit

y for

60 da

ys in

a ro

w.**H

igh D

educ

tible

Plan

F pa

ys th

e sam

e ben

efits

as P

lan F

after

one h

as pa

id a c

alend

ar ye

ar $2

,300 d

educ

tible.

Ben

efits

from

High

Ded

uctib

le Pl

an F

will

not b

egin

until

out-o

f-poc

ket e

xpen

ses e

xcee

d $2,3

00. O

ut-of-

pock

et ex

pens

es fo

r this

dedu

ctible

are e

xpen

ses t

hat w

ould

ordin

arily

be pa

id by

the p

olicy

/certif

icate.

The

se ex

pens

es

includ

e the

Med

icare

dedu

ctible

s for

Pay

A an

d Par

t B, b

ut do

not in

clude

the p

lan’s

sepa

rate

Fore

ign T

rave

l Eme

rgen

cy de

ducti

ble.

Serv

ices

Medi

care

Pay

s Pl

an F

Pay

s Yo

u Pa

y

High

Ded

uctib

le Pl

an F

Pa

ys (a

fter y

ou p

ay

$2,30

0 Ded

uctib

le***

You

Pay

(In ad

ditio

n to

$2,30

0 De

duct

ible*

**)

Hosp

italiz

atio

n Se

mipr

ivate

room

and b

oard

, gen

eral

nursi

ng

and m

iscell

aneo

us se

rvice

s and

supp

lies.

First

60 da

ys

All b

ut $1

,364

$1,36

4 Par

t A

Dedu

ctible

$0

P

art A

Ded

uctib

le $0

61st t

hru 9

0th day

Al

l but

$341

a da

y $3

41 a

day

$0

a da

y $0

91

st day

and a

fter

-W

hile u

sing 6

0 life

time r

eser

ve da

ys-

Once

lifeti

me re

serve

days

are u

sed

Ad

dition

al 36

5 day

s

Be

yond

the a

dditio

nal

365 d

ays

All b

ut $6

82 a

day

$0

$0

$682

a da

y

100%

of M

edica

re

Eligi

ble E

xpen

ses

$0

$0

$0**

All C

osts

$682

a da

y

100%

of M

edica

re

Eligi

ble E

xpen

ses

$0

$0

$0**

All C

osts

Skille

d Nu

rsin

g Fa

cility

Car

e Yo

u mus

t mee

t Med

icare

’s re

quire

ments

, inc

luding

havin

g bee

n in a

hosp

ital fo

r at le

ast

3 day

s and

enter

ed a

Medic

are a

ppro

ved

facilit

y with

in 30

days

after

leav

ing th

e hos

pital.

Fir

st 20

days

21

st thr

u 100

th day

s

101st d

ay an

d afte

r

All a

ppro

ved a

moun

ts Al

l but

$170

.50 a

day

$0

$0

Up to

$170

.50 a

day

$0

$0

$0

All C

osts

$0

Up to

$170

.50 a

day

$0

$0

$0

All C

osts

11 of

20

GREA

T SO

UTHE

RN L

IFE

INSU

RANC

E CO

MPAN

Y Ou

tline

of C

over

age

Medi

care

Sup

plem

ent B

enef

it Pl

ans A

, F, H

igh

Dedu

ctib

le F,

G, a

nd N

.

GO

H50

0-O

C

Effe

ctiv

e: 0

6/01

/201

9 Pl

an F

and

Hig

h D

educ

tible

Pla

n F

PLAN

F A

ND H

IGH

DEDU

CTIB

LE P

LAN

F ME

DICA

RE P

ART

A – H

OSPI

TAL

SERV

ICES

PER

BEN

EFIT

PER

IOD

(CON

TINU

ED)

Serv

ices

Medi

care

Pay

s Pl

an F

Pay

s Yo

u Pa

y

High

Ded

uctib

le Pl

an F

Pa

ys (a

fter y

ou p

ay

$2,30

0 Ded

uctib

le***

You

Pay

(In ad

ditio

n to

$2,30

0 De

duct

ible*

**)

Bloo

d Fir

st 3 p

ints

Addit

ional

amou

nts

$0

100%

3 p

ints

$0

$0

$0

3 pint

s $0

$0

$0

Ho

spice

Car

e Yo

u mus

t mee

t Med

icare

’s re

quire

ments

, inc

luding

a do

ctor’s

certif

icatio

n of te

rmina

l illn

ess.

All b

ut ve

ry lim

ited

copa

ymen

t/coin

sura

nce f

or ou

tpatie

nt dr

ugs

and i

npati

ent r

espit

e ca

re.

Medic

are

copa

ymen

t/ co

insur

ance

$0

Medic

are c

opay

ment/

co

insur

ance

$0

**NOT

ICE:

Whe

n you

r Med

icare

Par

t A ho

spita

l ben

efits

are e

xhau

sted,

the in

sure

r stan

ds in

the p

lace o

f Med

icare

and w

ill pa

y wha

tever

amou

nt Me

dicar

e wou

ld ha

ve

paid

for up

to an

addit

ional

365 d

ays a

s pro

vided

in th

e poli

cy’s

“Cor

e Ben

efits.

” Dur

ing th

is tim

e, the

hosp

ital is

proh

ibited

from

billin

g you

for t

he ba

lance

base

d on a

ny

differ

ence

betw

een i

ts bil

led ch

arge

s and

the a

moun

t Med

icare

wou

ld ha

ve pa

id. **

*High

Ded

uctib

le Pl

an F

pays

the s

ame b

enefi

ts as

Plan

F af

ter on

e has

paid

a ca

lenda

r yea

r $2,3

00 de

ducti

ble. B

enefi

ts fro

m Hi

gh D

educ

tible

Plan

F w

ill no

t beg

in un

til ou

t-of-p

ocke

t exp

ense

s exc

eed $

2,300

. Out-

of–po

cket

expe

nses

for t

his

dedu

ctible

are e

xpen

ses t

hat w

ould

ordin

arily

be pa

id by

the p

olicy

/certif

icate.

The

se ex

pens

es in

clude

the M

edica

re de

ducti

bles f

or P

ay A

and P

art B

, but

do no

t inclu

de

the pl

an’s

sepa

rate

Fore

ign T

rave

l Eme

rgen

cy de

ducti

ble.

12 of

20

GREA

T SO

UTHE

RN L

IFE

INSU

RANC

E CO

MPAN

Y Ou

tline

of C

over

age

Medi

care

Sup

plem

ent B

enef

it Pl

ans A

, F, H

igh

Dedu

ctib

le F,

G, a

nd N

.

GO

H50

0-O

C

Effe

ctiv

e: 0

6/01

/201

9 Pl

an F

and

Hig

h D

educ

tible

Pla

n F

PLAN

F A

ND H

IGH

DEDU

CTIB

LE P

LAN

F ME

DICA

RE P

ART

B – M

EDIC

AL S

ERVI

CES

PER

CALE

NDAR

YEA

R *O

nce y

ou ha

ve be

en bi

lled $

185 o

f Med

icare

App

rove

d amo

unts

for co

vere

d ser

vices

(whic

h are

noted

with

an as

terisk

), yo

ur M

edica

re P

art B

Ded

uctib

le wi

ll hav

e bee

nme

t for t

he ca

lenda

r yea

r.**H

igh D

educ

tible

Plan

F pa

ys th

e sam

e ben

efits

as P

lan F

after

one h

as pa

id a c

alend

ar ye

ar $2

,300 d

educ

tible.

Ben

efits

from

High

Ded

uctib

le Pl

an F

will

not b

egin

until

out-o

f-poc

ket e

xpen

ses e

xcee

d $2,3

00. O

ut-of-

pock

et ex

pens

es fo

r this

dedu

ctible

are e

xpen

ses t

hat w

ould

ordin

arily

be pa

id by

the p

olicy

/certif

icate.

The

se ex

pens

es

includ

e the

Med

icare

dedu

ctible

s for

Pay

A an

d Par

t B, b

ut do

not in

clude

the p

lan’s

sepa

rate

Fore

ign T

rave

l Eme

rgen

cy de

ducti

ble.

Serv

ices

Medi

care

Pay

s Pl

an F

Pay

s Yo

u Pa

y

High

Ded

uctib

le Pl

an F

Pa

ys (a

fter y

ou p

ay

$2,30

0 Ded

uctib

le***

You

Pay

(In ad

ditio

n to

$2,30

0 De

duct

ible*

**)

Medi

cal E

xpen

ses

In or

out o

f the h

ospit

al an

d outp

atien

t hos

pital

treatm

ent, s

uch a

s Phy

sician

’s se

rvice

s, inp

atien

t an

d outp

atien

t med

ical a

nd su

rgica

l ser

vices

and

supp

lies,

phys

ical a

nd sp

eech

ther

apy,

diagn

ostic

tes

ts, du

rable

med

ical e

quipm

ent

First

$185

of M

edica

re ap

prov

ed am

ounts

* Re

maind

er of

Med

icare

appr

oved

amou

nts

$0

Gene

rally

80%

$1

85 P

art B

De

ducti

ble

Gene

rally

20%

$0

$0

$185

Par

t B

Dedu

ctible

Ge

nera

lly 20

%

$0

$0

Part

B Ex

cess

Cha

rges

(abo

ve M

edica

re

appr

oved

amou

nts)

$0

100%

$0

10

0%

$0

Bloo

d Fir

st 3 p

ints

Next

$185

of M

edica

re ap

prov

ed am

ounts

*

Rema

inder

of M

edica

re ap

prov

ed am

ounts

$0

$0

80%

All c

osts

$185

Par

t B

Dedu

ctible

20

%

$0

$0

$0

All c

osts

$185

Par

t B

Dedu

ctible

20

%

$0

$0

$0

Clin

ical L

abor

ator

y Ser

vices

– Te

sts fo

r Di

agno

stic s

ervic

es

100%

$0

$0

$0

$0

13 of

20

GREA

T SO

UTHE

RN L

IFE

INSU

RANC

E CO

MPAN

Y Ou

tline

of C

over

age

Medi

care

Sup

plem

ent B

enef

it Pl

ans A

, F, H

igh

Dedu

ctib

le F,

G, a

nd N

.

GO

H50

0-O

C

Effe

ctiv

e: 0

6/01

/201

9 Pl

an F

and

Hig

h D

educ

tible

Pla

n F

PLAN

F A

ND H

IGH

DEDU

CTIB

LE P

LAN

F PA

RTS

A &

B Se

rvice

s Me

dica

re

Pays

Pl

an F

Pay

s Yo

u Pa

y Hi

gh D

educ

tible

Plan

F

Pays

(afte

r you

pay

$2

,300 D

educ

tible*

**

You

Pay

(In ad

ditio

n to

$2,30

0 De

duct

ible*

**)

Hom

e Hea

lth C

are

Medic

are A

ppro

ved S

ervic

es

-Med

ically

nece

ssar

y skil

led ca

re se

rvice

s and

medic

al su

pplie

s-D

urab

le me

dical

equip

ment.

Firs

t $18

5 of

Medic

are a

ppro

ved a

moun

ts*

-Rem

ainde

r of M

edica

re ap

prov

ed am

ounts

100%

$0

80%

$0

$185

Par

t B

Dedu

ctible

20

%

$0

$0

$0

$0

$185

Par

t B

Dedu

ctible

20

%

$0

$0

$0

OTHE

R BE

NEFI

TS N

OT C

OVER

ED B

Y ME

DICA

RE

Serv

ices

Medi

care

Pa

ys

Plan

F P

ays

You

Pay

High

Ded

uctib

le Pl

an

F Pa

ys (a

fter y

ou p

ay

$2,30

0 Ded

uctib

le***

You

Pay

(In ad

ditio

n to

$2,30

0 De

duct

ible*

**)

Fore

ign

Trav

el

Medic

ally n

eces

sary

emer

genc

y car

e ser

vices

be

ginnin

g dur

ing th

e firs

t 60 d

ays o

f eac

h trip

ou

tside

the U

SA.

First

$250

each

calen

dar y

ear

Rema

inder

of ch

arge

s $0

$0

$0

80

% to

a life

time

maxim

um be

nefit

of $5

0,000

.

$250

20

% an

d amo

unts

over

the

$50,0

00 lif

etime

ma

ximum

.

$0

80%

to a

lifetim

e ma

ximum

bene

fit of

$50,0

00.

$250

20

% an

d amo

unts

over

the

$50,0

00 lif

etime

ma

ximum

.

14 of

20

GREA

T SO

UTHE

RN L

IFE

INSU

RANC

E CO

MPAN

Y Ou

tline

of C

over

age

Medi

care

Sup

plem

ent B

enef

it Pl

ans A

, F, H

igh

Dedu

ctib

le F,

G, a

nd N

.

GO

H50

0-O

C

Effe

ctiv

e: 0

6/01

/201

9 Pl

an G

PLAN

G

MEDI

CARE

PAR

T A

– HOS

PITA

L SE

RVIC

ES P

ER C

ALEN

DAR

YEAR

*A

bene

fit pe

riod b

egins

on th

e firs

t day

you r

eceiv

e ser

vice a

s an i

npati

ent in

a ho

spita

l and

ends

after

you h

ave b

een o

ut of

the ho

spita

l and

have

not r

eceiv

ed sk

illed

care

in an

y othe

r fac

ility f

or 60

days

in a

row.

Serv

ices

Medi

care

Pay

s Pl

an G

Pay

s Yo

u Pa

y HO

SPIT

ALIZ

ATIO

N*

Semi

priva

te ro

om an

d boa

rd, g

ener

al nu

rsing

and m

iscell

aneo

us

servi

ces a

nd su

pplie

s. Fir

st 60

days

Al

l but

$1,36

4 $1

,364 P

art A

Ded

uctib

le $0

61

st thr

u 90th d

ay

All b

ut $3

41 a

day

$341

a da

y $0

91

st day

and a

fter

-W

hile u

sing 6

0 life

time r

eser

ve da

ys-

Once

lifeti

me re

serve

days

are u

sed

Ad

dition

al 36

5 day

s

Beyo

nd th

e add

itiona

l 365

days

All b

ut $6

82 a

day

$0

$0

$682

a da

y

100%

of M

edica

re E

ligibl

e Exp

ense

s $0

$0

$0**

All C

osts

SKIL

LED

NURS

ING

FACI

LITY

CAR

E*

You m

ust m

eet M

edica

re’s

requ

ireme

nts, in

cludin

g hav

ing be

en in

a ho

spita

l for a

t leas

t 3 da

ys an

d ente

red a

Med

icare

appr

oved

facil

ity

withi

n 30 d

ays a

fter le

aving

the h

ospit

al.

First

20 da

ys

21st t

hru 1

00 da

ys

101st d

ay an

d afte

r

All a

ppro

ved a

moun

ts Al

l but

$170

.50 a

day

$0

$0

Up to

$170

.50 a

day

$0

$0

$0

All C

osts

BLOO

D Fir

st 3 p

ints

Addit

ional

amou

nts

$0

100%

3 p

ints

$0

$0

$0

HOSP

ICE

CARE

Yo

u mus

t mee

t Med

icare

’s re

quire

ments

, inclu

ding a

docto

r’s

certif

icatio

n of te

rmina

l illne

ss.

All b

ut ve

ry lim

ited

copa

ymen

t/coin

sura

nce

for ou

tpatie

nt dr

ugs a

nd

inpati

ent r

espit

e car

e.

Medic

are c

opay

ment/

coins

uran

ce

$0

**NOT

ICE:

Whe

n you

r Med

icare

Par

t A ho

spita

l ben

efits

are e

xhau

sted,

the in

sure

r stan

ds in

the p

lace o

f Med

icare

and w

ill pa

y wha

tever

amou

nt Me

dicar

e wou

ld ha

ve

paid

for up

to an

addit

ional

365 d

ays a

s pro

vided

in th

e poli

cy’s

“Cor

e Ben

efits.

” Dur

ing th

is tim

e, the

hosp

ital is

proh

ibited

from

billin

g you

for t

he ba

lance

base

d on a

ny

differ

ence

betw

een i

ts bil

led ch

arge

s and

the a

moun

t Med

icare

wou

ld ha

ve pa

id. 15

of 20

GREA

T SO

UTHE

RN L

IFE

INSU

RANC

E CO

MPAN

Y Ou

tline

of C

over

age

Medi

care

Sup

plem

ent B

enef

it Pl

ans A

, F, H

igh

Dedu

ctib

le F,

G, a

nd N

.

GO

H50

0-O

C

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ctiv

e: 0

6/01

/201

9 Pl

an G

PLAN

G

MEDI

CARE

PAR

T B

– MED

ICAL

SER

VICE

S PE

R CA

LEND

AR Y

EAR

*Onc

e you

have

been

bille

d $18

5 of M

edica

re ap

prov

ed am

ounts

for c

over

ed se

rvice

s (wh

ich ar

e note

d with

an as

terisk

), yo

ur M

edica

re P

art B

Ded

uctib

le wi

ll hav

e bee

nme

t for t

he ca

lenda

r yea

r.Se

rvice

s Me

dica

re P

ays

Plan

G P

ays

You

Pay

MEDI

CAL

EXPE

NSES

In

or ou

t of th

e hos

pital

and o

utpati

ent h

ospit

al tre

atmen

t, suc

h as

Phys

ician

’s se

rvice

s, inp

atien

t and

outpa

tient

medic

al an

d sur

gical

servi

ces

and s

uppli

es, p

hysic

al an

d spe

ech t

hera

py, d

iagno

stic t

ests,

dura

ble

medic

al eq

uipme

nt Fir

st $1

85 of

Med

icare

appr

oved

amou

nts*

Rema

inder

of M

edica

re ap

prov

ed am

ounts

$0

Ge

nera

lly 80

%

$0

Gene

rally

20%

$1

85 P

art B

Ded

uctib

le $0

PA

RT B

EXC

ESS

CHAR

GES

(abo

ve M

edica

re ap

prov

ed am

ounts

) $0

10

0%

$0

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D Fir

st 3 p

ints

Next

$185

of M

edica

re ap

prov

ed am

ounts

* Re

maind

er of

Med

icare

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oved

amou

nts

$0

$0

80%

All c

osts

$0

20%

$0

$185

Par

t B D

educ

tible

$0

CLIN

ICAL

LAB

ORAT

ORY

SERV

ICES

– Te

sts fo

r Diag

nosti

c ser

vices

10

0%

$0

$0

PART

S A

& B

Serv

ices

Medi

care

Pay

s Pl

an G

Pay

s Yo

u Pa

y HO

ME H

EALT

H CA

RE

Medic

are A

ppro

ved S

ervic

es

-Med

ically

nece

ssar

y skil

led ca

re se

rvice

s and

med

ical s

uppli

es-D

urab

le me

dical

equip

ment.

Firs

t $18

5 of M

edica

re ap

prov

ed am

ounts

*-R

emain

der o

f Med

icare

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oved

amou

nts

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%

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Par

t B D

educ

tible

$0

16 of

20

GREA

T SO

UTHE

RN L

IFE

INSU

RANC

E CO

MPAN

Y Ou

tline

of C

over

age

Medi

care

Sup

plem

ent B

enef

it Pl

ans A

, F, H

igh

Dedu

ctib

le F,

G, a

nd N

.

GO

H50

0-O

C

Effe

ctiv

e: 0

6/01

/201

9 Pl

an G

PLAN

G

OTHE

R BE

NEFI

TS N

OT C

OVER

ED B

Y ME

DICA

RE

Serv

ices

Medi

care

Pay

s Pl

an G

Pay

s Yo

u Pa

y FO

REIG

N TR

AVEL

– NO

T CO

VERE

D BY

MED

ICAR

E Me

dicall

y nec

essa

ry em

erge

ncy c

are s

ervic

es be

ginnin

g dur

ing th

e firs

t 60

days

of ea

ch tr

ip ou

tside

the U

SA.

First

$250

each

calen

dar y

ear

Rema

inder

of C

harg

es

$0

$0

$0

80%

to a

lifetim

e max

imum

be

nefit

of $5

0,000

. $2

50

20%

and a

moun

ts ov

er th

e $5

0,000

lifeti

me m

axim

um.

17 of

20

GREA

T SO

UTHE

RN L

IFE

INSU

RANC

E CO

MPAN

Y Ou

tline

of C

over

age

Medi

care

Sup

plem

ent B

enef

it Pl

ans A

, F, H

igh

Dedu

ctib

le F,

G, a

nd N

.

GO

H50

0-O

C

Effe

ctiv

e: 0

6/01

/201

9 Pl

an N

PLAN

N

MEDI

CARE

PAR

T A

– HOS

PITA

L SE

RVIC

ES P

ER C

ALEN

DAR

YEAR

*A

bene

fit pe

riod b

egins

on th

e firs

t day

you r

eceiv

e ser

vice a

s an i

npati

ent in

a ho

spita

l and

ends

after

you h

ave b

een o

ut of

the ho

spita

l and

have

not r

eceiv

ed sk

illed c

are

in an

y othe

r fac

ility f

or 60

days

in a

row.

Serv

ices

Medi

care

Pay

s Pl

an N

Pay

s Yo

u Pa

y HO

SPIT

ALIZ

ATIO

N*

Semi

priva

te ro

om an

d boa

rd, g

ener

al nu

rsing

and m

iscell

aneo

us

servi

ces a

nd su

pplie

s. Fir

st 60

days

Al

l but

$1,36

4 $1

,364 P

art A

Ded

uctib

le $0

61

st thr

u 90th d

ay

All b

ut $3

41 a

day

$341

a da

y $0

91

st day

and a

fter

-W

hile u

sing 6

0 life

time r

eser

ve da

ys-

Once

lifeti

me re

serve

days

are u

sed

Ad

dition

al 36

5 day

s

Beyo

nd th

e add

itiona

l 365

days

All b

ut $6

82 a

day

$0

$0

$682

a da

y

100%

of M

edica

re E

ligibl

e Exp

ense

s $0

$0

$0**

All C

osts

SKIL

LED

NURS

ING

FACI

LITY

CAR

E*

You m

ust m

eet M

edica

re’s

requ

ireme

nts, in

cludin

g hav

ing be

en

in a h

ospit

al for

at le

ast 3

days

and e

ntere

d a M

edica

re ap

prov

ed

facilit

y with

in 30

days

after

leav

ing th

e hos

pital.

Fir

st 20

days

21

st thr

u 100

days

10

1st day

and a

fter

All a

ppro

ved a

moun

ts Al

l but

$170

.50 a

day

$0

$0

Up to

$170

.50 a

day

$0

$0

$0

All C

osts

BLOO

D Fir

st 3 p

ints

Addit

ional

amou

nts

$0

100%

3 p

ints

$0

$0

$0

HOSP

ICE

CARE

Yo

u mus

t mee

t Med

icare

’s re

quire

ments

, inclu

ding a

docto

r’s

certif

icatio

n of te

rmina

l illne

ss.

All b

ut ve

ry lim

ited

copa

ymen

t/coin

sura

nce f

or

outpa

tient

drug

s and

inp

atien

t res

pite c

are.

Medic

are c

opay

ment/

coins

uran

ce

$0

**NOT

ICE:

Whe

n you

r Med

icare

Par

t A ho

spita

l ben

efits

are e

xhau

sted,

the in

sure

r stan

ds in

the p

lace o

f Med

icare

and w

ill pa

y wha

tever

amou

nt Me

dicar

e wou

ld ha

ve

paid

for up

to an

addit

ional

365 d

ays a

s pro

vided

in th

e poli

cy’s

“Cor

e Ben

efits.

” Dur

ing th

is tim

e, the

hosp

ital is

proh

ibited

from

billin

g you

for t

he ba

lance

base

d on a

ny

differ

ence

betw

een i

ts bil

led ch

arge

s and

the a

moun

t Med

icare

wou

ld ha

ve pa

id. 18

of 20

GREA

T SO

UTHE

RN L

IFE

INSU

RANC

E CO

MPAN

Y Ou

tline

of C

over

age

Medi

care

Sup

plem

ent B

enef

it Pl

ans A

, F, H

igh

Dedu

ctib

le F,

G, a

nd N

.

GO

H50

0-O

C

Effe

ctiv

e: 0

6/01

/201

9 Pl

an N

PLAN

N

MEDI

CARE

PAR

T B

– MED

ICAL

SER

VICE

S PE

R CA

LEND

AR Y

EAR

Once

you h

ave b

een b

illed $

185 o

f Med

icare

App

rove

d amo

unts

for co

vere

d ser

vices

(whic

h are

noted

with

an as

terisk

), yo

ur M

edica

re P

art B

Ded

uctib

le wi

ll hav

e bee

n me

t for t

he ca

lenda

r yea

r.

Serv

ices

Medi

care

Pay

s Pl

an N

Pay

s Yo

u Pa

y ME

DICA

L EX

PENS

ES

In or

out o

f the h

ospit

al an

d outp

atien

t hos

pital

treatm

ent, s

uch a

s Phy

sician

’s se

rvice

s, inp

atien

t and

outpa

tient

medic

al an

d sur

gical

servi

ces a

nd su

pplie

s, ph

ysica

l and

spee

ch th

erap

y, dia

gnos

tic te

sts, d

urab

le me

dical

equip

ment

First

$185

of M

edica

re ap

prov

ed am

ounts

* Re

maind

er of

Med

icare

appr

oved

amou

nts

$0

Gene

rally

80%

$0

Ba

lance

, othe

r tha

n up t

o $20

pe

r offic

e visi

t and

up to

$50

per e

merg

ency

room

visit

. Th

e cop

ayme

nt of

up to

$50

is wa

ived i

f the i

nsur

ed is

ad

mitte

d to a

ny ho

spita

l and

the

emer

genc

y visi

t is

cove

red a

s a M

edica

re P

art

A ex

pens

e.

$185

Par

t B D

educ

tible

Up to

$20 p

er of

fice v

isit a

nd

up to

$50 p

er em

erge

ncy

room

visit

. The

copa

ymen

t of

up to

$50 i

s waiv

ed if

the

insur

ed is

admi

tted t

o any

ho

spita

l and

the e

merg

ency

vis

it is c

over

ed as

a Me

dicar

e Pa

rt A

expe

nse.

PART

B E

XCES

S CH

ARGE

S (a

bove

Med

icare

appr

oved

amou

nts)

$0

$0

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osts

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D Fir

st 3 p

ints

Next

$185

of M

edica

re ap

prov

ed am

ounts

* Re

maind

er of

Med

icare

appr

oved

amou

nts

$0

$0

80%

All c

osts

$0

20%

$0

$185

Par

t B D

educ

tible

$0

CLIN

ICAL

LAB

ORAT

ORY

SERV

ICES

– Te

sts fo

r diag

nosti

c ser

vices

10

0%

$0

$0

PART

S A

& B

Serv

ices

Medi

care

Pay

s Pl

an N

Pay

s Yo

u Pa

y HO

ME H

OSPI

CE C

ARE

Medic

are A

ppro

ved S

ervic

es

-Med

ically

nece

ssar

y skil

led ca

re se

rvice

s and

med

ical s

uppli

es-D

urab

le me

dical

equip

ment.

Firs

t $18

5 of M

edica

re ap

prov

ed am

ounts

-Rem

ainde

r of M

edica

re ap

prov

ed am

ounts

100%

$0

80

%

$0

$0

20%

$0

$185

Par

t B D

educ

tible

$0

19 of

20

GREA

T SO

UTHE

RN L

IFE

INSU

RANC

E CO

MPAN

Y Ou

tline

of C

over

age

Medi

care

Sup

plem

ent B

enef

it Pl

ans A

, F, H

igh

Dedu

ctib

le F,

G, a

nd N

.

GO

H50

0-O

C

Effe

ctiv

e: 0

6/01

/201

9

Plan

N

PLAN

N

OTHE

R BE

NEFI

TS N

OT C

OVER

ED B

Y ME

DICA

RE

Serv

ices

Medi

care

Pay

s Pl

an N

Pay

s Yo

u Pa

y FO

REIG

N TR

AVEL

– NO

T CO

VERE

D BY

MED

ICAR

E Me

dicall

y nec

essa

ry em

erge

ncy c

are s

ervic

es be

ginnin

g dur

ing th

e firs

t 60 d

ays

of ea

ch tr

ip ou

tside

the U

SA.

First

$250

each

calen

dar y

ear

Rema

inder

of ch

arge

s $0

$0

$0

80

% to

a life

time m

axim

um

bene

fit of

$50,0

00.

$25 0

20

% an

d amo

unts

over

the

$50,0

00 lif

etime

ma

ximum

.

20 of

20

great southern life medicare supplement · 1. you do not need more than one medicare supplement...

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