• Lifetime Inpatient Reserve Days - Medicare Part A This plan covers Part A Medicare-eligible expenses incurred for hospitalization to the extent not covered by Medicare for each Medicare lifetime inpatient reserve day used. • Hospice and Respite Care – Medicare Part A This plan covers cost-sharing for all Part A Medicare-eligible hospice care and respite care expenses. • Skilled Nursing Facility Care –Medicare Part A This plan covers the actual billed charges, up to the coinsurance amount, from the 21st day through the 100th day in a Medicare benefit period for post-hospital skilled nursing facility care eligible under Medicare Part A. • Blood Benefit - Medicare Parts A And B This plan covers the reasonable cost of the first 3 pints of blood (or equivalent quantities of packaged red blood cells, as defined under federal regulations) required under Medicare Parts A and B, unless replaced in accordance with federal regulations. • Medicare Part B Coinsurance After the Medicare Part B deductible is met in each calendar year, this plan covers the coinsurance amount of Medicare-eligible expenses under Part B (or the copayment amount, for hospital outpatient services paid under a prospective payment system), regardless of hospital confinement. Benefits For Expenses Not Covered By Medicare • Extended Inpatient Service Benefit - Medicare Part A Upon exhaustion of the Medicare hospital inpatient coverage, including the lifetime reserve days, coverage of 100 percent of the Medicare Part A eligible expenses for hospitalization paid at the applicable prospective payment system (PPS) rate or other appropriate Medicare standard of payment, subject to a lifetime maximum benefit of an additional 365 days. The provider must accept our payment as payment in full and may not bill you for any balance. • One Hundred Percent Of The Medicare Part B Excess Charges Coverage for all of the difference between the actual Medicare Part B charge as billed, not to exceed any charge limitation established by the Medicare program or state law, and the Medicare- approved Part B charge. • Medically Necessary Emergency Care In A Foreign Country Coverage to the extent not covered by Medicare for 80 percent of the billed charges for Medicare-eligible expenses for medically necessary emergency hospital, physician, and medical care received in a foreign country, when all of the following is true: • The care would have been covered by Medicare if provided in the United States • The care began during the first 60 consecutive days of each trip outside the United States This benefit is subject to a separate calendar year deductible of $250 and a lifetime maximum benefit of $50,000. For purposes of this benefit, "emergency care" shall 3 Group Plan G/Age