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mean care needed immediately because of an injury or an illness of sudden and unexpected onset. WHAT THIS PLAN DOES NOT COVER This plan will not provide benefits for: • Charges in excess of the Medicare-approved charge (see Definitions), except for Part B excess charges as stated in Benefits For Expenses Not Covered By Medicare above • Circumstances in which this plan’s payment would duplicate Medicare's payment • Services or supplies which are required as a result of war or an act of war • Services and supplies which are not specifically stated as covered under Benefits For Expenses Covered By Medicare and Benefits For Expenses Not Covered By Medicare above • Amounts that exceed the provider’s billed charge • Services and supplies which are excluded by Medicare, except as specifically stated under Benefits For Expenses Not Covered By Medicare above • Services or supplies which are received when this plan is not in effect, or when you are not covered under this plan, except as stated in Extended Benefits For Total Disability below. • Expenses for which claims are not filed within the time limits in Claim Filing Deadlines below. ELIGIBILITY To be covered under this plan, you must meet all the following requirements: • You must be younger than 65 and covered by both Medicare Part A and Medicare Part B. • You must not have coverage under another Medicare supplement plan or under a Medicare Advantage plan (either a group plan or an individual plan) unless you are planning to replace that coverage with this plan. • You must meet the Group's eligibility and enrollment requirements for coverage. (The Group should inform prospective subscribers of its eligibility and enrollment requirements.) If the Group's contract includes dependent coverage, a person who is eligible as a dependent is treated as a subscriber under this plan except when specifically stated otherwise. Please note that there are different eligibility and enrollment requirements for state residents and people who are enrolling in this Medicare Supplement plan through the Public Employees 5 Group Plan G/Dis

Plan G Certificate - Disability (2024) - Page 8 Plan G Certificate - Disability (2024) Page 7 Page 9