CIGNA HEALTH AND LIFE INSURANCE COMPANY PO Box ......CIGNA HEALTH AND LIFE INSURANCE COMPANY PO Box...

CIGNA HEALTH AND LIFE INSURANCE COMPANY PO Box 5700, Scranton, PA 18505 • 866-459-4272

Benefit Chart of Medicare Supplement Plans Sold on or after January 1, 2020 This chart shows the benefits included in each of the standard Medicare Supplement plans. Some plans may not be available. Only Applicants first eligible for Medicare before 2020 may purchase Plans C, F, and high-deductible F.

Note: A means 100% of the benefit is paid.

Benefits

Plans available to all Applicants

Medicare first eligible before

2020 only A B D G1 K L M N C F1

Medicare Part A coinsurance and hospital coverage (up to an additional 365 days after Medicare benefits are used up)

Medicare Part B coinsurance or copayment 50% 75%

copays apply3

Blood (first three pints) 50% 75%

Part A hospice care coinsurance or copayment 50% 75%

Skilled nursing facility coinsurance 50% 75%

Medicare Part A deductible 50% 75% 50%

Medicare Part B deductible

Medicare Part B excess charges

Foreign travel emergency (up to plan limits)

Out-of-pocket limit in 20212 $6,2202 $3,1102

1Plans F and G also have a high-deductible option which requires first paying a plan deductible of $2,370 before the plan begins to pay. Once the plan deductible is met, the plan pays 100% of covered services for the rest of the calendar year. High-deductible Plan G does not cover the Medicare Part B deductible. However, high-deductible Plans F and G count your payment of the Medicare Part B deductible toward meeting the plan deductible.

2Plans K and L pay 100% of covered services for the rest of the calendar year once you meet the out-of-pocket yearly limit.

3Plan N pays 100% of the Part B coinsurance except for a copayment of up to $20 for some office visits and up to a $50 copayment for emergency room visits that do not result in an inpatient admission.

CHLIC-OC-2020-OH 1 01/21

Annual Monthly Annual Monthly Annual Monthly Annual Monthly Annual Monthly Annual Monthly Annual Monthly Annual Monthly Annual Monthly Annual Monthly

1,567.16 130.54 2,035.86 169.59 551.16 45.91 1,567.47 130.57 1,284.33 106.98 65 1,775.58 147.91 2,306.62 192.14 624.46 52.02 1,775.94 147.94 1,455.15 121.211,567.16 130.54 2,035.86 169.59 551.16 45.91 1,567.47 130.57 1,284.33 106.98 66 1,775.58 147.91 2,306.62 192.14 624.46 52.02 1,775.94 147.94 1,455.15 121.211,567.16 130.54 2,035.86 169.59 551.16 45.91 1,567.47 130.57 1,284.33 106.98 67 1,775.58 147.91 2,306.62 192.14 624.46 52.02 1,775.94 147.94 1,455.15 121.211,577.76 131.43 2,049.64 170.73 554.89 46.22 1,600.32 133.31 1,291.20 107.56 68 1,787.60 148.91 2,322.23 193.44 628.69 52.37 1,813.17 151.04 1,462.93 121.861,637.43 136.40 2,127.16 177.19 575.88 47.97 1,661.24 138.38 1,341.14 111.72 69 1,855.21 154.54 2,410.07 200.76 652.46 54.35 1,882.18 156.79 1,519.51 126.571,695.18 141.21 2,202.16 183.44 596.18 49.66 1,711.36 142.56 1,379.79 114.94 70 1,920.63 159.99 2,495.05 207.84 675.47 56.27 1,938.98 161.52 1,563.30 130.221,749.43 145.73 2,272.66 189.31 615.27 51.25 1,766.74 147.17 1,426.82 118.85 71 1,982.11 165.11 2,574.92 214.49 697.09 58.07 2,001.72 166.74 1,616.58 134.661,803.70 150.25 2,343.15 195.18 634.34 52.84 1,822.10 151.78 1,471.46 122.57 72 2,043.58 170.23 2,654.78 221.14 718.71 59.87 2,064.44 171.97 1,667.17 138.881,857.94 154.77 2,413.62 201.05 653.43 54.43 1,877.43 156.39 1,516.11 126.29 73 2,105.05 175.35 2,734.63 227.79 740.32 61.67 2,127.14 177.19 1,717.76 143.091,912.18 159.28 2,484.08 206.92 672.50 56.02 1,932.76 161.00 1,560.76 130.01 74 2,166.50 180.47 2,814.46 234.44 761.94 63.47 2,189.81 182.41 1,768.34 147.301,976.02 164.60 2,567.02 213.83 694.95 57.89 1,999.72 166.58 1,605.41 133.73 75 2,238.84 186.50 2,908.42 242.27 787.38 65.59 2,265.69 188.73 1,818.93 151.522,040.56 169.98 2,650.85 220.82 717.65 59.78 2,070.04 172.43 1,651.72 137.59 76 2,311.96 192.59 3,003.42 250.18 813.10 67.73 2,345.36 195.37 1,871.40 155.892,098.44 174.80 2,737.32 228.02 741.06 61.73 2,135.61 177.90 1,720.07 143.28 77 2,377.53 198.05 3,101.39 258.35 839.62 69.94 2,419.64 201.56 1,948.84 162.342,151.67 179.23 2,824.15 235.25 764.56 63.69 2,194.84 182.83 1,786.00 148.77 78 2,437.85 203.07 3,199.76 266.54 866.25 72.16 2,486.74 207.15 2,023.55 168.562,207.24 183.86 2,914.74 242.80 789.09 65.73 2,251.77 187.57 1,851.62 154.24 79 2,500.80 208.32 3,302.41 275.09 894.04 74.47 2,551.26 212.52 2,097.88 174.752,263.02 188.51 3,005.97 250.40 813.79 67.79 2,311.09 192.51 1,914.82 159.50 80 2,564.00 213.58 3,405.77 283.70 922.02 76.80 2,618.46 218.12 2,169.49 180.722,293.03 191.01 3,073.74 256.04 832.13 69.32 2,357.05 196.34 1,945.72 162.08 81 2,598.00 216.41 3,482.54 290.10 942.80 78.54 2,670.55 222.46 2,204.51 183.642,324.14 193.60 3,143.41 261.85 851.00 70.89 2,395.31 199.53 1,982.51 165.14 82 2,633.26 219.35 3,561.48 296.67 964.18 80.32 2,713.89 226.07 2,246.18 187.112,354.29 196.11 3,211.34 267.50 869.38 72.42 2,436.73 202.98 2,043.47 170.22 83 2,667.41 222.20 3,638.46 303.08 985.01 82.05 2,760.82 229.98 2,315.25 192.862,397.16 199.68 3,278.00 273.06 887.44 73.92 2,483.96 206.91 2,087.75 173.91 84 2,715.99 226.24 3,713.98 309.37 1,005.47 83.76 2,814.34 234.43 2,365.41 197.042,443.16 203.51 3,340.90 278.30 904.46 75.34 2,531.95 210.91 2,120.41 176.63 85 2,768.10 230.58 3,785.24 315.31 1,024.76 85.36 2,868.70 238.96 2,402.43 200.122,496.91 207.99 3,414.40 284.42 924.36 77.00 2,591.40 215.86 2,173.13 181.02 86 2,829.00 235.66 3,868.51 322.25 1,047.30 87.24 2,936.05 244.57 2,462.15 205.102,551.83 212.57 3,489.51 290.68 944.70 78.69 2,652.18 220.93 2,226.93 185.50 87 2,891.24 240.84 3,953.62 329.34 1,070.34 89.16 3,004.91 250.31 2,523.11 210.182,607.98 217.25 3,566.28 297.07 965.48 80.42 2,714.32 226.10 2,281.85 190.08 88 2,954.84 246.14 4,040.60 336.58 1,093.89 91.12 3,075.32 256.17 2,585.34 215.362,665.36 222.02 3,644.74 303.61 986.72 82.19 2,777.85 231.39 2,337.93 194.75 89 3,019.85 251.55 4,129.50 343.99 1,117.95 93.13 3,147.29 262.17 2,648.87 220.652,723.99 226.91 3,724.92 310.29 1,008.42 84.00 2,842.80 236.81 2,395.18 199.52 90 3,086.28 257.09 4,220.34 351.55 1,142.54 95.17 3,220.88 268.30 2,713.73 226.052,783.91 231.90 3,806.87 317.11 1,030.61 85.85 2,908.14 242.25 2,454.05 204.42 91 3,154.18 262.74 4,313.19 359.29 1,167.69 97.27 3,294.91 274.47 2,780.44 231.612,845.16 237.00 3,890.63 324.09 1,053.28 87.74 2,974.96 247.81 2,514.13 209.43 92 3,223.57 268.52 4,408.07 367.19 1,193.38 99.41 3,370.63 280.77 2,848.52 237.282,907.76 242.22 3,976.21 331.22 1,076.45 89.67 3,043.29 253.51 2,575.46 214.54 93 3,294.49 274.43 4,505.06 375.27 1,219.62 101.59 3,448.05 287.22 2,917.99 243.072,971.73 247.55 4,063.70 338.51 1,100.14 91.64 3,113.18 259.33 2,638.04 219.75 94 3,366.97 280.47 4,604.17 383.53 1,246.46 103.83 3,527.23 293.82 2,988.91 248.983,037.10 252.99 4,153.09 345.95 1,124.34 93.66 3,184.65 265.28 2,701.93 225.07 95 3,441.04 286.64 4,705.46 391.96 1,273.89 106.11 3,608.21 300.56 3,061.29 255.013,037.10 252.99 4,153.09 345.95 1,124.34 93.66 3,184.65 265.28 2,701.93 225.07 96 3,441.04 286.64 4,705.46 391.96 1,273.89 106.11 3,608.21 300.56 3,061.29 255.013,037.10 252.99 4,153.09 345.95 1,124.34 93.66 3,184.65 265.28 2,701.93 225.07 97 3,441.04 286.64 4,705.46 391.96 1,273.89 106.11 3,608.21 300.56 3,061.29 255.013,037.10 252.99 4,153.09 345.95 1,124.34 93.66 3,184.65 265.28 2,701.93 225.07 98 3,441.04 286.64 4,705.46 391.96 1,273.89 106.11 3,608.21 300.56 3,061.29 255.013,037.10 252.99 4,153.09 345.95 1,124.34 93.66 3,184.65 265.28 2,701.93 225.07 99 3,441.04 286.64 4,705.46 391.96 1,273.89 106.11 3,608.21 300.56 3,061.29 255.01

Policies may be issued on an annual, semi-annual, quarterly or monthly mode. To obtain semi-annual premiums, multiply the above-quoted annual premium by 0.52. To obtain quarterly premiums, multiply the above quoted premium by 0.265.

Cigna Health and Life Insurance CompanyMEDICARE SUPPLEMENT

OHIOAttained Age Rates -- Effective 10/1/2020 -- Area I (430-435, 437-439, 446-449, 455-458)

PREFERRED ANNUAL & MONTHLY BANK DRAFT RATES

FEMALE RATES MALE RATESPlan A Plan F Plan G Plan N Attained

AgePlan A Plan F Plan G Plan NPlan HDF

Applicants who qualify for Household Discount multiply above rates by 0.93.

Plan HDF

CHLIC-OC-2020-OH 2 01/21


1,723.87 143.60 2,239.45 186.55 606.27 50.50 1,724.22 143.63 1,412.76 117.68 65 1,953.14 162.70 2,537.29 211.36 686.91 57.22 1,953.53 162.73 1,600.66 133.331,723.87 143.60 2,239.45 186.55 606.27 50.50 1,724.22 143.63 1,412.76 117.68 66 1,953.14 162.70 2,537.29 211.36 686.91 57.22 1,953.53 162.73 1,600.66 133.331,723.87 143.60 2,239.45 186.55 606.27 50.50 1,724.22 143.63 1,412.76 117.68 67 1,953.14 162.70 2,537.29 211.36 686.91 57.22 1,953.53 162.73 1,600.66 133.331,735.54 144.57 2,254.60 187.81 610.38 50.84 1,760.35 146.64 1,420.31 118.31 68 1,966.36 163.80 2,554.46 212.79 691.55 57.61 1,994.48 166.14 1,609.21 134.051,801.18 150.04 2,339.87 194.91 633.46 52.77 1,827.36 152.22 1,475.26 122.89 69 2,040.73 169.99 2,651.07 220.83 717.72 59.79 2,070.40 172.46 1,671.46 139.231,864.69 155.33 2,422.39 201.78 655.80 54.63 1,882.50 156.81 1,517.76 126.43 70 2,112.70 175.99 2,744.56 228.62 743.02 61.89 2,132.87 177.67 1,719.64 143.251,924.39 160.30 2,499.93 208.24 676.79 56.38 1,943.41 161.89 1,569.49 130.74 71 2,180.33 181.62 2,832.42 235.94 766.81 63.88 2,201.89 183.42 1,778.24 148.131,984.06 165.27 2,577.45 214.70 697.78 58.13 2,004.30 166.96 1,618.61 134.83 72 2,247.95 187.25 2,920.26 243.26 790.59 65.86 2,270.88 189.16 1,833.89 152.762,043.73 170.24 2,654.97 221.16 718.77 59.87 2,065.18 172.03 1,667.72 138.92 73 2,315.55 192.89 3,008.08 250.57 814.36 67.84 2,339.85 194.91 1,889.53 157.402,103.40 175.21 2,732.48 227.62 739.75 61.62 2,126.03 177.10 1,716.84 143.01 74 2,383.14 198.52 3,095.90 257.89 838.14 69.82 2,408.80 200.65 1,945.17 162.032,173.63 181.06 2,823.71 235.22 764.44 63.68 2,199.70 183.24 1,765.95 147.10 75 2,462.72 205.14 3,199.27 266.50 866.12 72.15 2,492.26 207.61 2,000.82 166.672,244.62 186.98 2,915.94 242.90 789.42 65.76 2,277.05 189.68 1,816.89 151.35 76 2,543.15 211.84 3,303.76 275.20 894.41 74.50 2,579.89 214.90 2,058.54 171.482,308.28 192.28 3,011.06 250.82 815.17 67.90 2,349.17 195.69 1,892.08 157.61 77 2,615.28 217.85 3,411.53 284.18 923.58 76.93 2,661.61 221.71 2,143.73 178.572,366.84 197.16 3,106.57 258.78 841.02 70.06 2,414.32 201.11 1,964.61 163.65 78 2,681.63 223.38 3,519.73 293.19 952.87 79.37 2,735.42 227.86 2,225.90 185.422,427.97 202.25 3,206.22 267.08 868.00 72.30 2,476.94 206.33 2,036.78 169.66 79 2,750.88 229.15 3,632.65 302.60 983.44 81.92 2,806.38 233.77 2,307.67 192.232,489.33 207.36 3,306.58 275.44 895.17 74.57 2,542.20 211.76 2,106.30 175.46 80 2,820.41 234.94 3,746.35 312.07 1,014.23 84.49 2,880.30 239.93 2,386.44 198.792,522.34 210.11 3,381.11 281.65 915.34 76.25 2,592.76 215.98 2,140.30 178.29 81 2,857.81 238.06 3,830.79 319.10 1,037.09 86.39 2,937.60 244.70 2,424.96 202.002,556.57 212.96 3,457.76 288.03 936.09 77.98 2,634.84 219.48 2,180.76 181.66 82 2,896.58 241.29 3,917.64 326.34 1,060.60 88.35 2,985.28 248.67 2,470.79 205.822,589.72 215.72 3,532.48 294.26 956.33 79.66 2,680.41 223.28 2,247.82 187.24 83 2,934.15 244.41 4,002.30 333.39 1,083.52 90.26 3,036.89 252.97 2,546.78 212.152,636.88 219.65 3,605.80 300.36 976.18 81.32 2,732.35 227.61 2,296.51 191.30 84 2,987.58 248.87 4,085.37 340.31 1,106.01 92.13 3,095.76 257.88 2,601.95 216.742,687.47 223.87 3,674.99 306.13 994.91 82.88 2,785.15 232.00 2,332.45 194.29 85 3,044.91 253.64 4,163.76 346.84 1,127.23 93.90 3,155.57 262.86 2,642.67 220.132,746.60 228.79 3,755.84 312.86 1,016.80 84.70 2,850.53 237.45 2,390.44 199.12 86 3,111.89 259.22 4,255.37 354.47 1,152.03 95.96 3,229.66 269.03 2,708.37 225.612,807.02 233.82 3,838.47 319.74 1,039.16 86.56 2,917.39 243.02 2,449.63 204.05 87 3,180.36 264.92 4,348.98 362.27 1,177.38 98.08 3,305.41 275.34 2,775.42 231.192,868.78 238.97 3,922.91 326.78 1,062.02 88.47 2,985.74 248.71 2,510.04 209.09 88 3,250.33 270.75 4,444.66 370.24 1,203.28 100.23 3,382.85 281.79 2,843.87 236.892,931.89 244.23 4,009.21 333.97 1,085.39 90.41 3,055.63 254.53 2,571.72 214.22 89 3,321.82 276.71 4,542.44 378.39 1,229.75 102.44 3,462.02 288.39 2,913.76 242.722,996.39 249.60 4,097.41 341.31 1,109.27 92.40 3,127.08 260.49 2,634.69 219.47 90 3,394.91 282.80 4,642.37 386.71 1,256.81 104.69 3,542.97 295.13 2,985.10 248.663,062.31 255.09 4,187.57 348.82 1,133.68 94.44 3,198.94 266.47 2,699.47 224.87 91 3,469.60 289.02 4,744.50 395.22 1,284.45 106.99 3,624.41 301.91 3,058.49 254.773,129.69 260.70 4,279.69 356.50 1,158.61 96.51 3,272.45 272.59 2,765.56 230.37 92 3,545.93 295.38 4,848.88 403.91 1,312.71 109.35 3,707.69 308.85 3,133.37 261.013,198.53 266.44 4,373.85 364.34 1,184.10 98.64 3,347.62 278.86 2,833.00 235.99 93 3,623.93 301.87 4,955.56 412.80 1,341.60 111.75 3,792.85 315.94 3,209.79 267.383,268.90 272.30 4,470.07 372.36 1,210.16 100.81 3,424.50 285.26 2,901.86 241.72 94 3,703.66 308.52 5,064.59 421.88 1,371.11 114.21 3,879.96 323.20 3,287.80 273.873,340.82 278.29 4,568.40 380.55 1,236.78 103.02 3,503.12 291.81 2,972.13 247.58 95 3,785.14 315.30 5,176.00 431.16 1,401.27 116.73 3,969.03 330.62 3,367.42 280.513,340.82 278.29 4,568.40 380.55 1,236.78 103.02 3,503.12 291.81 2,972.13 247.58 96 3,785.14 315.30 5,176.00 431.16 1,401.27 116.73 3,969.03 330.62 3,367.42 280.513,340.82 278.29 4,568.40 380.55 1,236.78 103.02 3,503.12 291.81 2,972.13 247.58 97 3,785.14 315.30 5,176.00 431.16 1,401.27 116.73 3,969.03 330.62 3,367.42 280.513,340.82 278.29 4,568.40 380.55 1,236.78 103.02 3,503.12 291.81 2,972.13 247.58 98 3,785.14 315.30 5,176.00 431.16 1,401.27 116.73 3,969.03 330.62 3,367.42 280.513,340.82 278.29 4,568.40 380.55 1,236.78 103.02 3,503.12 291.81 2,972.13 247.58 99 3,785.14 315.30 5,176.00 431.16 1,401.27 116.73 3,969.03 330.62 3,367.42 280.51



OHIOAttained Age Rates -- Effective 10/1/2020 -- Area I (430-435, 437-439, 446-449, 455-458)

STANDARD ANNUAL & MONTHLY BANK DRAFT RATES

MALE RATESPlan A Plan F Plan G Plan N Attained

AgePlan N


Plan AFEMALE RATES

Plan F Plan GPlan HDF Plan HDF

CHLIC-OC-2020-OH 3 01/21


1,634.56 136.16 2,123.43 176.88 574.86 47.89 1,634.89 136.19 1,339.56 111.59 65 1,851.95 154.27 2,405.83 200.41 651.32 54.26 1,852.32 154.30 1,517.74 126.431,634.56 136.16 2,123.43 176.88 574.86 47.89 1,634.89 136.19 1,339.56 111.59 66 1,851.95 154.27 2,405.83 200.41 651.32 54.26 1,852.32 154.30 1,517.74 126.431,634.56 136.16 2,123.43 176.88 574.86 47.89 1,634.89 136.19 1,339.56 111.59 67 1,851.95 154.27 2,405.83 200.41 651.32 54.26 1,852.32 154.30 1,517.74 126.431,645.62 137.08 2,137.79 178.08 578.75 48.21 1,669.15 139.04 1,346.73 112.18 68 1,864.49 155.31 2,422.11 201.76 655.73 54.62 1,891.15 157.53 1,525.85 127.101,707.86 142.26 2,218.65 184.81 600.65 50.03 1,732.69 144.33 1,398.82 116.52 69 1,935.01 161.19 2,513.73 209.39 680.53 56.69 1,963.13 163.53 1,584.86 132.021,768.09 147.28 2,296.88 191.33 621.82 51.80 1,784.97 148.69 1,439.14 119.88 70 2,003.24 166.87 2,602.37 216.78 704.52 58.69 2,022.37 168.46 1,630.54 135.821,824.68 152.00 2,370.41 197.46 641.73 53.46 1,842.72 153.50 1,488.19 123.97 71 2,067.37 172.21 2,685.67 223.72 727.08 60.57 2,087.82 173.92 1,686.11 140.451,881.28 156.71 2,443.93 203.58 661.62 55.11 1,900.47 158.31 1,534.75 127.84 72 2,131.48 177.55 2,768.97 230.65 749.63 62.44 2,153.23 179.36 1,738.88 144.851,937.85 161.42 2,517.43 209.70 681.53 56.77 1,958.18 163.12 1,581.32 131.72 73 2,195.59 182.89 2,852.24 237.59 772.17 64.32 2,218.63 184.81 1,791.64 149.241,994.43 166.14 2,590.92 215.82 701.43 58.43 2,015.89 167.92 1,627.89 135.60 74 2,259.68 188.23 2,935.51 244.53 794.72 66.20 2,283.99 190.26 1,844.40 153.642,061.01 171.68 2,677.42 223.03 724.84 60.38 2,085.73 173.74 1,674.46 139.48 75 2,335.13 194.52 3,033.52 252.69 821.25 68.41 2,363.14 196.85 1,897.17 158.032,128.33 177.29 2,764.87 230.31 748.51 62.35 2,159.07 179.85 1,722.76 143.51 76 2,411.40 200.87 3,132.60 260.95 848.07 70.64 2,446.23 203.77 1,951.89 162.592,188.69 182.32 2,855.06 237.83 772.93 64.39 2,227.47 185.55 1,794.05 149.44 77 2,479.79 206.57 3,234.79 269.46 875.73 72.95 2,523.72 210.23 2,032.66 169.322,244.22 186.94 2,945.62 245.37 797.44 66.43 2,289.24 190.69 1,862.82 155.17 78 2,542.70 211.81 3,337.39 278.00 903.51 75.26 2,593.70 216.05 2,110.58 175.812,302.17 191.77 3,040.11 253.24 823.03 68.56 2,348.62 195.64 1,931.26 160.87 79 2,608.36 217.28 3,444.45 286.92 932.50 77.68 2,660.99 221.66 2,188.12 182.272,360.35 196.62 3,135.26 261.17 848.79 70.70 2,410.49 200.79 1,997.18 166.37 80 2,674.28 222.77 3,552.26 295.90 961.68 80.11 2,731.08 227.50 2,262.80 188.492,391.66 199.22 3,205.94 267.05 867.92 72.30 2,458.43 204.79 2,029.41 169.05 81 2,709.75 225.72 3,632.32 302.57 983.35 81.91 2,785.41 232.02 2,299.33 191.532,424.11 201.93 3,278.61 273.11 887.60 73.94 2,498.33 208.11 2,067.78 172.25 82 2,746.52 228.79 3,714.67 309.43 1,005.65 83.77 2,830.61 235.79 2,342.79 195.152,455.55 204.55 3,349.47 279.01 906.78 75.53 2,541.54 211.71 2,131.36 177.54 83 2,782.14 231.75 3,794.96 316.12 1,027.38 85.58 2,879.56 239.87 2,414.83 201.162,500.26 208.27 3,418.99 284.80 925.61 77.10 2,590.79 215.81 2,177.54 181.39 84 2,832.80 235.97 3,873.72 322.68 1,048.71 87.36 2,935.38 244.52 2,467.15 205.512,548.24 212.27 3,484.59 290.27 943.36 78.58 2,640.85 219.98 2,211.61 184.23 85 2,887.16 240.50 3,948.04 328.87 1,068.83 89.03 2,992.08 249.24 2,505.76 208.732,604.30 216.94 3,561.26 296.65 964.12 80.31 2,702.85 225.15 2,266.60 188.81 86 2,950.67 245.79 4,034.90 336.11 1,092.34 90.99 3,062.34 255.09 2,568.05 213.922,661.59 221.71 3,639.60 303.18 985.33 82.08 2,766.25 230.43 2,322.72 193.48 87 3,015.59 251.20 4,123.67 343.50 1,116.38 92.99 3,134.15 261.07 2,631.63 219.222,720.15 226.59 3,719.67 309.85 1,007.01 83.88 2,831.06 235.83 2,380.00 198.25 88 3,081.93 256.73 4,214.39 351.06 1,140.94 95.04 3,207.60 267.19 2,696.54 224.622,779.99 231.57 3,801.51 316.67 1,029.16 85.73 2,897.32 241.35 2,438.49 203.13 89 3,149.73 262.37 4,307.11 358.78 1,166.04 97.13 3,282.66 273.45 2,762.80 230.142,841.15 236.67 3,885.13 323.63 1,051.80 87.61 2,965.07 246.99 2,498.20 208.10 90 3,219.03 268.14 4,401.86 366.68 1,191.69 99.27 3,359.41 279.84 2,830.45 235.782,903.65 241.87 3,970.61 330.75 1,074.93 89.54 3,033.22 252.67 2,559.60 213.21 91 3,289.85 274.04 4,498.71 374.74 1,217.91 101.45 3,436.63 286.27 2,900.03 241.572,967.54 247.20 4,057.97 338.03 1,098.59 91.51 3,102.91 258.47 2,622.27 218.43 92 3,362.21 280.07 4,597.67 382.99 1,244.71 103.68 3,515.60 292.85 2,971.04 247.493,032.82 252.63 4,147.23 345.46 1,122.75 93.53 3,174.19 264.41 2,686.24 223.76 93 3,436.19 286.23 4,698.82 391.41 1,272.08 105.96 3,596.36 299.58 3,043.50 253.523,099.55 258.19 4,238.48 353.07 1,147.46 95.58 3,247.08 270.48 2,751.51 229.20 94 3,511.78 292.53 4,802.20 400.02 1,300.07 108.30 3,678.94 306.46 3,117.47 259.693,167.73 263.87 4,331.72 360.83 1,172.70 97.69 3,321.63 276.69 2,818.14 234.75 95 3,589.05 298.97 4,907.84 408.82 1,328.68 110.68 3,763.40 313.49 3,192.96 265.973,167.73 263.87 4,331.72 360.83 1,172.70 97.69 3,321.63 276.69 2,818.14 234.75 96 3,589.05 298.97 4,907.84 408.82 1,328.68 110.68 3,763.40 313.49 3,192.96 265.973,167.73 263.87 4,331.72 360.83 1,172.70 97.69 3,321.63 276.69 2,818.14 234.75 97 3,589.05 298.97 4,907.84 408.82 1,328.68 110.68 3,763.40 313.49 3,192.96 265.973,167.73 263.87 4,331.72 360.83 1,172.70 97.69 3,321.63 276.69 2,818.14 234.75 98 3,589.05 298.97 4,907.84 408.82 1,328.68 110.68 3,763.40 313.49 3,192.96 265.973,167.73 263.87 4,331.72 360.83 1,172.70 97.69 3,321.63 276.69 2,818.14 234.75 99 3,589.05 298.97 4,907.84 408.82 1,328.68 110.68 3,763.40 313.49 3,192.96 265.97



OHIOAttained Age Rates -- Effective 10/1/2020 -- Area II (450-454, 459)



AgePlan A Plan F Plan G Plan N


Plan HDF Plan HDF

CHLIC-OC-2020-OH 4 01/21


1,798.02 149.77 2,335.77 194.57 632.35 52.67 1,798.38 149.80 1,473.52 122.74 65 2,037.15 169.69 2,646.42 220.45 716.45 59.68 2,037.55 169.73 1,669.50 139.071,798.02 149.77 2,335.77 194.57 632.35 52.67 1,798.38 149.80 1,473.52 122.74 66 2,037.15 169.69 2,646.42 220.45 716.45 59.68 2,037.55 169.73 1,669.50 139.071,798.02 149.77 2,335.77 194.57 632.35 52.67 1,798.38 149.80 1,473.52 122.74 67 2,037.15 169.69 2,646.42 220.45 716.45 59.68 2,037.55 169.73 1,669.50 139.071,810.19 150.79 2,351.57 195.89 636.63 53.03 1,836.06 152.94 1,481.40 123.40 68 2,050.94 170.84 2,664.33 221.94 721.30 60.08 2,080.26 173.29 1,678.43 139.811,878.65 156.49 2,440.51 203.29 660.70 55.04 1,905.96 158.77 1,538.71 128.17 69 2,128.51 177.30 2,765.10 230.33 748.59 62.36 2,159.45 179.88 1,743.35 145.221,944.89 162.01 2,526.57 210.46 684.01 56.98 1,963.47 163.56 1,583.04 131.87 70 2,203.56 183.56 2,862.61 238.46 774.98 64.56 2,224.60 185.31 1,793.60 149.412,007.16 167.20 2,607.46 217.20 705.90 58.80 2,027.00 168.85 1,637.00 136.36 71 2,274.11 189.43 2,954.24 246.09 799.79 66.62 2,296.59 191.31 1,854.72 154.502,069.39 172.38 2,688.31 223.94 727.79 60.63 2,090.51 174.14 1,688.23 140.63 72 2,344.64 195.31 3,045.86 253.72 824.59 68.69 2,368.55 197.30 1,912.77 159.332,131.63 177.56 2,769.17 230.67 749.69 62.45 2,154.00 179.43 1,739.45 144.90 73 2,415.14 201.18 3,137.46 261.35 849.39 70.75 2,440.49 203.29 1,970.80 164.172,193.87 182.75 2,850.01 237.41 771.57 64.27 2,217.47 184.72 1,790.68 149.16 74 2,485.64 207.05 3,229.05 268.98 874.19 72.82 2,512.40 209.28 2,028.84 169.002,267.12 188.85 2,945.16 245.33 797.32 66.42 2,294.31 191.12 1,841.91 153.43 75 2,568.65 213.97 3,336.88 277.96 903.37 75.25 2,599.45 216.53 2,086.88 173.842,341.17 195.02 3,041.35 253.34 823.37 68.59 2,374.98 197.84 1,895.04 157.86 76 2,652.53 220.96 3,445.85 287.04 932.88 77.71 2,690.85 224.15 2,147.08 178.852,407.56 200.55 3,140.57 261.61 850.23 70.82 2,450.21 204.10 1,973.46 164.39 77 2,727.77 227.22 3,558.26 296.40 963.30 80.24 2,776.09 231.25 2,235.93 186.252,468.64 205.64 3,240.18 269.91 877.19 73.07 2,518.16 209.76 2,049.11 170.69 78 2,796.97 232.99 3,671.12 305.80 993.86 82.79 2,853.07 237.66 2,321.64 193.392,532.40 210.95 3,344.12 278.57 905.33 75.41 2,583.48 215.20 2,124.39 176.96 79 2,869.20 239.00 3,788.89 315.61 1,025.74 85.44 2,927.09 243.83 2,406.93 200.502,596.39 216.28 3,448.80 287.29 933.67 77.77 2,651.54 220.87 2,196.90 183.00 80 2,941.72 245.05 3,907.48 325.49 1,057.85 88.12 3,004.19 250.25 2,489.08 207.342,630.82 219.15 3,526.53 293.76 954.71 79.53 2,704.28 225.27 2,232.36 185.96 81 2,980.73 248.29 3,995.55 332.83 1,081.69 90.11 3,063.95 255.23 2,529.26 210.692,666.53 222.12 3,606.48 300.42 976.36 81.33 2,748.17 228.92 2,274.55 189.47 82 3,021.16 251.66 4,086.15 340.38 1,106.22 92.15 3,113.68 259.37 2,577.06 214.672,701.11 225.00 3,684.41 306.91 997.46 83.09 2,795.69 232.88 2,344.50 195.30 83 3,060.35 254.93 4,174.45 347.73 1,130.12 94.14 3,167.51 263.85 2,656.32 221.272,750.30 229.10 3,760.89 313.28 1,018.17 84.81 2,849.87 237.39 2,395.29 199.53 84 3,116.08 259.57 4,261.09 354.95 1,153.58 96.09 3,228.91 268.97 2,713.86 226.062,803.06 233.49 3,833.06 319.29 1,037.70 86.44 2,904.94 241.98 2,432.77 202.65 85 3,175.87 264.55 4,342.85 361.76 1,175.71 97.94 3,291.29 274.16 2,756.33 229.602,864.73 238.63 3,917.38 326.32 1,060.53 88.34 2,973.13 247.66 2,493.25 207.69 86 3,245.74 270.37 4,438.40 369.72 1,201.58 100.09 3,368.57 280.60 2,824.86 235.312,927.75 243.88 4,003.56 333.50 1,083.86 90.29 3,042.87 253.47 2,554.99 212.83 87 3,317.15 276.32 4,536.03 377.85 1,228.02 102.29 3,447.58 287.18 2,894.79 241.142,992.17 249.25 4,091.64 340.83 1,107.70 92.27 3,114.16 259.41 2,618.00 218.08 88 3,390.13 282.40 4,635.83 386.16 1,255.03 104.54 3,528.35 293.91 2,966.19 247.083,057.99 254.73 4,181.65 348.33 1,132.07 94.30 3,187.06 265.48 2,682.34 223.44 89 3,464.70 288.61 4,737.82 394.66 1,282.64 106.84 3,610.93 300.79 3,039.08 253.163,125.27 260.33 4,273.65 355.99 1,156.98 96.38 3,261.58 271.69 2,748.01 228.91 90 3,540.93 294.96 4,842.04 403.34 1,310.86 109.20 3,695.36 307.82 3,113.50 259.353,194.02 266.06 4,367.68 363.83 1,182.44 98.50 3,336.53 277.93 2,815.57 234.54 91 3,618.83 301.45 4,948.57 412.22 1,339.70 111.60 3,780.30 314.90 3,190.04 265.733,264.30 271.92 4,463.76 371.83 1,208.45 100.66 3,413.20 284.32 2,884.51 240.28 92 3,698.44 308.08 5,057.43 421.28 1,369.17 114.05 3,867.16 322.13 3,268.14 272.243,336.10 277.90 4,561.97 380.01 1,235.03 102.88 3,491.60 290.85 2,954.85 246.14 93 3,779.80 314.86 5,168.70 430.55 1,399.30 116.56 3,955.99 329.53 3,347.85 278.883,409.50 284.01 4,662.33 388.37 1,262.21 105.14 3,571.79 297.53 3,026.67 252.12 94 3,862.96 321.78 5,282.42 440.03 1,430.08 119.13 4,046.84 337.10 3,429.21 285.653,484.51 290.26 4,764.89 396.92 1,289.98 107.46 3,653.79 304.36 3,099.97 258.23 95 3,947.94 328.86 5,398.62 449.71 1,461.54 121.75 4,139.74 344.84 3,512.26 292.573,484.51 290.26 4,764.89 396.92 1,289.98 107.46 3,653.79 304.36 3,099.97 258.23 96 3,947.94 328.86 5,398.62 449.71 1,461.54 121.75 4,139.74 344.84 3,512.26 292.573,484.51 290.26 4,764.89 396.92 1,289.98 107.46 3,653.79 304.36 3,099.97 258.23 97 3,947.94 328.86 5,398.62 449.71 1,461.54 121.75 4,139.74 344.84 3,512.26 292.573,484.51 290.26 4,764.89 396.92 1,289.98 107.46 3,653.79 304.36 3,099.97 258.23 98 3,947.94 328.86 5,398.62 449.71 1,461.54 121.75 4,139.74 344.84 3,512.26 292.573,484.51 290.26 4,764.89 396.92 1,289.98 107.46 3,653.79 304.36 3,099.97 258.23 99 3,947.94 328.86 5,398.62 449.71 1,461.54 121.75 4,139.74 344.84 3,512.26 292.57



OHIOAttained Age Rates -- Effective 10/1/2020 -- Area II (450-454, 459)

STANDARD ANNUAL & MONTHLY BANK DRAFT RATES

FEMALE RATES MALE RATESPlan F Attained

AgePlan A Plan FPlan G Plan N Plan G Plan NPlan A


Plan HDF Plan HDF

CHLIC-OC-2020-OH 5 01/21


1,735.67 144.58 2,254.77 187.82 610.42 50.85 1,736.02 144.61 1,422.42 118.49 65 1,966.51 163.81 2,554.64 212.80 691.61 57.61 1,966.90 163.84 1,611.62 134.251,735.67 144.58 2,254.77 187.82 610.42 50.85 1,736.02 144.61 1,422.42 118.49 66 1,966.51 163.81 2,554.64 212.80 691.61 57.61 1,966.90 163.84 1,611.62 134.251,735.67 144.58 2,254.77 187.82 610.42 50.85 1,736.02 144.61 1,422.42 118.49 67 1,966.51 163.81 2,554.64 212.80 691.61 57.61 1,966.90 163.84 1,611.62 134.251,747.41 145.56 2,270.03 189.09 614.55 51.19 1,772.40 147.64 1,430.03 119.12 68 1,979.82 164.92 2,571.93 214.24 696.29 58.00 2,008.13 167.28 1,620.23 134.971,813.50 151.06 2,355.88 196.25 637.80 53.13 1,839.86 153.26 1,485.34 123.73 69 2,054.70 171.16 2,669.22 222.35 722.62 60.19 2,084.56 173.64 1,682.89 140.191,877.46 156.39 2,438.95 203.16 660.28 55.00 1,895.38 157.89 1,528.15 127.30 70 2,127.15 177.19 2,763.34 230.19 748.10 62.32 2,147.47 178.88 1,731.40 144.231,937.55 161.40 2,517.03 209.67 681.42 56.76 1,956.71 162.99 1,580.24 131.63 71 2,195.24 182.86 2,851.80 237.55 772.05 64.31 2,216.96 184.67 1,790.40 149.141,997.65 166.40 2,595.10 216.17 702.55 58.52 2,018.02 168.10 1,629.68 135.75 72 2,263.32 188.53 2,940.24 244.92 795.99 66.31 2,286.42 190.46 1,846.44 153.812,057.72 171.41 2,673.15 222.67 723.69 60.28 2,079.31 173.21 1,679.13 139.87 73 2,331.40 194.21 3,028.67 252.29 819.93 68.30 2,355.86 196.24 1,902.46 158.472,117.79 176.41 2,751.18 229.17 744.81 62.04 2,140.58 178.31 1,728.59 143.99 74 2,399.45 199.87 3,117.09 259.65 843.87 70.29 2,425.27 202.03 1,958.48 163.142,188.50 182.30 2,843.04 236.83 769.67 64.11 2,214.75 184.49 1,778.03 148.11 75 2,479.57 206.55 3,221.16 268.32 872.05 72.64 2,509.31 209.03 2,014.52 167.812,259.98 188.26 2,935.89 244.56 794.81 66.21 2,292.63 190.98 1,829.33 152.38 76 2,560.56 213.29 3,326.37 277.09 900.53 75.01 2,597.54 216.38 2,072.62 172.652,324.07 193.60 3,031.66 252.54 820.74 68.37 2,365.25 197.03 1,905.03 158.69 77 2,633.18 219.34 3,434.87 286.13 929.90 77.46 2,679.82 223.23 2,158.40 179.792,383.04 198.51 3,127.82 260.55 846.77 70.54 2,430.84 202.49 1,978.05 164.77 78 2,699.98 224.91 3,543.82 295.20 959.40 79.92 2,754.13 229.42 2,241.13 186.692,444.57 203.63 3,228.15 268.91 873.94 72.80 2,493.89 207.74 2,050.72 170.83 79 2,769.70 230.72 3,657.51 304.67 990.18 82.48 2,825.58 235.37 2,323.46 193.542,506.35 208.78 3,329.20 277.32 901.29 75.08 2,559.59 213.21 2,120.72 176.66 80 2,839.70 236.55 3,771.99 314.21 1,021.16 85.06 2,900.01 241.57 2,402.77 200.152,539.59 211.55 3,404.25 283.57 921.61 76.77 2,610.50 217.45 2,154.94 179.51 81 2,877.36 239.68 3,857.00 321.29 1,044.18 86.98 2,957.70 246.38 2,441.55 203.382,574.05 214.42 3,481.41 290.00 942.50 78.51 2,652.86 220.98 2,195.68 182.90 82 2,916.41 242.94 3,944.44 328.57 1,067.86 88.95 3,005.70 250.38 2,487.71 207.232,607.44 217.20 3,556.65 296.27 962.87 80.21 2,698.74 224.81 2,263.20 188.52 83 2,954.23 246.09 4,029.70 335.67 1,090.93 90.87 3,057.68 254.70 2,564.21 213.602,654.92 221.15 3,630.48 302.42 982.86 81.87 2,751.05 229.16 2,312.23 192.61 84 3,008.03 250.57 4,113.34 342.64 1,113.58 92.76 3,116.95 259.64 2,619.76 218.232,705.86 225.40 3,700.14 308.22 1,001.71 83.44 2,804.20 233.59 2,348.41 195.62 85 3,065.75 255.38 4,192.25 349.21 1,134.95 94.54 3,177.16 264.66 2,660.75 221.642,765.39 230.36 3,781.54 315.00 1,023.75 85.28 2,870.04 239.07 2,406.80 200.49 86 3,133.19 260.99 4,284.48 356.90 1,159.91 96.62 3,251.76 270.87 2,726.90 227.152,826.23 235.42 3,864.72 321.93 1,046.28 87.15 2,937.36 244.68 2,466.39 205.45 87 3,202.12 266.74 4,378.74 364.75 1,185.43 98.75 3,328.02 277.22 2,794.42 232.772,888.41 240.60 3,949.76 329.01 1,069.30 89.07 3,006.18 250.41 2,527.21 210.52 88 3,272.57 272.61 4,475.07 372.77 1,211.51 100.92 3,406.00 283.72 2,863.33 238.522,951.95 245.90 4,036.65 336.25 1,092.82 91.03 3,076.54 256.28 2,589.32 215.69 89 3,344.56 278.60 4,573.53 380.97 1,238.16 103.14 3,485.71 290.36 2,933.70 244.383,016.89 251.31 4,125.45 343.65 1,116.86 93.03 3,148.48 262.27 2,652.72 220.97 90 3,418.14 284.73 4,674.15 389.36 1,265.40 105.41 3,567.21 297.15 3,005.53 250.363,083.26 256.84 4,216.21 351.21 1,141.43 95.08 3,220.84 268.30 2,717.93 226.40 91 3,493.34 291.00 4,776.98 397.92 1,293.24 107.73 3,649.20 303.98 3,079.42 256.523,151.10 262.49 4,308.98 358.94 1,166.54 97.17 3,294.85 274.46 2,784.47 231.95 92 3,570.19 297.40 4,882.06 406.68 1,321.70 110.10 3,733.06 310.96 3,154.81 262.803,220.42 268.26 4,403.76 366.83 1,192.20 99.31 3,370.53 280.76 2,852.39 237.60 93 3,648.74 303.94 4,989.47 415.62 1,350.76 112.52 3,818.81 318.11 3,231.76 269.213,291.28 274.16 4,500.66 374.90 1,218.43 101.50 3,447.93 287.21 2,921.70 243.38 94 3,729.01 310.63 5,099.25 424.77 1,380.49 114.99 3,906.50 325.41 3,310.30 275.753,363.68 280.19 4,599.66 383.15 1,245.24 103.73 3,527.09 293.81 2,992.46 249.27 95 3,811.05 317.46 5,211.42 434.11 1,410.86 117.53 3,996.19 332.88 3,390.46 282.433,363.68 280.19 4,599.66 383.15 1,245.24 103.73 3,527.09 293.81 2,992.46 249.27 96 3,811.05 317.46 5,211.42 434.11 1,410.86 117.53 3,996.19 332.88 3,390.46 282.433,363.68 280.19 4,599.66 383.15 1,245.24 103.73 3,527.09 293.81 2,992.46 249.27 97 3,811.05 317.46 5,211.42 434.11 1,410.86 117.53 3,996.19 332.88 3,390.46 282.433,363.68 280.19 4,599.66 383.15 1,245.24 103.73 3,527.09 293.81 2,992.46 249.27 98 3,811.05 317.46 5,211.42 434.11 1,410.86 117.53 3,996.19 332.88 3,390.46 282.433,363.68 280.19 4,599.66 383.15 1,245.24 103.73 3,527.09 293.81 2,992.46 249.27 99 3,811.05 317.46 5,211.42 434.11 1,410.86 117.53 3,996.19 332.88 3,390.46 282.43



OHIOAttained Age Rates -- Effective 10/1/2020 -- Area III (436, 440-445)



AgePlan A Plan F Plan G Plan N


Plan HDF Plan HDF

CHLIC-OC-2020-OH 6 01/21


1,909.24 159.04 2,480.25 206.60 671.46 55.93 1,909.62 159.07 1,564.66 130.34 65 2,163.16 180.19 2,810.12 234.08 760.77 63.37 2,163.59 180.23 1,772.77 147.671,909.24 159.04 2,480.25 206.60 671.46 55.93 1,909.62 159.07 1,564.66 130.34 66 2,163.16 180.19 2,810.12 234.08 760.77 63.37 2,163.59 180.23 1,772.77 147.671,909.24 159.04 2,480.25 206.60 671.46 55.93 1,909.62 159.07 1,564.66 130.34 67 2,163.16 180.19 2,810.12 234.08 760.77 63.37 2,163.59 180.23 1,772.77 147.671,922.16 160.12 2,497.03 208.00 676.01 56.31 1,949.64 162.40 1,573.04 131.03 68 2,177.80 181.41 2,829.13 235.67 765.91 63.80 2,208.94 184.00 1,782.25 148.461,994.86 166.17 2,591.47 215.87 701.57 58.44 2,023.85 168.59 1,633.89 136.10 69 2,260.17 188.27 2,936.13 244.58 794.89 66.21 2,293.02 191.01 1,851.19 154.202,065.20 172.03 2,682.86 223.48 726.32 60.50 2,084.92 173.67 1,680.96 140.02 70 2,339.87 194.91 3,039.68 253.21 822.91 68.55 2,362.21 196.77 1,904.54 158.652,131.31 177.54 2,768.74 230.64 749.56 62.44 2,152.38 179.29 1,738.26 144.80 71 2,414.77 201.15 3,136.98 261.31 849.26 70.74 2,438.65 203.14 1,969.45 164.052,197.40 183.04 2,854.60 237.79 772.81 64.38 2,219.82 184.91 1,792.65 149.33 72 2,489.67 207.39 3,234.27 269.41 875.59 72.94 2,515.06 209.50 2,031.08 169.192,263.49 188.55 2,940.45 244.94 796.06 66.31 2,287.24 190.53 1,847.05 153.86 73 2,564.53 213.63 3,331.53 277.52 901.93 75.13 2,591.45 215.87 2,092.71 174.322,329.57 194.05 3,026.30 252.09 819.29 68.25 2,354.64 196.14 1,901.44 158.39 74 2,639.39 219.86 3,428.79 285.62 928.26 77.32 2,667.81 222.23 2,154.33 179.462,407.35 200.53 3,127.34 260.51 846.64 70.53 2,436.23 202.94 1,955.84 162.92 75 2,727.53 227.20 3,543.28 295.16 959.25 79.91 2,760.24 229.93 2,215.97 184.592,485.98 207.08 3,229.48 269.02 874.30 72.83 2,521.89 210.07 2,012.26 167.62 76 2,816.61 234.62 3,659.00 304.79 990.59 82.52 2,857.29 238.01 2,279.89 189.912,556.48 212.96 3,334.83 277.79 902.82 75.20 2,601.77 216.73 2,095.53 174.56 77 2,896.50 241.28 3,778.36 314.74 1,022.89 85.21 2,947.80 245.55 2,374.24 197.772,621.34 218.36 3,440.61 286.60 931.45 77.59 2,673.92 222.74 2,175.86 181.25 78 2,969.98 247.40 3,898.20 324.72 1,055.33 87.91 3,029.55 252.36 2,465.25 205.362,689.04 224.00 3,550.98 295.80 961.33 80.08 2,743.28 228.52 2,255.79 187.91 79 3,046.67 253.79 4,023.26 335.14 1,089.19 90.73 3,108.14 258.91 2,555.81 212.902,757.00 229.66 3,662.13 305.06 991.42 82.59 2,815.55 234.54 2,332.79 194.32 80 3,123.68 260.20 4,149.18 345.63 1,123.28 93.57 3,190.01 265.73 2,643.04 220.172,793.55 232.70 3,744.67 311.93 1,013.77 84.45 2,871.56 239.20 2,370.44 197.46 81 3,165.10 263.65 4,242.70 353.42 1,148.60 95.68 3,253.47 271.01 2,685.71 223.722,831.47 235.86 3,829.56 319.00 1,036.75 86.36 2,918.16 243.08 2,415.25 201.19 82 3,208.04 267.23 4,338.90 361.43 1,174.64 97.85 3,306.28 275.41 2,736.46 227.952,868.19 238.92 3,912.32 325.90 1,059.16 88.23 2,968.62 247.29 2,489.52 207.38 83 3,249.65 270.70 4,432.66 369.24 1,200.03 99.96 3,363.44 280.17 2,820.62 234.962,920.42 243.27 3,993.52 332.66 1,081.15 90.06 3,026.15 252.08 2,543.45 211.87 84 3,308.83 275.63 4,524.66 376.90 1,224.94 102.04 3,428.64 285.61 2,881.73 240.052,976.44 247.94 4,070.15 339.04 1,101.89 91.79 3,084.62 256.95 2,583.25 215.18 85 3,372.32 280.91 4,611.48 384.14 1,248.44 103.99 3,494.88 291.12 2,926.82 243.803,041.93 253.39 4,159.69 346.50 1,126.13 93.81 3,157.04 262.98 2,647.48 220.53 86 3,446.50 287.09 4,712.94 392.59 1,275.90 106.28 3,576.93 297.96 2,999.59 249.873,108.85 258.97 4,251.21 354.13 1,150.90 95.87 3,231.08 269.15 2,713.03 226.00 87 3,522.33 293.41 4,816.61 401.22 1,303.98 108.62 3,660.83 304.95 3,073.85 256.053,177.25 264.67 4,344.73 361.92 1,176.22 97.98 3,306.79 275.46 2,779.93 231.57 88 3,599.82 299.87 4,922.58 410.05 1,332.66 111.01 3,746.60 312.09 3,149.67 262.373,247.15 270.49 4,440.31 369.88 1,202.10 100.13 3,384.20 281.90 2,848.25 237.26 89 3,679.01 306.46 5,030.88 419.07 1,361.98 113.45 3,834.28 319.40 3,227.07 268.813,318.58 276.44 4,538.00 378.01 1,228.55 102.34 3,463.33 288.50 2,918.00 243.07 90 3,759.96 313.20 5,141.55 428.29 1,391.95 115.95 3,923.94 326.86 3,306.08 275.403,391.59 282.52 4,637.84 386.33 1,255.58 104.59 3,542.92 295.12 2,989.73 249.04 91 3,842.68 320.10 5,254.66 437.71 1,422.56 118.50 4,014.13 334.38 3,387.36 282.173,466.21 288.74 4,739.87 394.83 1,283.20 106.89 3,624.32 301.91 3,062.93 255.14 92 3,927.21 327.14 5,370.27 447.34 1,453.87 121.11 4,106.36 342.06 3,470.29 289.073,542.46 295.09 4,844.15 403.52 1,311.42 109.24 3,707.58 308.84 3,137.62 261.36 93 4,013.61 334.33 5,488.41 457.18 1,485.85 123.77 4,200.69 349.92 3,554.93 296.133,620.40 301.58 4,950.72 412.40 1,340.28 111.65 3,792.72 315.93 3,213.88 267.72 94 4,101.91 341.69 5,609.16 467.24 1,518.54 126.49 4,297.16 357.95 3,641.33 303.323,700.05 308.21 5,059.63 421.47 1,369.77 114.10 3,879.80 323.19 3,291.72 274.20 95 4,192.15 349.21 5,732.56 477.52 1,551.95 129.28 4,395.81 366.17 3,729.51 310.673,700.05 308.21 5,059.63 421.47 1,369.77 114.10 3,879.80 323.19 3,291.72 274.20 96 4,192.15 349.21 5,732.56 477.52 1,551.95 129.28 4,395.81 366.17 3,729.51 310.673,700.05 308.21 5,059.63 421.47 1,369.77 114.10 3,879.80 323.19 3,291.72 274.20 97 4,192.15 349.21 5,732.56 477.52 1,551.95 129.28 4,395.81 366.17 3,729.51 310.673,700.05 308.21 5,059.63 421.47 1,369.77 114.10 3,879.80 323.19 3,291.72 274.20 98 4,192.15 349.21 5,732.56 477.52 1,551.95 129.28 4,395.81 366.17 3,729.51 310.673,700.05 308.21 5,059.63 421.47 1,369.77 114.10 3,879.80 323.19 3,291.72 274.20 99 4,192.15 349.21 5,732.56 477.52 1,551.95 129.28 4,395.81 366.17 3,729.51 310.67



OHIO

FEMALE RATES MALE RATES

Attained Age Rates -- Effective 10/1/2020 -- Area III (436, 440-445)STANDARD ANNUAL & MONTHLY BANK DRAFT RATES

Plan A Plan F Plan G Plan N Attained Age

Plan A Plan F Plan G


Plan NPlan HDF Plan HDF

CHLIC-OC-2020-OH 7 01/21

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CHLIC-OC-2020-OH 8 01/21

PREMIUM INFORMATION We, Cigna Health and Life Insurance Company, can only raise your premium if we raise the premium for all policies like yours in this State. Your premium will increase each year because of the increase in your attained age. HOUSEHOLD DISCOUNT Household Discount is a discount that is available when more than one member of your household enrolls or is enrolled in a Medicare Supplement policy provided by or through an Affiliate of Cigna Health and Life Insurance Company. The Household Discount will be removed if the other Medicare Supplement policyholder whose policy status entitles you to the discount no longer resides with you or no longer has a Medicare Supplement policy through Cigna Health and Life Insurance Company or an Affiliate of Cigna Health and Life Insurance Company. The addition or removal of the discount will occur on the billing cycle following the date we learn your eligibility has changed. 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 your insurance company. RIGHT TO RETURN POLICY If you find that you are not satisfied with your policy, you may return it to PO Box 5700, Scranton, PA 18505. If you send the policy back to us within 30 days after you receive it, we will treat the policy as if it had never been issued and return all of your payments. 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 The policy may not fully cover all of your medical costs. Neither Cigna Health and 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. The company 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.

CHLIC-OC-2020-OH 9 01/21

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CHLIC-OC-2020-OH 10 01/21

PLAN A MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD

*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.

SERVICES MEDICARE PAYS PLAN A PAYS YOU PAY HOSPITALIZATION* Semi-private room and board, general nursing, and miscellaneous services and supplies First 60 days 61st through 90th day 91st day and after: – while using 60 lifetime reserve days – once lifetime reserve days are used, additional 365 days – beyond the additional 365 days

All but $1,484 All but $371 per day All but $742 per day $0 $0

$0 $371 per day $742 per day 100% of Medicare eligible expenses $0

$1,484 (Part A deductible) $0 $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 entering a Medicare-approved facility within 30 days after leaving the hospital First 20 days 21st through 100th day 101st day and after

All approved amounts All but $185.50 per day $0

$0 $0 $0

$0 Up to $185.50 per day All costs

BLOOD First 3 pints Additional amounts

$0 100%

3 pints $0

$0 $0

HOSPICE CARE You must meet Medicare’s requirements, including a doctor’s certification of terminal illness

All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care

Medicare copayment/coinsurance $0

**NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Benefits.” During this time, the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.

CHLIC-OC-2020-OH 11 01/21

PLAN A MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR

*Once you have been billed $203 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.

SERVICES MEDICARE PAYS PLAN A PAYS YOU PAY MEDICAL EXPENSES – IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $203 of Medicare-approved amounts* Remainder of Medicare-approved amounts

$0 Generally 80%

$0 Generally 20%

$203 (Part B deductible) $0

PART B EXCESS CHARGES (above Medicare-approved amounts)

$0 $0 All costs

BLOOD First 3 pints Next $203 of Medicare-approved amounts* Remainder of Medicare-approved amounts

$0 $0 80%

All costs $0 20%

$0 $203 (Part B deductible) $0

CLINICAL LABORATORY SERVICES Tests for diagnostic services

100% $0 $0

PARTS A & B

SERVICES MEDICARE PAYS PLAN A PAYS YOU PAY HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically-necessary skilled care services and medical supplies Durable medical equipment First $203 of Medicare-approved amounts* Remainder of Medicare-approved amounts

100% $0 80%

$0 $0 20%


CHLIC-OC-2020-OH 12 01/21

PLAN F MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD


SERVICES MEDICARE PAYS PLAN F PAYS YOU PAY HOSPITALIZATION* Semi-private room and board, general nursing, and miscellaneous services and supplies First 60 days 61st through 90th day 91st day and after: – while using 60 lifetime reserve days – once lifetime reserve days are used, additional 365 days – beyond the additional 365 days


$1,484 (Part A deductible) $371 per day $742 per day 100% of Medicare eligible expenses $0

$0 $0 $0 $0** All costs



$0 Up to $185.50 per day $0

$0 $0 All costs


$0 100%

3 pints $0

$0 $0





CHLIC-OC-2020-OH 13 01/21

PLAN F MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR


SERVICES MEDICARE PAYS PLAN F PAYS YOU PAY MEDICAL EXPENSES – IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $203 of Medicare-approved amounts* Remainder of Medicare-approved amounts

$0 Generally 80%

$203 (Part B deductible) Generally 20%

$0 $0


$0 100% $0


$0 $0 80%

All costs $203 (Part B deductible) 20%

$0 $0 $0


100% $0 $0

PARTS A & B

SERVICES MEDICARE PAYS PLAN F PAYS YOU PAY HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically-necessary skilled care services and medical supplies Durable medical equipment First $203 of Medicare-approved amounts* Remainder of Medicare-approved amounts

100% $0 80%

$0 $203 (Part B deductible) 20%

$0 $0 $0

CHLIC-OC-2020-OH 14 01/21

PLAN F MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR (cont’d.)

OTHER BENEFITS – NOT COVERED BY MEDICARE

SERVICES MEDICARE PAYS PLAN F PAYS YOU PAY

FOREIGN TRAVEL – NOT COVERED BY MEDICARE Medically-necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year Remainder of charges

$0 $0

$0 80% to a lifetime maximum benefit of $50,000

$250 20% and amounts over the $50,000 lifetime maximum

CHLIC-OC-2020-OH 15 01/21

HIGH-DEDUCTIBLE PLAN F MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD


**This high-deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,370 deductible. Benefits from the high-deductible Plan F

will not begin until out-of-pocket expenses are $2,370. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductible for Part A and Part B, but does not include the plan’s separate foreign travel emergency deductible.

SERVICES MEDICARE PAYS AFTER YOU PAY $2,370 DEDUCTIBLE**, PLAN PAYS

IN ADDITION TO $2,370 DEDUCTIBLE**, YOU PAY

HOSPITALIZATION* Semi-private room and board, general nursing, and miscellaneous services and supplies First 60 days 61st through 90th day 91st day and after: – while using 60 lifetime reserve days – once lifetime reserve days are used, additional 365 days – beyond the additional 365 days



$0 $0 $0 $0*** All costs



$0 Up to $185.50 per day $0

$0 $0 All costs


$0 100%

3 pints $0

$0 $0




***NOTICE: When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy’s “Core Benefits.” During this time, the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.

CHLIC-OC-2020-OH 16 01/21

HIGH-DEDUCTIBLE PLAN F MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR


**This high-deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,370 deductible. Benefits from the high-deductible Plan F

will not begin until out-of-pocket expenses are $2,370. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. This includes the Medicare deductible for Part A and Part B, but does not include the plan’s separate foreign travel emergency deductible.



MEDICAL EXPENSES – IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $203 of Medicare-approved amounts* Remainder of Medicare-approved amounts

$0 Generally 80%

$203 (Part B deductible) Generally 20%

$0 $0


$0 100% $0


$0 $0 80%

All costs $203 (Part B deductible) 20%

$0 $0 $0


100% $0 $0

PARTS A & B



HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically-necessary skilled care services and medical supplies Durable medical equipment First $203 of Medicare-approved amounts* Remainder of Medicare-approved amounts

100% $0 80%

$0 $203 (Part B deductible) 20%

$0 $0 $0

CHLIC-OC-2020-OH 17 01/21

HIGH-DEDUCTIBLE PLAN F MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR (cont’d.)


SERVICES MEDICARE PAYS AFTER YOU PAY $2,370

DEDUCTIBLE**, PLAN PAYS IN ADDITION TO $2,370

DEDUCTIBLE**, YOU PAY FOREIGN TRAVEL – NOT COVERED BY MEDICARE Medically-necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year Remainder of charges

$0 $0



CHLIC-OC-2020-OH 18 01/21

PLAN G MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD


SERVICES MEDICARE PAYS PLAN G PAYS YOU PAY HOSPITALIZATION* Semi-private room and board, general nursing, and miscellaneous services and supplies First 60 days 61st through 90th day 91st day and after: – while using 60 lifetime reserve days – once lifetime reserve days are used, additional 365 days – beyond the additional 365 days



$0 $0 $0 $0** All costs



$0 Up to $185.50 per day $0

$0 $0 All costs


$0 100%

3 pints $0

$0 $0





CHLIC-OC-2020-OH 19 01/21

PLAN G MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR


SERVICES MEDICARE PAYS PLAN G PAYS YOU PAY MEDICAL EXPENSES – IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $203 of Medicare-approved amounts* Remainder of Medicare-approved amounts

$0 Generally 80%

$0 Generally 20%

$203 (Part B deductible) $0


$0 100% $0


$0 $0 80%

All costs $0 20%



100% $0 $0

PARTS A & B

SERVICES MEDICARE PAYS PLAN G PAYS YOU PAY HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically-necessary skilled care services and medical supplies Durable medical equipment First $203 of Medicare-approved amounts* Remainder of Medicare-approved amounts

100% $0 80%

$0 $0 20%


CHLIC-OC-2020-OH 20 01/21

PLAN G MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR (cont’d.)


SERVICES MEDICARE PAYS PLAN G PAYS YOU PAY


$0 $0



CHLIC-OC-2020-OH 21 01/21

PLAN N MEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD


SERVICES MEDICARE PAYS PLAN N PAYS YOU PAY HOSPITALIZATION* Semi-private room and board, general nursing, and miscellaneous services and supplies First 60 days 61st through 90th day 91st day and after: – while using 60 lifetime reserve days – once lifetime reserve days are used, additional 365 days – beyond the additional 365 days



$0 $0 $0 $0** All costs



$0 Up to $185.50 per day $0

$0 $0 All costs


$0 100%

3 pints $0

$0 $0





CHLIC-OC-2020-OH 22 01/21

PLAN N MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR


SERVICES MEDICARE PAYS PLAN N PAYS YOU PAY MEDICAL EXPENSES – IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT such as physician’s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $203 of Medicare-approved amounts* Remainder of Medicare-approved amounts

$0 Generally 80%

$0 Balance, other than up to $20 per office visit and up to $50 per emergency room visit. The copayment of up to $50 is waived if the Insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense.

$203 (Part B deductible) Up to $20 per office visit and up to $50 per emergency room visit. The copayment of up to $50 is waived if the Insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense.


$0 $0 All costs


$0 $0 80%

All costs $0 20%



100% $0 $0

PARTS A & B

SERVICES MEDICARE PAYS PLAN N PAYS YOU PAY

HOME HEALTH CARE MEDICARE-APPROVED SERVICES Medically-necessary skilled care services and medical supplies Durable medical equipment First $203 of Medicare-approved amounts* Remainder of Medicare-approved amounts

100% $0 80%

$0 $0 20%


CHLIC-OC-2020-OH 23 01/21

PLAN N MEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR (cont’d.)


SERVICES MEDICARE PAYS PLAN N PAYS YOU PAY


$0 $0



CHLIC-OC-2020-OH 24 01/21

CIGNA HEALTH AND LIFE INSURANCE COMPANY PO Box ......CIGNA HEALTH AND LIFE INSURANCE COMPANY PO Box...

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