Applicant's Name

Policy Number

Name of Existing Insurer

Expiration Date of Existing Insurance

SERVICE

BENEFIT

MEDICARE PAYS

EXISTING COVERAGE

SUPPLEMENT PAYS

YOU PAY

Hospital

Inpatient

First 60 Days

All But

($        )

61^st to 90^th Day

All But

($        )

a Day

91^st to 150^th Day (Lifetime Reserve)

($        )

a Day

Beyond 150 Days

Nothing

Skilled

Nursing

Home Care

First 20 Days

Additional 80

Days

100% of Cost

All But

($        )

A Day

Beyond 100

Days

Nothing

Medical

Expense

Physician's Services in hospital, office or home, inpatient and out-patient medical services and supplies at a hospital, physical and speech therapy and ambulance

80% of Medicare Determined allowable charges after

($              ) Deductible

Prescription Drugs

Inpatient Prescription Drugs.  80% of allowable charges for immunosuppressive drugs during the first year following a covered transplant.

DATE

SIGNATURE OF APPLICANT

SIGNATURE OF INSURANCE PRODUCER