LOYAL AMERICAN LIFE INSURANCE COMPANY

LOYAL AMERICAN LIFE INSURANCE COMPANY

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

Outline of Medicare Supplement Coverage - Benefit Plans A, C, 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 $20

100%; Other

100%; Other

Part B

Coinsurance Coinsurance Coinsurance Coinsurance

Basic Benefits Basic Benefits Coinsurance Copayment for

Office Visit, and

paid at 50%

Paid at 75%

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

Coinsurance

Coinsurance

Facility

Facility

Coinsurance

Coinsurance

Facility

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

Deductible

Foreign

Travel

Emergency

Foreign

Travel

Emergency

Part B

Deductible

Part B

Excess (100%)

Foreign

Travel

Emergency

Part B

Excess (100%)

Foreign

Travel

Emergency

Foreign

Travel

Emergency

Foreign

Travel

Emergency

Out-of-Pocket

Out-of-Pocket

Limit $4,940;

Limit $2,470;

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 $2,140 deductible.

Benefits from high deductible Plan F will not begin until out-of-pocket expenses exceed $2,140. 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.

LY-OC-AA-NJ

PAGE 1

01/14

Loyal American Life Insurance Company

MEDICARE SUPPLEMENT

NEW JERSEY

Attained Age Rates -- Effective 5/16/2013 -- Area I (070-089)

PREFERRED ANNUAL RATES

FEMALE RATES

Plan A

1,507.47

1,507.47

1,575.32

1,642.39

1,708.26

1,772.04

1,825.01

1,877.98

1,930.94

1,983.91

2,038.91

2,086.37

2,134.59

2,185.72

2,237.71

2,290.59

2,349.98

2,410.47

2,474.52

2,539.83

2,606.41

2,677.57

2,750.43

2,825.04

2,898.60

2,970.92

3,041.25

3,112.92

3,179.64

3,247.45

3,316.36

3,382.69

3,450.36

3,519.36

3,589.75

Plan C

2,229.23

2,229.23

2,229.23

2,326.36

2,419.11

2,514.02

2,602.23

2,687.43

2,772.62

2,857.82

2,943.02

3,031.25

3,122.44

3,215.16

3,312.69

3,411.98

3,513.05

3,637.40

3,764.24

3,897.43

4,033.46

4,172.38

4,318.91

4,469.36

4,623.84

4,777.73

4,930.65

5,087.52

5,247.65

5,400.38

5,555.85

5,714.07

5,828.35

5,944.92

6,063.82

6,185.10

MALE RATES

Plan F

Plan G

Plan N

1,857.69

1,857.69

1,938.64

2,015.92

2,095.01

2,168.52

2,239.53

2,310.52

2,381.52

2,452.52

2,526.04

2,602.04

2,679.30

2,760.58

2,843.32

2,927.54

3,031.17

3,136.87

3,247.86

3,361.22

3,476.98

3,599.09

3,724.47

3,853.20

3,981.44

4,108.88

4,239.60

4,373.04

4,500.31

4,629.88

4,761.73

4,856.96

4,954.10

5,053.18

5,154.25

1,598.57

1,598.57

1,676.35

1,750.63

1,826.64

1,897.27

1,965.49

2,033.72

2,101.94

2,170.16

2,240.63

2,311.80

2,384.15

2,460.16

2,537.55

2,616.35

2,712.56

2,810.73

2,913.72

3,018.92

3,126.36

3,238.77

3,354.21

3,472.77

3,590.96

3,708.53

3,828.71

3,951.40

4,068.58

4,187.87

4,309.27

4,395.46

4,483.37

4,573.03

4,664.50

1,273.00

1,273.00

1,332.74

1,390.63

1,448.54

1,503.07

1,557.85

1,612.62

1,667.39

1,722.18

1,778.73

1,838.30

1,898.87

1,962.42

2,027.14

2,093.04

2,175.91

2,260.47

2,349.07

2,439.58

2,532.06

2,628.31

2,727.22

2,828.84

2,930.34

3,031.50

3,135.86

3,242.41

3,344.59

3,448.61

3,554.53

3,625.63

3,698.14

3,772.10

3,847.54

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

1,733.59

1,733.59

1,811.62

1,888.74

1,964.51

2,037.85

2,098.75

2,159.67

2,220.58

2,281.50

2,344.74

2,399.33

2,454.77

2,513.57

2,573.36

2,634.18

2,702.48

2,772.04

2,845.71

2,920.81

2,997.38

3,079.19

3,162.98

3,248.79

3,333.39

3,416.56

3,497.45

3,579.85

3,656.59

3,734.57

3,813.82

3,890.10

3,967.90

4,047.26

4,128.20

Plan C

2,563.60

2,563.60

2,563.60

2,675.31

2,781.99

2,891.12

2,992.56

3,090.54

3,188.52

3,286.50

3,384.47

3,485.94

3,590.81

3,697.43

3,809.59

3,923.77

4,040.00

4,183.02

4,328.88

4,482.05

4,638.49

4,798.23

4,966.75

5,139.76

5,317.42

5,494.38

5,670.25

5,850.65

6,034.79

6,210.43

6,389.22

6,571.18

6,702.61

6,836.66

6,973.39

7,112.86

Plan F

Plan G

Plan N

2,136.33

2,136.33

2,229.43

2,318.32

2,409.27

2,493.80

2,575.45

2,657.10

2,738.75

2,820.39

2,904.95

2,992.35

3,081.19

3,174.66

3,269.81

3,366.67

3,485.85

3,607.40

3,735.04

3,865.41

3,998.53

4,138.96

4,283.14

4,431.18

4,578.65

4,725.21

4,875.55

5,028.99

5,175.36

5,324.35

5,475.98

5,585.51

5,697.22

5,811.16

5,927.39

1,838.35

1,838.35

1,927.81

2,013.22

2,100.62

2,181.85

2,260.31

2,338.78

2,417.23

2,495.69

2,576.73

2,658.56

2,741.77

2,829.18

2,918.18

3,008.79

3,119.45

3,232.33

3,350.78

3,471.76

3,595.32

3,724.58

3,857.34

3,993.68

4,129.60

4,264.81

4,403.02

4,544.12

4,678.87

4,816.04

4,955.66

5,054.77

5,155.88

5,259.00

5,364.17

1,463.95

1,463.95

1,532.63

1,599.22

1,665.82

1,728.52

1,791.53

1,854.52

1,917.50

1,980.49

2,045.53

2,114.04

2,183.71

2,256.78

2,331.21

2,407.00

2,502.30

2,599.54

2,701.43

2,805.52

2,911.86

3,022.57

3,136.31

3,253.16

3,369.89

3,486.23

3,606.23

3,728.77

3,846.27

3,965.90

4,087.71

4,169.46

4,252.85

4,337.91

4,424.67

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.

LY-OC-AA-NJ

PAGE 2

01/14

Loyal American Life Insurance Company

MEDICARE SUPPLEMENT

NEW JERSEY

Attained Age Rates -- Effective 5/16/2013 -- Area I (070-089)

PREFERRED MONTHLY BANK DRAFT RATES

FEMALE RATES

Plan A

125.57

125.57

131.22

136.81

142.30

147.61

152.02

156.44

160.85

165.26

169.84

173.79

177.81

182.07

186.40

190.81

195.75

200.79

206.13

211.57

217.11

223.04

229.11

235.33

241.45

247.48

253.34

259.31

264.86

270.51

276.25

281.78

287.41

293.16

299.03

Plan C

185.69

185.69

185.69

193.79

201.51

209.42

216.77

223.86

230.96

238.06

245.15

252.50

260.10

267.82

275.95

284.22

292.64

303.00

313.56

324.66

335.99

347.56

359.77

372.30

385.17

397.98

410.72

423.79

437.13

449.85

462.80

475.98

485.50

495.21

505.12

515.22

MALE RATES

Plan F

Plan G

Plan N

154.75

154.75

161.49

167.93

174.51

180.64

186.55

192.47

198.38

204.29

210.42

216.75

223.19

229.96

236.85

243.86

252.50

261.30

270.55

279.99

289.63

299.80

310.25

320.97

331.65

342.27

353.16

364.27

374.88

385.67

396.65

404.58

412.68

420.93

429.35

133.16

133.16

139.64

145.83

152.16

158.04

163.73

169.41

175.09

180.77

186.64

192.57

198.60

204.93

211.38

217.94

225.96

234.13

242.71

251.48

260.43

269.79

279.41

289.28

299.13

308.92

318.93

329.15

338.91

348.85

358.96

366.14

373.46

380.93

388.55

106.04

106.04

111.02

115.84

120.66

125.21

129.77

134.33

138.89

143.46

148.17

153.13

158.18

163.47

168.86

174.35

181.25

188.30

195.68

203.22

210.92

218.94

227.18

235.64

244.10

252.52

261.22

270.09

278.60

287.27

296.09

302.01

308.06

314.22

320.50

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

144.41

144.41

150.91

157.33

163.64

169.75

174.83

179.90

184.97

190.05

195.32

199.86

204.48

209.38

214.36

219.43

225.12

230.91

237.05

243.30

249.68

256.50

263.48

270.62

277.67

284.60

291.34

298.20

304.59

311.09

317.69

324.05

330.53

337.14

343.88

Plan C

213.55

213.55

213.55

222.85

231.74

240.83

249.28

257.44

265.60

273.77

281.93

290.38

299.11

308.00

317.34

326.85

336.53

348.45

360.60

373.35

386.39

399.69

413.73

428.14

442.94

457.68

472.33

487.36

502.70

517.33

532.22

547.38

558.33

569.49

580.88

592.50

Plan F

Plan G

Plan N

177.96

177.96

185.71

193.12

200.69

207.73

214.53

221.34

228.14

234.94

241.98

249.26

256.66

264.45

272.38

280.44

290.37

300.50

311.13

321.99

333.08

344.78

356.79

369.12

381.40

393.61

406.13

418.91

431.11

443.52

456.15

465.27

474.58

484.07

493.75

153.13

153.13

160.59

167.70

174.98

181.75

188.28

194.82

201.36

207.89

214.64

221.46

228.39

235.67

243.08

250.63

259.85

269.25

279.12

289.20

299.49

310.26

321.32

332.67

344.00

355.26

366.77

378.53

389.75

401.18

412.81

421.06

429.48

438.07

446.84

121.95

121.95

127.67

133.22

138.76

143.99

149.23

154.48

159.73

164.97

170.39

176.10

181.90

187.99

194.19

200.50

208.44

216.54

225.03

233.70

242.56

251.78

261.25

270.99

280.71

290.40

300.40

310.61

320.39

330.36

340.51

347.32

354.26

361.35

368.58

Due to rounding, actual premium charged may vary slightly from rates shown above. System rates prevail.

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

LY-OC-AA-NJ

PAGE 3

01/14

Loyal American Life Insurance Company

MEDICARE SUPPLEMENT

NEW JERSEY

Attained Age Rates -- Effective 5/16/2013 -- Area I (070-089)

STANDARD ANNUAL RATES

FEMALE RATES

Plan A

1,658.21

1,658.21

1,732.86

1,806.63

1,879.09

1,949.25

2,007.50

2,065.77

2,124.03

2,182.30

2,242.80

2,295.01

2,348.04

2,404.29

2,461.48

2,519.64

2,584.99

2,651.52

2,721.97

2,793.82

2,867.06

2,945.32

3,025.47

3,107.55

3,188.47

3,268.02

3,345.38

3,424.22

3,497.60

3,572.20

3,648.01

3,720.97

3,795.39

3,871.30

3,948.72

Plan C

2,452.15

2,452.15

2,452.15

2,558.99

2,661.03

2,765.43

2,862.44

2,956.17

3,049.88

3,143.61

3,237.32

3,334.38

3,434.68

3,536.67

3,643.96

3,753.17

3,864.36

4,001.14

4,140.66

4,287.18

4,436.81

4,589.61

4,750.80

4,916.29

5,086.22

5,255.50

5,423.72

5,596.28

5,772.41

5,940.42

6,111.42

6,285.48

6,411.19

6,539.41

6,670.20

6,803.60

MALE RATES

Plan F

Plan G

Plan N

2,043.46

2,043.46

2,132.49

2,217.52

2,304.52

2,385.37

2,463.48

2,541.57

2,619.67

2,697.77

2,778.65

2,862.23

2,947.23

3,036.63

3,127.64

3,220.30

3,334.28

3,450.55

3,572.65

3,697.34

3,824.68

3,959.00

4,096.91

4,238.52

4,379.58

4,519.77

4,663.56

4,810.34

4,950.35

5,092.85

5,237.90

5,342.66

5,449.51

5,558.50

5,669.67

1,758.43

1,758.43

1,843.99

1,925.70

2,009.29

2,086.99

2,162.04

2,237.08

2,312.14

2,387.19

2,464.69

2,542.98

2,622.57

2,706.18

2,791.31

2,877.98

2,983.82

3,091.80

3,205.09

3,320.81

3,439.00

3,562.65

3,689.64

3,820.04

3,950.05

4,079.37

4,211.58

4,346.53

4,475.44

4,606.64

4,740.20

4,835.01

4,931.70

5,030.34

5,130.94

1,400.29

1,400.29

1,466.01

1,529.69

1,593.38

1,653.38

1,713.63

1,773.89

1,834.14

1,894.39

1,956.60

2,022.12

2,088.76

2,158.67

2,229.85

2,302.35

2,393.51

2,486.52

2,583.97

2,683.55

2,785.25

2,891.15

2,999.95

3,111.72

3,223.39

3,334.66

3,449.45

3,566.64

3,679.04

3,793.47

3,909.98

3,988.19

4,067.94

4,149.30

4,232.29

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

1,906.96

1,906.96

1,992.79

2,077.62

2,160.96

2,241.63

2,308.63

2,375.64

2,442.64

2,509.64

2,579.23

2,639.27

2,700.25

2,764.93

2,830.71

2,897.59

2,972.72

3,049.25

3,130.28

3,212.89

3,297.11

3,387.11

3,479.28

3,573.67

3,666.73

3,758.22

3,847.19

3,937.84

4,022.25

4,108.03

4,195.21

4,279.12

4,364.70

4,451.99

4,541.03

Plan C

2,819.96

2,819.96

2,819.96

2,942.85

3,060.17

3,180.24

3,291.82

3,399.60

3,507.36

3,615.14

3,722.93

3,834.53

3,949.89

4,067.17

4,190.55

4,316.16

4,444.02

4,601.32

4,761.75

4,930.25

5,102.33

5,278.05

5,463.41

5,653.74

5,849.15

6,043.82

6,237.28

6,435.72

6,638.27

6,831.48

7,028.14

7,228.31

7,372.86

7,520.33

7,670.74

7,824.15

Plan F

Plan G

Plan N

2,349.96

2,349.96

2,452.38

2,550.14

2,650.20

2,743.18

2,833.00

2,922.80

3,012.62

3,102.44

3,195.44

3,291.57

3,389.31

3,492.12

3,596.80

3,703.35

3,834.43

3,968.13

4,108.54

4,251.94

4,398.37

4,552.84

4,711.45

4,874.29

5,036.52

5,197.73

5,363.10

5,531.89

5,692.90

5,856.78

6,023.59

6,144.05

6,266.94

6,392.28

6,520.13

2,022.18

2,022.18

2,120.59

2,214.54

2,310.69

2,400.04

2,486.35

2,572.65

2,658.96

2,745.27

2,834.41

2,924.42

3,015.95

3,112.10

3,210.00

3,309.67

3,431.40

3,555.56

3,685.85

3,818.93

3,954.85

4,097.05

4,243.08

4,393.05

4,542.57

4,691.29

4,843.33

4,998.52

5,146.75

5,297.64

5,451.23

5,560.26

5,671.46

5,784.88

5,900.58

1,610.34

1,610.34

1,685.90

1,759.14

1,832.40

1,901.38

1,970.68

2,039.96

2,109.26

2,178.55

2,250.09

2,325.44

2,402.07

2,482.46

2,564.33

2,647.71

2,752.54

2,859.49

2,971.57

3,086.07

3,203.05

3,324.81

3,449.93

3,578.48

3,706.89

3,834.85

3,966.86

4,101.64

4,230.90

4,362.50

4,496.49

4,586.41

4,678.14

4,771.70

4,867.14

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.

LY-OC-AA-NJ

PAGE 4

01/14

Loyal American Life Insurance Company

MEDICARE SUPPLEMENT

NEW JERSEY

Attained Age Rates -- Effective 5/16/2013 -- Area I (070-089)

STANDARD MONTHLY BANK DRAFT RATES

FEMALE RATES

Plan A

138.13

138.13

144.35

150.49

156.53

162.37

167.22

172.08

176.93

181.79

186.83

191.17

195.59

200.28

205.04

209.89

215.33

220.87

226.74

232.73

238.83

245.35

252.02

258.86

265.60

272.23

278.67

285.24

291.35

297.56

303.88

309.96

316.16

322.48

328.93

Plan C

204.26

204.26

204.26

213.16

221.66

230.36

238.44

246.25

254.06

261.86

269.67

277.75

286.11

294.60

303.54

312.64

321.90

333.29

344.92

357.12

369.59

382.31

395.74

409.53

423.68

437.78

451.80

466.17

480.84

494.84

509.08

523.58

534.05

544.73

555.63

566.74

MALE RATES

Plan F

Plan G

Plan N

170.22

170.22

177.64

184.72

191.97

198.70

205.21

211.71

218.22

224.72

231.46

238.42

245.50

252.95

260.53

268.25

277.75

287.43

297.60

307.99

318.60

329.78

341.27

353.07

364.82

376.50

388.47

400.70

412.36

424.23

436.32

445.04

453.94

463.02

472.28

146.48

146.48

153.60

160.41

167.37

173.85

180.10

186.35

192.60

198.85

205.31

211.83

218.46

225.42

232.52

239.74

248.55

257.55

266.98

276.62

286.47

296.77

307.35

318.21

329.04

339.81

350.82

362.07

372.80

383.73

394.86

402.76

410.81

419.03

427.41

116.64

116.64

122.12

127.42

132.73

137.73

142.75

147.77

152.78

157.80

162.98

168.44

173.99

179.82

185.75

191.79

199.38

207.13

215.24

223.54

232.01

240.83

249.90

259.21

268.51

277.78

287.34

297.10

306.46

316.00

325.70

332.22

338.86

345.64

352.55

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

158.85

158.85

166.00

173.07

180.01

186.73

192.31

197.89

203.47

209.05

214.85

219.85

224.93

230.32

235.80

241.37

247.63

254.00

260.75

267.63

274.65

282.15

289.82

297.69

305.44

313.06

320.47

328.02

335.05

342.20

349.46

356.45

363.58

370.85

378.27

Plan C

234.90

234.90

234.90

245.14

254.91

264.91

274.21

283.19

292.16

301.14

310.12

319.42

329.03

338.80

349.07

359.54

370.19

383.29

396.65

410.69

425.02

439.66

455.10

470.96

487.23

503.45

519.57

536.10

552.97

569.06

585.44

602.12

614.16

626.44

638.97

651.75

Plan F

Plan G

Plan N

195.75

195.75

204.28

212.43

220.76

228.51

235.99

243.47

250.95

258.43

266.18

274.19

282.33

290.89

299.61

308.49

319.41

330.55

342.24

354.19

366.38

379.25

392.46

406.03

419.54

432.97

446.75

460.81

474.22

487.87

501.77

511.80

522.04

532.48

543.13

168.45

168.45

176.65

184.47

192.48

199.92

207.11

214.30

221.49

228.68

236.11

243.60

251.23

259.24

267.39

275.70

285.84

296.18

307.03

318.12

329.44

341.28

353.45

365.94

378.40

390.78

403.45

416.38

428.72

441.29

454.09

463.17

472.43

481.88

491.52

134.14

134.14

140.44

146.54

152.64

158.38

164.16

169.93

175.70

181.47

187.43

193.71

200.09

206.79

213.61

220.55

229.29

238.20

247.53

257.07

266.81

276.96

287.38

298.09

308.78

319.44

330.44

341.67

352.43

363.40

374.56

382.05

389.69

397.48

405.43

Due to rounding, actual premium charged may vary slightly from rates shown above. System rates prevail.

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

LY-OC-AA-NJ

PAGE 5

01/14

 ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download