AMERICAN RETIREMENT LIFE INSURANCE COMPANY P. O. BOX 26580 ...

AMERICAN RETIREMENT LIFE INSURANCE COMPANY

P. O. BOX 26580 ? AUSTIN, TX 78755-0580 ? 866-459-4272

Outline of Medicare Supplement Coverage - Benefit Plans A, F, G and N

This chart shows the benefits included in each of the standard Medicare supplement plans. Every company must make Plan ¡°A¡± available. Some plans may not be

available in your state.

BASIC BENEFITS:

? Hospitalization: Part A coinsurance plus coverage for 365 additional days after Medicare benefits end.

? Medical Expenses: Part B coinsurance (generally 20% of Medicare-approved expenses) or co-payments for hospital outpatient services. Plans K, L and N

require insureds to pay a portion of Part B coinsurance or co-payments.

? Blood: First three pints of blood each year.

? Hospice: Part A coinsurance.

A

B

C

D

F

F*

G

K

L

M

N

Basic,

Basic,

Basic,

Basic,

Basic,

Basic,

Hospitalization Hospitalization Basic,

Basic, Including

Including

Including

Including

Including

Including 100% Including 100% and Preventive and Preventive Including

100% Part B

100%

100%

100%

100%

Part B

Part B

Coinsurance,

Care Paid at

Care Paid at

100%

Part B

Part B

Part B

Part B

Coinsurance*

Coinsurance

Except Up to

100%; Other

100%; Other

Part B

Coinsurance Coinsurance Coinsurance Coinsurance

Basic Benefits Basic Benefits Coinsurance $20 Copayment

for Office Visit,

paid at 50%

Paid at 75%

and up to $50

Copayment for

ER Visit

Skilled

Skilled

Skilled

Skilled

50% Skilled

75% Skilled

Skilled

Skilled Nursing

Nursing

Nursing

Nursing Facility Nursing Facility Nursing Facility Nursing Facility Nursing

Facility

Facility

Facility

Coinsurance

Coinsurance

Facility

Coinsurance

Coinsurance

Coinsurance

Coinsurance Coinsurance

Coinsurance

Part A

Part A

Part A

Part A

Part A

50% Part A

75% Part A

50% Part A

Part A

Deductible

Deductible

Deductible

Deductible

Deductible

Deductible

Deductible

Deductible

Deductible

Part B

Part B

Deductible

Deductible

Part B

Part B

Excess (100%) Excess (100%)

Foreign

Foreign

Foreign

Foreign

Foreign

Foreign

Travel

Travel

Travel

Travel

Travel

Travel

Emergency

Emergency

Emergency

Emergency

Emergency

Emergency

Out-of-Pocket

Out-of-Pocket

Limit $4,800;

Limit $2,400;

Paid at 100%

Paid At 100%

After Reached After Reached

* Plan F also has an option called a high deductible Plan F. This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,110 deductible.

Benefits from high deductible Plan F will not begin until out-of-pocket expenses exceed $2,110. Out-of-pocket expenses for this deductible are expenses that would ordinarily be

paid by the policy. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan¡¯s separate foreign travel emergency deductible.

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American Retirement Life Insurance Company

MEDICARE SUPPLEMENT

SOUTH DAKOTA

Attained Age Rates -- Effective 1/1/2013 -- Area I (570-577)

PREFERRED ANNUAL RATES

FEMALE RATES

Plan A

1,433.61

1,059.94

1,059.94

1,107.65

1,154.81

1,201.12

1,245.97

1,283.21

1,320.45

1,357.70

1,394.94

1,433.61

1,466.98

1,500.89

1,536.83

1,573.39

1,610.57

1,652.33

1,694.86

1,739.90

1,785.82

1,832.63

1,882.67

1,933.89

1,986.35

2,038.08

2,088.93

2,138.38

2,188.77

2,235.68

2,283.36

2,331.82

2,378.46

2,426.03

2,474.55

2,524.04

Plan F

1,776.12

1,306.19

1,306.19

1,363.10

1,417.45

1,473.06

1,524.74

1,574.67

1,624.58

1,674.50

1,724.43

1,776.12

1,829.56

1,883.88

1,941.03

1,999.21

2,058.43

2,131.29

2,205.61

2,283.65

2,363.36

2,444.75

2,530.61

2,618.77

2,709.28

2,799.45

2,889.05

2,980.97

3,074.80

3,164.28

3,255.38

3,348.09

3,415.05

3,483.35

3,553.02

3,624.08

Plan G

1,575.44

1,123.99

1,123.99

1,178.69

1,230.91

1,284.35

1,334.02

1,381.99

1,429.96

1,477.93

1,525.90

1,575.44

1,625.48

1,676.36

1,729.80

1,784.21

1,839.62

1,907.27

1,976.29

2,048.71

2,122.68

2,198.22

2,277.26

2,358.43

2,441.79

2,524.90

2,607.56

2,692.06

2,778.33

2,860.72

2,944.59

3,029.96

3,090.56

3,152.37

3,215.41

3,279.73

MALE RATES

Plan N

1,250.67

895.08

895.08

937.08

977.79

1,018.50

1,056.84

1,095.36

1,133.87

1,172.39

1,210.91

1,250.67

1,292.55

1,335.14

1,379.83

1,425.33

1,471.67

1,529.94

1,589.39

1,651.69

1,715.33

1,780.35

1,848.03

1,917.58

1,989.03

2,060.40

2,131.52

2,204.90

2,279.82

2,351.66

2,424.81

2,499.28

2,549.27

2,600.25

2,652.26

2,705.30

Attained

Age

Under 65

65

66

67

68

69

70

71

72

73

74

75

76

77

78

79

80

81

82

83

84

85

86

87

88

89

90

91

92

93

94

95

96

97

98

99

Plan A

1,648.65

1,218.93

1,218.93

1,273.80

1,328.02

1,381.29

1,432.86

1,475.69

1,518.52

1,561.35

1,604.18

1,648.65

1,687.03

1,726.01

1,767.36

1,809.40

1,852.16

1,900.18

1,949.09

2,000.89

2,053.69

2,107.53

2,165.06

2,223.97

2,284.31

2,343.79

2,402.27

2,459.14

2,517.08

2,571.04

2,625.87

2,681.60

2,735.23

2,789.93

2,845.73

2,902.64

Plan F

2,042.54

1,502.11

1,502.11

1,567.57

1,630.07

1,694.02

1,753.45

1,810.86

1,868.27

1,925.69

1,983.09

2,042.54

2,103.99

2,166.46

2,232.18

2,299.09

2,367.19

2,450.99

2,536.45

2,626.20

2,717.87

2,811.47

2,910.20

3,011.58

3,115.67

3,219.36

3,322.41

3,428.12

3,536.01

3,638.93

3,743.69

3,850.30

3,927.31

4,005.86

4,085.97

4,167.69

Plan G

1,811.76

1,292.59

1,292.59

1,355.49

1,415.55

1,477.00

1,534.11

1,589.28

1,644.45

1,699.61

1,754.78

1,811.76

1,869.30

1,927.81

1,989.27

2,051.85

2,115.56

2,193.36

2,272.73

2,356.02

2,441.08

2,527.96

2,618.85

2,712.20

2,808.05

2,903.63

2,998.69

3,095.87

3,195.08

3,289.83

3,386.28

3,484.45

3,554.14

3,625.23

3,697.73

3,771.68

Plan N

1,438.26

1,029.34

1,029.34

1,077.63

1,124.45

1,171.28

1,215.37

1,259.67

1,303.96

1,348.25

1,392.53

1,438.26

1,486.43

1,535.42

1,586.80

1,639.13

1,692.42

1,759.43

1,827.80

1,899.44

1,972.63

2,047.40

2,125.24

2,205.22

2,287.38

2,369.46

2,451.26

2,535.63

2,621.79

2,704.41

2,788.52

2,874.17

2,931.65

2,990.29

3,050.09

3,111.09

Policies may be issued on an annual, semi-annual, quarterly or monthly mode. To obtain semi-annual premiums, multiply

the above-quoted premium by 0.52, for quarterly premiums, multiply the above quoted premium by 0.265,

and for monthly bank draft premiums, multiply the above-quoted premium by 0.0833.

Add one-time enrollment fee of $20.00 to the first premium.

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American Retirement Life Insurance Company

MEDICARE SUPPLEMENT

SOUTH DAKOTA

Attained Age Rates -- Effective 1/1/2013 -- Area I (570-577)

STANDARD ANNUAL RATES

FEMALE RATES

Plan A

1,576.97

1,165.93

1,165.93

1,218.42

1,270.29

1,321.24

1,370.57

1,411.52

1,452.49

1,493.46

1,534.43

1,576.97

1,613.68

1,650.97

1,690.52

1,730.73

1,771.62

1,817.57

1,864.35

1,913.89

1,964.40

2,015.90

2,070.93

2,127.29

2,184.99

2,241.89

2,297.83

2,352.22

2,407.65

2,459.25

2,511.70

2,565.01

2,616.31

2,668.64

2,722.01

2,776.45

Plan F

1,953.74

1,436.81

1,436.81

1,499.41

1,559.20

1,620.37

1,677.21

1,732.13

1,787.04

1,841.96

1,896.87

1,953.74

2,012.51

2,072.27

2,135.13

2,199.12

2,264.27

2,344.42

2,426.17

2,512.02

2,599.70

2,689.23

2,783.67

2,880.64

2,980.21

3,079.40

3,177.96

3,279.07

3,382.27

3,480.71

3,580.91

3,682.90

3,756.56

3,831.69

3,908.32

3,986.49

Plan G

1,732.99

1,236.39

1,236.39

1,296.56

1,354.01

1,412.78

1,467.41

1,520.18

1,572.95

1,625.72

1,678.49

1,732.99

1,788.03

1,843.99

1,902.78

1,962.64

2,023.58

2,098.00

2,173.92

2,253.58

2,334.94

2,418.05

2,504.99

2,594.28

2,685.97

2,777.38

2,868.31

2,961.27

3,056.16

3,146.80

3,239.05

3,332.95

3,399.62

3,467.60

3,536.96

3,607.70

MALE RATES

Plan N

1,375.73

984.58

984.58

1,030.79

1,075.56

1,120.35

1,162.53

1,204.89

1,247.27

1,289.63

1,331.99

1,375.73

1,421.80

1,468.66

1,517.81

1,567.86

1,618.84

1,682.94

1,748.33

1,816.86

1,886.87

1,958.38

2,032.84

2,109.34

2,187.93

2,266.44

2,344.68

2,425.39

2,507.80

2,586.83

2,667.29

2,749.20

2,804.19

2,860.27

2,917.48

2,975.83

Attained

Age

Under 65

65

66

67

68

69

70

71

72

73

74

75

76

77

78

79

80

81

82

83

84

85

86

87

88

89

90

91

92

93

94

95

96

97

98

99

Plan A

1,813.52

1,340.83

1,340.83

1,401.18

1,460.83

1,519.43

1,576.14

1,623.26

1,670.37

1,717.48

1,764.59

1,813.52

1,855.74

1,898.61

1,944.09

1,990.34

2,037.37

2,090.20

2,144.01

2,200.98

2,259.06

2,318.28

2,381.56

2,446.37

2,512.74

2,578.17

2,642.50

2,705.06

2,768.80

2,828.14

2,888.46

2,949.76

3,008.75

3,068.93

3,130.31

3,192.91

Plan F

2,246.80

1,652.32

1,652.32

1,724.33

1,793.07

1,863.42

1,928.80

1,991.95

2,055.10

2,118.25

2,181.40

2,246.80

2,314.39

2,383.11

2,455.40

2,529.00

2,603.92

2,696.09

2,790.09

2,888.82

2,989.65

3,092.61

3,201.22

3,312.74

3,427.24

3,541.30

3,654.66

3,770.93

3,889.61

4,002.82

4,118.05

4,235.34

4,320.04

4,406.45

4,494.57

4,584.47

Plan G

1,992.94

1,421.85

1,421.85

1,491.04

1,557.10

1,624.71

1,687.53

1,748.21

1,808.89

1,869.58

1,930.27

1,992.94

2,056.23

2,120.59

2,188.20

2,257.03

2,327.11

2,412.70

2,500.00

2,591.61

2,685.19

2,780.76

2,880.74

2,983.42

3,088.86

3,193.99

3,298.56

3,405.47

3,514.58

3,618.81

3,724.90

3,832.89

3,909.56

3,987.75

4,067.50

4,148.85

Plan N

1,582.09

1,132.27

1,132.27

1,185.40

1,236.90

1,288.40

1,336.91

1,385.63

1,434.35

1,483.07

1,531.79

1,582.09

1,635.08

1,688.96

1,745.48

1,803.04

1,861.67

1,935.38

2,010.58

2,089.39

2,169.89

2,252.14

2,337.76

2,425.73

2,516.12

2,606.41

2,696.38

2,789.20

2,883.97

2,974.85

3,067.38

3,161.59

3,224.82

3,289.32

3,355.10

3,422.21

Policies may be issued on an annual, semi-annual, quarterly or monthly mode. To obtain semi-annual premiums, multiply

the above-quoted premium by 0.52, for quarterly premiums, multiply the above quoted premium by 0.265,

and for monthly bank draft premiums, multiply the above-quoted premium by 0.0833.

Add one-time enrollment fee of $20.00 to the first premium.

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Locate appropriate Area according to the applicant's ZIP Code in the ZIP Code chart below.

SOUTH DAKOTA ZIP CODES:

Area

3 Digit ZIP Codes

Area I

570-577

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01/13

PREMIUM INFORMATION

Your premium will increase each year because of the increase in your attained age. We, American Retirement Life Insurance

Company, can also raise your premium if (a) we change the rates which apply to all policies of this form issued by us and in-force in

your state; (b) coverage under Medicare changes; or (c) you move to a different ZIP Code location. We will send you a written notice at

least thirty (30) days in advance when we change the premium rates for all policies of this form issued by us and in-force in your state.

There will be a one-time enrollment fee of $20.00 added to the first premium.

DISCLOSURES

Use this Outline to compare benefits and premiums among policies.

READ YOUR POLICY VERY CAREFULLY

This is only an Outline describing your policy¡¯s most important features. The policy is your insurance contract. You must read the policy

itself to understand all of the rights and duties of both you and American Retirement Life Insurance Company.

30-DAY RIGHT TO RETURN POLICY

If you find that you are not satisfied with your policy, you may return it to American Retirement Life Insurance Company, P. O. Box

26580, Austin, TX 78755-0580. If you send the policy back to us within thirty (30) days after you receive it, we will treat the policy as if it

had never been issued and return all of your premiums.

POLICY REPLACEMENT

If you are replacing another health insurance policy, do NOT cancel it until you have actually received your new policy and are sure you

want to keep it.

NOTICE

This policy may not fully cover all of your medical costs. Neither American Retirement Life Insurance Company nor its agents are

connected with Medicare. This Outline of Coverage does not give all the details of Medicare coverage. Contact your local Social

Security Office or consult the Medicare and You for more details.

COMPLETE ANSWERS ARE VERY IMPORTANT

When you fill out the application for the new policy, be sure to answer truthfully and completely all questions about your medical and

health history. We may cancel your policy and refuse to pay any claims if you leave out or falsify important medical information.

Review the application carefully before you sign it. Be certain that all information has been properly recorded.

RENEWABILITY

This policy is guaranteed renewable for life.

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