Retiree Medical Insurance Plan Summary of Benefits Underwritten by: United American Insurance Company MEDICARE PARTS A & B Services Medicare Pays Plan Pays You Pay HOME HEALTH CARE – Medicare Approved Services: Medically necessary skilled care 100% $0 $0 services and medical supplies DURABLE MEDICAL EQUIPMENT First of Medicare Approved $0 $0 Part B Deductible Amounts** 20% until Calendar Next Medicare-approved amounts Generally 80% $0 year deductible is met ($400) 4% until Out Of Next Medicare-approved amounts Generally 80% 16% Pocket Maximum is met ($1,250) Remainder of Medicare Approved 80% 20% $0 Amounts OTHER BENEFITS NOT COVERED BY MEDICARE Services Medicare Pays Plan Pays You Pay FOREIGN TRAVEL -Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA: First $250 each calendar year $0 $0 $250 80% to a lifetime 20% and amounts Remainder of charges $0 maximum of $50,000 over the $50,000 lifetime max *A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. **Once you have been billed the first dollars of Medicare-Approved amounts for covered services (which are noted with two asterisks), your Medicare Part B Deductible will have been met for the calendar year. Benefits are paid only for those expenses which have been approved as eligible by the federal Medicare program. Benefits will not be paid for any expenses which are not determined to be Medicare Eligible Expenses by the Federal Medicare Program or its administrators, except as otherwise specified. This policy’s renewability, cancellability and termination provisions are at the option of the group policy holder except in cases of non-payment of premium The summary of program benefits described herein is for illustrative purposes only. In case of differences or errors, the Group Policy governs. The Medicare Parts A and B deductibles and co-insurance amounts shown are the 2024 amounts. Your plan will automatically adjust to the changes to Medicare Parts A and B amounts for 2025.