Retiree Medical Insurance Plan Summary of Benefits Underwritten by: United American Insurance Company MEDICARE (PART A) - HOSPITAL SERVICES - PER BENEFIT PERIOD* Services Medicare Pays Plan Pays You Pay HOSPITAL CONFINEMENT BENEFIT* Semiprivate room and board, general nursing and miscellaneous services and supplies: First 60 days All but Part A Part A Deductible $0 Deductible st th All but Part A $0 61 through 90 day Coinsurance Part A Coinsurance 91st through 150th day All but Part A (While using 60 lifetime reserve Coinsurance Part A Coinsurance $0 days) Once Lifetime Reserve days are used: Additional 365 days: $0 100% of Medicare $0 Eligible Expenses Beyond the Additional 365 days $0 $0 All costs SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital: First 20 days All approved $0 $0 amounts 21st through 100th day All but Part A $0 Coinsurance Part A Coinsurance 101st day and after $0 $0 All costs BLOOD DEDUCTIBLE – Hospital Confinement and Out-Patient Medical Expense When furnished by a hospital or skilled nursing facility during a covered stay. First 3 pints $0 3 pints $0 Additional amounts 100% $0 $0 HOSPICE CARE All but very limited Available as long as your doctor coinsurance for certifies you are terminally ill and outpatient drugs $0 Balance you elect to receive these services. and inpatient respite care MEDICARE (PART B) - MEDICAL SERVICES - PER CALENDAR YEAR