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Medicare Supplement Insurance
Stonebridge Life Insurance Company
Application for Oregon
You can rely on Stonebridge Life Insurance Company’s Medicare Supplement Plans to help pay your
Medicare Parts A and B charges Medicare doesn’t cover.
What’s more, you have:
	 •	 Multiple plans from which to select the coverage that best meets your needs.
	 •	 Your choice of physicians and specialists for your personalized care.
	 •	 The option to use any hospital or medical facility.
	 •	 Virtually no claims paperwork to file.
Put a Stonebridge Life Insurance Company
Medicare Supplement Plan on your team today.
Medicare Supplement insurance is underwritten by:
Stonebridge Life Insurance Company
Administrative Office:
4333 Edgewood Road NE, Cedar Rapids, Iowa 52499
Home Office: Rutland, VT
Choose the Medicare Supplement Plan
that’s Right for You.
This program is not connected with or endorsed by the U.S. Government or the Federal Medicare Program.
2014 Medicare Supplement Insurance Plans
78965MS_OR 1113
Medicare Part A Hospital Coverage
The Stonebridge Standard Plan pays the $1,216
Part A (inpatient) deductible for plans F, G & N for
each benefit period.
First 60-days - After the Part A Deductible, Medicare pays
all eligible expenses for services from your first through
60th day of hospital confinement. Services include semi-
private room and board, general nursing and miscellaneous
hospital services and supplies.
Co-insurance – Stonebridge Standard Plans A, F, G &
N pay $304 a day when you are hospitalized from the
61st day through the 90th day. When you are hospitalized
from the 91st day through the 150th day, Stonebridge
Standard Plans pay $608 a day for each Lifetime Reserve
day used.
Extended Hospital Coverage – If you are in the hospital
longer than 150 days during a benefit period and you have
exhausted your 60 days of Medicare Lifetime Reserve the
Stonebridge Standard Plans A, F, G & N pay the Part A
Medicare eligible expenses for hospitalization, paid at the
same rate Medicare would have paid had Medicare Part
A hospital days not been exhausted, subject to a lifetime
maximum benefit of an additional 365 days.
Benefit for Blood – Medicare has one calendar
year deductible for blood that is the cost of the first
three pints. Stonebridge Standard Plans A, F, G & N
pay the deductible.
Skilled Nursing Facility Care – Medicare pays all eligible
expenses for the first 20 days. Stonebridge Standard Plans
F, G & N pay up to $152 from the 21st through the 100th
day during which you receive skilled nursing care. You must
enter a Medicare certified skilled nursing facility within 30
days of being hospitalized for at least three days.
Hospice Care – Medicare pays all but a very limited Co-
insurance/Co-payment for outpatient drugs and inpatient
respite care. Stonebridge Standard Plans A, F, G & N pay
the Co-insurance/Co-payment.
MSH1A,F,G,N OR (EXISTING BUSINESS)
MSH2A,F,G,N OR (NEW BUSINESS)
Medicare Part B Physician
Services and Supplies
Deductible - Stonebridge Standard Plan F pays the $147
calendar-year deductible.
Co-insurance – After the Part B Deductible, Stonebridge
Standard Plans A, F, G & N generally pay 20% of eligible
expenses for physician’s services, supplies, physical
and speech therapy and diagnostic tests and durable
medical equipment.
After the Part B deductible, Plan N pays balance of the
eligible expenses for physician’s services, supplies, physical
and speech therapy, diagnostic tests and durable medical
equipment except up to a $20 co-payment for office visits
and up to a $50 co-payment for emergency room visits.
For hospital outpatient services, the co-payment amount
will be paid under a prospective payment system. If this
system is not used, then 20% of eligible expenses will
be paid.
Excess Benefits – Your bill for Part B services and
supplies may exceed the Medicare eligible expense.
When that occurs, Stonebridge Standard Plans F
and G pays 100% up to the charge limitation established
by Medicare.
BenefitforBlood–StonebridgeStandardPlansA, F, G & N
pay expenses for the first three pints of blood.
Additional Benefits**
Emergency Care received outside the U.S. After
you pay a $250 calendar-year deductible, Stonebridge
Standard Plans F, G & N pay you 80% of eligible expenses
for care which begins during the first 60 days of a trip up
to a lifetime maximum of $50,000. Benefits are payable
for health care you need because of a covered injury
or illness.
covered benefits
78965MS_OR 1113
PREMIUM INFORMATION
You cannot be singled out for a rate increase, no matter how many times you receive benefits. Your
premium changes when the same premium change is made on all in-force Medicare Supplement policies
of the same form issued to persons of your classification in the same geographic area of your state.  
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 the insurance
contract. You must read the Policy itself to understand all of the rights and duties of both you and
Stonebridge Life Insurance Company.
RIGHT TO RETURN POLICY
If you find that you are not satisfied with your Policy, you may return it to Stonebridge Life Insurance
Company, 4333 Edgewood Road, Cedar Rapids, Iowa 52499.
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
•	 This Policy may not fully cover all of your medical costs.
•	 Neither Stonebridge 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 Medicare and You for 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.
STONEBRIDGE LIFE INSURANCE COMPANY
Administrative Office: 4333 Edgewood Rd. NE, Cedar Rapids, IA 52499
Home Office: Rutland, VT
78965MS_OR 1113
MSH1O
STONEBRIDGELIFEINSURANCECOMPANY
OUTLINEOFMEDICARESUPPLEMENTCOVERAGE–COVERPAGE
BENEFITPLANSA,F,GANDN
ThesechartsshowthebenefitsincludedineachofthestandardMedicaresupplementplans.EverycompanymustmakeavailablePlan“A”.Some
plansmaynotbeavailableinyourstate.SeeOutlinesofCoveragesectionsfordetailsaboutALLplans.
BasicBenefits:
Hospitalization:PartAcoinsurancepluscoveragefor365additionaldaysafterMedicarebenefitsend.
MedicalExpenses:PartBcoinsurance(generally20%ofMedicare-approvedexpenses)orcopaymentsforhospitaloutpatientservices.
PlansK,LandNrequireinsured’stopayaportionofPartBcoinsuranceorcopayments.
Blood:First3pintsofbloodeachyear.
Hospice:PartAcoinsurance.
*PlanFalsohasanoptioncalledahighdeductiblePlanF.ThishighdeductibleplanpaysthesamebenefitsasPlanFafteronehaspaida
calendaryear$2,070deductible.BenefitsfromhighdeductiblePlanFwillnotbeginuntilout-of-pocketexpensesexceed$2,070.Out-ofpocket
expensesforthisdeductibleareexpensesthatwouldordinarilybepaidbythepolicy.TheseexpensesincludetheMedicaredeductiblesforPart
AandPartB,butdonotincludetheplan’sseparateforeigntravelemergencydeductible.Pleasenote:HighdeductiblePlanFiscurrentlynot
availableaspartofthisprogram.
ABCDFF*GKLMN
Basic,
including
100%PartB
Co-insurance
Basic,
Including
100%PartB
Co-insurance
Basic,
including
100%PartB
Co-insurance
Basic,
including
100%PartB
Co-insurance
Basic,
including
100%PartB
Co-insurance
Basic,
including
100%PartB
Co-insurance
Hospitalization
andpreventive
carepaidat100%;
otherbasicbenefits
paidat50%
Hospitalization
andpreventive
carepaidat100%;
otherbasicbenefits
paidat75%
Basic,
including
100%PartB
Co-insurance
Basic,including100%Part
BCo-insurance,exceptup
to$20co-paymentforoffice
visit,andupto$50co-
paymentforER
Skilled
Nursing
Facility
Co-insurance
Skilled
Nursing
Facility
Co-insurance
Skilled
Nursing
Facility
Co-insurance
Skilled
Nursing
Facility
Co-insurance
50%Skilled
Nursing
Facility
Co-insurance
75%Skilled
Nursing
Facility
Co-insurance
Skilled
Nursing
Facility
Co-insurance
Skilled
Nursing
Facility
Co-insurance
PartA
Deductible
PartA
Deductible
PartA
Deductible
PartA
Deductible
PartA
Deductible
50%PartA
Deductible
75%PartA
Deductible
50%PartA
Deductible
PartA
Deductible
PartB
Deductible
PartB
Deductible
PartBExcess
(100%)
PartBExcess
(100%)
Foreign
Travel
Emergency
Foreign
Travel
Emergency
Foreign
Travel
Emergency
Foreign
Travel
Emergency
Foreign
Travel
Emergency
Foreign
Travel
Emergency
Out-of-pocketlimit$4,660;
paidat100%afterlimit
reached
Out-of-pocketlimit
$2,330;paidat100%
afterlimitreached
25525085-OR
Non-TobaccoRatesTobaccoRates
PlanAPlanFPlanGPlanNAttained
Age
PlanAPlanFPlanGPlanN
FemaleMaleFemaleMaleFemaleMaleFemaleMaleFemaleMaleFemaleMaleFemaleMaleFemaleMale
62.0266.27104.80111.9896.64103.2680.7686.29Under6568.2272.90115.28123.18106.30113.5988.8494.92
62.0266.27104.80111.9896.64103.2680.7686.296568.2272.90115.28123.18106.30113.5988.8494.92
62.9567.36106.37113.8398.08104.9681.9787.726669.2574.10117.01125.21107.89115.4690.1796.49
63.8868.39107.94115.5799.53106.5783.1889.066770.2775.23118.73127.13109.48117.2391.5097.97
66.0070.79111.53119.62102.84110.3085.9592.186872.6077.87122.68131.58113.12121.3394.55101.40
68.0472.81114.97123.04106.01113.4688.6094.826974.8480.09126.47135.34116.61124.8197.46104.30
69.9974.89118.28126.56109.07116.7091.1597.537076.9982.38130.11139.22119.98128.37100.27107.28
71.9877.55121.64131.05112.16120.8493.74100.997179.1885.31133.80144.16123.38132.92103.11111.09
74.2180.65125.41136.28115.64125.6696.64105.027281.6388.72137.95149.91127.20138.23106.30115.52
76.5884.02129.41141.99119.33130.9399.72109.427384.2492.42142.35156.19131.26144.02109.69120.36
78.8987.48133.32147.83122.93136.31102.74113.927486.7896.23146.65162.61135.22149.94113.01125.31
80.9890.79136.85153.43126.19141.48105.46118.237589.0899.87150.54168.77138.81155.63116.01130.05
82.7893.84139.88158.57128.98146.22107.79122.207691.06103.22153.87174.43141.88160.84118.57134.42
84.3196.56142.48163.17131.38150.46109.80125.747792.74106.22156.73179.49144.52165.51120.78138.31
85.9299.25145.20167.72133.89154.65111.89129.257894.51109.18159.72184.49147.28170.12123.08142.18
87.55101.77147.94171.97136.42158.57114.00132.527996.31111.95162.73189.17150.06174.43125.40145.77
89.94104.93151.98177.31140.14163.50117.12136.648098.93115.42167.18195.04154.15179.85128.83150.30
92.55108.07156.39182.63144.21168.40120.52140.7481101.81118.88172.03200.89158.63185.24132.57154.81
95.33111.20161.10187.92148.55173.28124.15144.8182104.86122.32177.21206.71163.41190.61136.57159.29
98.26114.29166.05193.14153.11178.09127.96148.8483108.09125.72182.66212.45168.42195.90140.76163.72
101.24117.32171.08198.26157.75182.82131.84152.7884111.36129.05188.19218.09173.53201.10145.02168.06
104.23120.29176.13203.28162.41187.44135.73156.6585114.65132.32193.74223.61178.65206.18149.30172.32
107.24123.23181.22208.24167.10192.02139.65160.4786117.96135.55199.34229.06183.81211.22153.62176.52
110.34126.22186.46213.29171.93196.67143.69164.3687121.37138.84205.11234.62189.12216.34158.06180.80
113.55129.30191.89218.50176.94201.48147.87168.3888124.91142.23211.08240.35194.63221.63162.66185.22
116.74132.42197.28223.77181.91206.34152.03172.4489128.41145.66217.01246.15200.10226.97167.23189.68
119.54135.32202.01228.68186.27210.87155.67176.2290131.49148.85222.21251.55204.90231.96171.24193.84
120.68136.90203.93231.35188.04213.33157.15178.2891132.75150.59224.32254.49206.84234.66172.87196.11
121.92138.79206.03234.53189.98216.26158.77180.7392134.11152.67226.63257.98208.98237.89174.65198.80
123.25140.83208.27237.99192.05219.45160.50183.4093135.58154.91229.10261.79211.26241.40176.55201.74
124.66143.06210.66241.75194.25222.92162.34186.3094137.13157.37231.73265.93213.68245.21178.57204.93
126.17145.47213.21245.82196.60226.67164.30189.4395+138.79160.02234.53270.40216.26249.34180.73208.37
ForQuarterly,Semi-AnnualandAnnualPremiumModes,multiplymonthlyratesby3,6and12respectively
ForTier1ratesmultiplyby1.1andforTier2ratesmultiplyby1.2
Ratesquotedaboveareperpersonandbaseduponindividualage.Ratesincreaseeveryyearontheanniversarydateofyour
policy/certificate,asyougrowolder.NeitherStonebridgeLifenoritsagentsareconnectedwithMedicare.FORAGENTUSEONLY.
NOTFORPUBLICDISSEMINATION.Rateseffectiveasof10/01/13.
MonthlyRatesbyPlan-Oregon
HomeOffice:Rutland,VT
aTransamericaCompany
MSH1O
StonebridgeLifeInsuranceCompany
AdministrativeOffice:4333EdgewoodRd.NECedarRapids,Iowa52499
PREMIUMINFORMATIONRIGHTTORETURNPOLICYThisoutlineofcoveragedoesnot
We,StonebridgeLifeInsuranceCompany,canIfyoufindthatyouarenotsatisfiedwithyourgiveallthedetailsofMedicare
onlyraiseyourpremiumifweraisethepremiumPolicy,youmayreturnittoStonebridgeLifecoverage.ContactyourlocalSocial
forallpolicieslikeyoursinthisstate.InsuranceCompany,4333EdgewoodRoad,SecurityOfficeorconsultMedicare
CedarRapids,Iowa52499.andYoufordetails.
However,becausethepremiumrateisbasedupon
yourattainedage,thepremiumwillincreaseasyouIfyousendthePolicybacktouswithin30COMPLETEANSWERSARE
agefromage65throughage95.Thisannualchangedaysafteryoureceiveit,wewilltreattheVERYIMPORTANT
willoccuroneachPolicyRenewalDate.PolicyasifithadneverbeenissuedandWhenyoufillouttheapplicationfor
returnallofyourpayments.thenewPolicy,besuretoanswer
Therewillbeaone-timeenrollmentfeeof$25.00truthfullyandcompletelyall
addedtothefirstpremium.POLICYREPLACEMENTquestionsaboutyourmedicaland
Ifyouarereplacinganotherhealthhealthhistory.Thecompanymay
DISCLOSURESinsurancePolicy,doNOTcancelituntilyoucancelyourPolicyandrefuseto
UsethisoutlinetocomparebenefitsandpremiumshaveactuallyreceivedyournewPolicyandpayanyclaimsifyouleaveoutor
amongpolicies.aresureyouwanttokeepit.falsifyimportantmedical
information.
READYOURPOLICYVERYCAREFULLYNOTICEReviewtheapplicationcarefully
ThisisonlyanoutlinedescribingyourPolicy’smostThisPolicymaynotfullycoverallofyourbeforeyousignit.Becertainthat
importantfeatures.ThePolicyistheinsurancemedicalcosts.allinformationhasbeenproperly
contract.YoumustreadthePolicyitselftounderstandrecorded.
alloftherightsanddutiesofbothyouandStonebridge
LifeInsuranceCompany.NeitherStonebridgeLifeInsuranceCompany
noritsagentsareconnectedwithMedicare.
MSH1O
PLANA
MEDICARE(PARTA)–HOSPITALSERVICES–PERBENEFITPERIOD
*Abenefitperiodbeginsonthefirstdayyoureceiveserviceasaninpatientinahospitalandendsafteryouhavebeenoutofthehospitalandhave
notreceivedskilledcareinanyotherfacilityfor60daysinarow.
ServicesMedicarePaysPlanAPaysYouPay
HOSPITALIZATION*
Semiprivateroomandboard,generalnursingandmiscellaneousservicesandsupplies
First60daysAllbut$1,216$0$1,216(PartADeductible)
61stthrough90thdayAllbut$304aday$304aday$0
91stdayandafter:
Whileusing60lifetimereservedaysAllbut$608aday$608aday$0
Oncelifetimereservedaysareused:
Additional365days$0100%ofMedicareEligible
Expenses
$0**
Beyondtheadditional365days$0$0Allcosts
SKILLEDNURSINGFACILITYCARE*
YoumustmeetMedicare’srequirements,includinghavingbeeninahospitalforat
least3daysandenteredaMedicareapprovedfacilitywithin30daysafterleavingthe
hospital
First20daysAllapprovedamounts$0$0
21stthrough100thdayAllbut$152aday$0Upto$152aday
101stdayandafter$0$0Allcosts
BLOOD
First3pints$03pints$0
Additionalamounts100%$0$0
HOSPICECARE
YoumustmeetMedicare’srequirements,includingadoctor’scertificationofterminal
illness.
Allbutverylimited
copayment/coinsurancefor
outpatientdrugsandinpatient
respitecare
Medicarecopayment/
coinsurance
$0
**NOTICE:WhenyourMedicarePartAhospitalbenefitsareexhausted,theinsurerstandsintheplaceofMedicareandwillpaywhateveramount
Medicarewouldhavepaidforuptoanadditional365daysasprovidedinthepolicy’s“CoreBenefits.”Duringthistimethehospitalisprohibited
frombillingyouforthebalancebasedonanydifferencebetweenitsbilledchargesandtheamountMedicarewouldhavepaid.
MSH1O
PLANA
MEDICARE(PARTB)–MEDICALSERVICES–PERCALENDARYEAR
*Onceyouhavebeenbilled$147ofMedicareApprovedamountsforcoveredservices(whicharenotedwithanasterisk),yourMedicarePartB
Deductiblewillhavebeenmetforthecalendaryear.
ServicesMedicarePaysPlanAPaysYouPay
MEDICALEXPENSES–INOROUTOFTHEHOSPITALAND
OUTPATIENTHOSPITALTREATMENT,suchasphysician’sservices,inpatient
andoutpatientmedicalandsurgicalservicesandsupplies,physicalandspeech
therapy,diagnostictests,durablemedicalequipment
First$147ofMedicareApprovedAmounts*$0$0$147(PartBDeductible)
RemainderofMedicareApprovedAmountsGenerally80%Generally20%$0
PartBExcessCharges(aboveMedicareApprovedAmounts)$0$0Allcosts
BLOOD
First3pints$0Allcosts$0
Next$147ofMedicareApprovedAmounts*$0$0$147(PartBDeductible)
RemainderofMedicareApprovedAmounts80%20%$0
CLINICALLABORATORYSERVICES-TESTSFORDIAGNOSTIC
SERVICES100%$0$0
PARTSA&B
HOMEHEALTHCARE–MEDICAREAPPROVEDSERVICES
Medicallynecessaryskilledcareservicesandmedicalsupplies100%$0$0
Durablemedicalequipment
First$147ofMedicareApprovedAmounts*$0$0$147(PartBDeductible)
RemainderofMedicareApprovedAmounts80%20%$0
MSH1O
PLANSFANDG
MEDICARE(PARTA)–HOSPITALSERVICES–PERBENEFITPERIOD
*Abenefitperiodbeginsonthefirstdayyoureceiveserviceasaninpatientinahospitalandendsafteryouhavebeenoutofthehospitaland
havenotreceivedskilledcareinanyotherfacilityfor60daysinarow.
ServicesMedicarePaysPlanFPaysYouPayPlanGPaysYouPay
HOSPITALIZATION*
Semiprivateroomandboard,generalnursingandmiscellaneous
servicesandsupplies
First60daysAllbut$1,216$1,216(PartA
Deductible)
$0$1,216(PartA
Deductible)
$0
61stthrough90thdayAllbut$304aday$304aday$0$304aday$0
91stdayandafter:
Whileusing60lifetimereservedaysAllbut$608aday$608aday$0$608aday$0
Oncelifetimereservedaysareused:
Additional365days$0100%ofMedicare
EligibleExpenses
$0**100%ofMedicare
EligibleExpenses
$0**
Beyondtheadditional365days$0$0Allcosts$0Allcosts
SKILLEDNURSINGFACILITYCARE*
YoumustmeetMedicare’srequirements,includinghaving
beeninahospitalforatleast3daysandentereda
Medicareapprovedfacilitywithin30daysafterleavingthe
hospital
First20daysAllapprovedamounts$0$0$0$0
21stthrough100thdayAllbut$152adayUpto$152aday$0Upto$152aday$0
101stdayandafter$0$0Allcosts$0Allcosts
BLOOD
First3pints$03pints$03pints$0
Additionalamounts100%$0$0$0$0
HOSPICECARE
YoumustmeetMedicare’srequirements,includinga
doctor’scertificationofterminalillness.
Allbutverylimited
copayment/coinsurance
foroutpatientdrugsand
inpatientrespitecare
Medicarecopayment/
coinsurance
$0Medicarecopayment/
coinsurance
$0
**NOTICE:WhenyourMedicarePartAhospitalbenefitsareexhausted,theinsurerstandsintheplaceofMedicareandwillpaywhateveramount
Medicarewouldhavepaidforuptoanadditional365daysasprovidedinthepolicy’s“CoreBenefits.”Duringthistimethehospitalisprohibited
frombillingyouforthebalancebasedonanydifferencebetweenitsbilledchargesandtheamountMedicarewouldhavepaid.
MSH1O
PLANSFANDG
MEDICARE(PARTB)–MEDICALSERVICES–PERCALENDARYEAR
*Onceyouhavebeenbilled$147ofMedicareApprovedAmountsforcoveredservices(whicharenotedwithanasterisk),yourPartBDeductible
willhavebeenmetforthecalendaryear.
ServicesMedicarePaysPlanFPaysYouPayPlanGPaysYouPay
MEDICALEXPENSES---INOROUTOFTHEHOSPITALAND
OUTPATIENTHOSPITALTREATMENT,suchasphysician’s
services,inpatientandoutpatientmedicalandsurgicalservices
andmedicalequipment
First$147ofMedicareApprovedAmounts*$0$147(PartB
Deductible)
$0$0$147(PartB
Deductible)
RemainderofMedicareApprovedAmountsGenerally80%Generally20%$0Generally20%$0
PartBExcessCharges(aboveMedicareApprovedAmounts)$0100%$0100%$0
BLOOD
First3pints$0Allcosts$0Allcosts$0
Next$147ofMedicareApprovedAmounts*$0$147(PartB
Deductible)
$0$0$147(PartB
Deductible)
RemainderofMedicareApprovedAmounts80%20%$020%$0
CLINICALLABORATORYSERVICES---TESTSFOR
DIAGNOSTICSERVICES100%$0$0$0$0
PARTSA&B
HOMEHEALTHCARE---MEDICAREAPPROVED
SERVICES
Medicallynecessaryskilledcareservicesandmedicalsupplies100%$0$0$0$0
Durablemedicalequipment
First$147ofMedicareApprovedAmounts*$0$147(PartB
Deductible)
$0$0$147(PartB
Deductible)
RemainderofMedicareApprovedAmounts80%20%$020%$0
OTHERBENEFITS-NOTCOVEREDBYMEDICARE
FOREIGNTRAVEL---NOTCOVEREDBYMEDICARE
Medicallynecessaryemergencycareservicesbeginningduring
thefirst60daysofeachtripoutsidetheUSA
First$250eachcalendaryear$0$0$250$0$250
Remainderofcharges$080%toalifetime
MaximumBenefit
of$50,000
20%andamounts
overthe$50,000
lifetimeMaximum
Benefit
80%toalifetime
MaximumBenefitof
$50,000
20%andamounts
overthe$50,000
lifetimeMaximum
Benefit
MSH1O
PLANN
MEDICARE(PARTA)–HOSPITALSERVICES–PERBENEFITPERIOD
*Abenefitperiodbeginsonthefirstdayyoureceiveserviceasaninpatientinahospitalandendsafteryouhavebeenoutofthehospitaland
havenotreceivedskilledcareinanyotherfacilityfor60daysinarow.
ServicesMedicarePaysPlanNPaysYouPay
HOSPITALIZATION*
Semiprivateroomandboard,generalnursingandmiscellaneousservicesandsupplies
First60daysAllbut$1,216$1,216(PartADeductible)$0
61stthrough90thdaysAllbut$304aday$304aday$0
91stdayandafter:
Whileusing60lifetimereservedaysAllbut$608aday$608aday$0
Oncelifetimereservedaysareused:
Additional365days$0100%ofMedicare
EligibleExpenses
$0**
Beyondtheadditional365days$0$0Allcosts
SKILLEDNURSINGFACILITYCARE*
YoumustmeetMedicare’srequirements,includinghavingbeeninahospitalforatleast3
daysandenteredaMedicareapprovedfacilitywithin30daysafterleavingthehospital.
First20daysAllapprovedamounts$0$0
21stthrough100thdayAllbut$152adayUpto$152aday$0
101stdayandafter$0$0Allcosts
BLOOD
First3pints$03pints$0
Additionalamounts100%$0$0
HOSPICECARE
YoumustmeetMedicare’srequirements,includingadoctor’scertificationofterminalillness.
Allbutverylimited
copayment/coinsurance
foroutpatientdrugsand
inpatientrespitecare
Medicarecopayment/coinsurance$0
**NOTICE:WhenyourMedicarePartAhospitalbenefitsareexhausted,theinsurerstandsintheplaceofMedicareandwillpaywhateveramount
Medicarewouldhavepaidforuptoanadditional365daysasprovidedinthepolicy’s“CoreBenefits.”Duringthistimethehospitalisprohibited
frombillingyouforthebalancebasedonanydifferencebetweenitsbilledchargesandtheamountMedicarewouldhavepaid.
MSH1O
PLANN
MEDICARE(PARTB)–MEDICALSERVICES–PERCALENDARYEAR
*Onceyouhavebeenbilled$147ofMedicareApprovedAmountsforcoveredservices(whicharenotedwithanasterisk),yourPartB
Deductiblewillhavebeenmetforthecalendaryear.
ServicesMedicarePaysPlanNPaysYouPay
MEDICALEXPENSES---INOROUTOFTHEHOSPITALANDOUTPATIENTHOSPITAL
TREATMENT,suchasphysician’sservices,inpatientandoutpatientmedicalandsurgical
servicesandsupplies,physicalandspeechtherapy,diagnostictests,durablemedical
equipment
First$147ofMedicareApprovedAmounts*$0$0$147(PartBDeductible)
RemainderofMedicareApprovedAmountsGenerally80%Balance,otherthanupto$20per
officevisitandupto$50per
emergencyroomvisit.The
copaymentofupto$50iswaivedif
theinsuredisadmittedtoanyhospital
andtheemergencyvisitiscoveredas
aMedicarePartAexpense.
Upto$20perofficevisitandup
to$50peremergencyroom
visit.Thecopaymentofupto
$50iswaivediftheinsuredis
admittedtoanyhospitaland
theemergencyvisitiscovered
asaMedicarePartAexpense.
PartBExcessCharges(aboveMedicareApprovedAmounts)$0$0Allcosts
BLOOD
First3pints$0Allcosts$0
Next$147ofMedicareApprovedAmounts*$0$0$147(PartBDeductible)
RemainderofMedicareApprovedAmounts80%20%$0
CLINICALLABORATORYSERVICES---TESTSFORDIAGNOSTICSERVICES100%$0$0
PARTSA&B
HOMEHEALTHCARE---MEDICAREAPPROVEDSERVICES
Medicallynecessaryskilledcareservicesandmedicalsupplies100%$0$0
Durablemedicalequipment
First$147ofMedicareApprovedAmounts*$0$0$147(PartBDeductible)
RemainderofMedicareApprovedAmounts80%20%$0
OTHERBENEFITS–NOTCOVEREDBYMEDICARE
FOREIGNTRAVEL---NOTCOVEREDBYMEDICARE
Medicallynecessaryemergencycareservicesbeginningduringthefirst60daysofeachtrip
outsidetheUSA
First$250eachcalendaryear$0$0$250
Remainderofcharges$080%toalifetimeMaximum
Benefitof$50,000
20%andamountsoverthe
$50,000lifetimeMaximum
Benefit
At Stonebridge Life Insurance Company we take very seriously the trust
our customers place in us to help ensure their financial security. For over
100 years, we have navigated through good times and tough times.
Throughout our history, our company has remained resilient, strong and
dedicated to delivering on our long-term commitments to our customers.
We understand that now, more than ever, you need to feel confident
about your financial future. Despite historical changes in the financial
markets, our goal has remained the same: to help our customers protect
their financial future by offering a wide range of competitive and innovative
products and services.
We accomplish this by:
• Delivering on our long-term commitments,
• Maintaining a prudent risk management culture,
• Implementing effective capital and liquidity strategies, and
• Adhering to a sound and disciplined investment philosophy.
Stonebridge Life Insurance Company is a Transamerica company.  The
Transamerica companies offer a wide array of innovative financial services
and products with a common purpose:  to help individuals, families, and
businesses build, protect and preserve their hard-earned assets.  With
more than a century of experience, we have built a solid reputation on
solid management, sound decisions and consumer confidence.
MSH1A,F,G,N OR (EXISTING BUSINESS)
MSH2A,F,G,N OR (NEW BUSINESS)
78965MS_OR 0413
LL #26068891_OR
Home Office: Rutland, VT

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