Ill. Admin. Code tit. 50, § 2008.APPENDIX A
| 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 ($ ) | |||||||||
| 61st to 90th Day | All But ($ ) a Day | ||||||||||
| 91st to 150th 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. | ||||||||||
This policy does/does not comply with the minimum standards set forth in Section 363 of the Illinois Insurance Code.
| DATE | SIGNATURE OF APPLICANT | |||
| SIGNATURE OF INSURANCE PRODUCER | ||||
(Source: Amended at 16 Ill. Reg. 2766, effective February 11, 1992; corrected at 16 Ill. Reg. 3590)