Policy Pages

388950
Accendo Insurance Company

part of the CVS Health® family of companies and Aetna affiliate
PO Box 14770
Lexington, KY 40512-4770
JIMMY BOYD JR
PO BOX 11212
SOUTH BEND, IN 46634-0212
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Welcome
Dear valued policyholder,
Thank you for your recent application for Medicare Supplement insurance and welcome to
our family of policyholders. Accendo Insurance Company is part of the CVS Health® family
of companies and Aetna affiliate. Your policy is administered by Aetna Life Insurance
Company and its affiliates.
Enclosed is your policy. Keep it in a handy place for future reference.
Please take a few minutes to review your policy, along with the copy of your application
that is in the back. It’s important that all information including your date of birth,
height, weight and health questions are answered correctly. Pay close attention to the
answers on the health and medical questions as an incorrect answer could jeopardize your
coverage under this policy. If you applied during the Open Enrollment or Guarantee Issue
period, these health questions will not be answered as they do not apply. If there are any
corrections or additions, please notify us immediately.
It’s easy to manage your policy online. Remember that you will always have access to the
member secure side of aetnaseniorproducts.com where you can view your policy details,
update your contact/billing information, and sign up for electronic correspondence.
Accendo Insurance Company is committed to providing outstanding service to our

policyholders. If you have any questions regarding your policy benefits or if we can be of
assistance in other ways concerning your insurance needs, please let us hear from you.
Our staff of dedicated professionals is ready to assist you.
Thank you for trusting us with your insurance coverage.
Our Commitment
At CVS Health, we share a clear purpose: helping people on their path to better health.
Through our health services, insurance plans and community pharmacists, we’re pioneering
a bold new approach to total health. Making quality care more affordable, accessible,
simple and seamless, to not only help people get well, but help them stay well in body, mind
and spirit.
ACCLP06036
(012820)
388950
388950
Medicare Supplement Insurance

part of the CVS Health family of companies and Aetna affiliate
®
ACCMS05378
(010820) ©2020 CVS Health
388950
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ACCENDO INSURANCE COMPANY

MEDICARE SUPPLEMENT ADMINISTRATIVE OFFICE
1021 Reams Fleming Blvd, Franklin, TN 37064
Telephone: 800 264.4000
PREMIUMS ARE SUBJECT TO CHANGE

MEDICARE SUPPLEMENT POLICY – PLAN N
THIS POLICY PROVIDES BENEFITS FOR LOSS DUE TO INJURY OR SICKNESS AS HEREIN LIMITED AND PROVIDED.
Notice to buyer: This policy may not cover all of the costs associated with medical care incurred by the buyer
during the period of coverage. The buyer is advised to review all policy limitations.
In this policy the person insured is also called “you” or “your”. Accendo Insurance Company is called “us”, “we”,
“our”, or “the Company”. The Definitions section defines other words and terms used in this policy.
In consideration of your payment of the required premiums for this policy, the Company insures you against
Loss caused by Injury or Sickness as herein limited and provided. Coverage is provided subject to the terms of
this policy. The amount of the initial premium and the Effective Date of your policy are shown on the Policy
Schedule. This policy is a legal contract between you and the Company. READ YOUR POLICY CAREFULLY.
RIGHT TO EXAMINE POLICY FOR THIRTY (30) DAYS: You have 30 days after receipt of this policy to examine its
provisions. During that 30-day period, if you are dissatisfied with the policy, it may be returned to the Company
at its Home Office, to any state office of the Company or to the agent from whom it was purchased. Immediately
upon such return, this policy shall be void from the beginning and any premium paid will be refunded.
GUARANTEED RENEWABLE: You have the right to renew this policy, for consecutive terms, by paying the
required premium before the end of each grace period. You have the right to renew this policy regardless of
changes in your physical, mental or health conditions.
PREMIUM AGREEMENT: On each annual anniversary of your Effective Date, premiums will increase due to the
increase in your age. The renewal premium for this policy will be the renewal premium then in effect for your
attained age. The premium may also change for other reasons. Any change in premium will apply to all covered
persons in your same class based on the issue state of your policy. For any premium change under this
paragraph, we will give you at least 30 days advance notice in writing of such premium change.
IMPORTANT NOTICE
Please read the copy of your application attached to your policy. Any fraudulent misstatements in your
application could cause a claim to be denied or your policy rescinded. If your policy is rescinded, it will be
voided back to its Effective Date and you will have no insurance coverage under your policy. Carefully check
your application and write to the Medicare Supplement Administrative Office within 10 days of the receipt of
your policy if any information shown on it is not correct and complete or if any past medical history is left out
of your application. Your application is part of your policy and your policy was issued on the basis that the
answers to all questions and information shown on your application are correct and complete.
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TABLE OF CONTENTS
RIGHT TO EXAMINE POLICY FOR THIRTY (30) DAYS .................................................................................1

GUARANTEED RENEWABLE ....................................................................................................................1
PREMIUM AGREEMENT..........................................................................................................................1
IMPORTANT NOTICE ..............................................................................................................................1
POLICY SCHEDULE ..................................................................................................................................3
CHANGES IN MEDICARE COINSURANCE AND DEDUCTIBLES .....................................................................4
DEFINITIONS ..........................................................................................................................................5
BENEFIT PROVISIONS .............................................................................................................................7
EXCLUSIONS ..........................................................................................................................................8
RECEIPT OF MEDICAL ASSISTANCE ..........................................................................................................9
POLICY TERMINATION............................................................................................................................9
POLICY PROVISIONS ............................................................................................................................. 10
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POLICY SCHEDULE
PLAN N
Insured: JIMMY BOYD JR Age: 65 Gender: M
Address: PO BOX 11212 Policy Number: ACC6365374

SOUTH BEND, IN 46634
Initial Premium: $81.09 Premium Mode: Monthly
Policy Effective Date: 06/01/2021
To Inquire About Your Coverage, or to Express a Concern, Call us Toll-Free at:
Policyholder Services: 800 264.4000
Claims Customer Service: 800 264.4000
Or Write to Us at:
P.O. Box 14770
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POLICY SCHEDULE (CONT’D)
MEDICARE (PART A) – HOSPITAL SERVICES THIS POLICY PAYS
DAILY BENEFIT NOT COVERED BY MEDICARE:

First 60 Days 100%
Part A Deductible per Benefit Period
61st to 90th Day 100%
Part A Coinsurance per Benefit Period
91st to 150th Day 100%
Part A Coinsurance for 60 Lifetime Inpatient Reserve Days
151st to 515th Day 100%
(limited to a lifetime maximum of 365 days and payable at the same
rate Medicare would have paid had Medicare Part A Hospital days not
been exhausted)
SKILLED NURSING FACILITY CARE
First 20 Days 0%
21st through 100th Days, Amount Not Paid By Medicare 100%
BLOOD TRANSFUSIONS (First three (3) Pints-Part A) 100%
Additional Amounts - Remainder of Medicare Approved Amount 0%
HOSPICE AND RESPITE CARE COINSURANCE OR COPAYMENT 100%
MEDICARE (PART B) MEDICAL SERVICES THIS POLICY PAYS
PER CALENDAR YEAR
BLOOD TRANSFUSIONS (First three (3) Pints-Part B) 100%
Additional Amounts - Remainder of Medicare Approved Amount after 100%
Part B Deductible is met
MEDICAL EXPENSES APPROVED BY MEDICARE:
Part B Deductible Amount of Medicare Approved Amounts 0%
Remainder of Medicare Approved Amounts 100%
Part B Excess Charges Above Medicare Approved Amounts 0%
PARTS A & B THIS POLICY PAYS
HOME HEALTH CARE, MEDICARE APPROVED SERVICES:

Durable Medical Equipment, Part B Deductible Amount of Medicare
Approved Amounts 0%
Remainder of Medicare Approved Amounts After Deductible 100%
FOREIGN TRAVEL
First $250 Each Calendar Year 0%
Remainder of Charges (Lifetime Maximum Benefit $50,000) 80%
CHANGES IN MEDICARE COINSURANCE AND DEDUCTIBLES

Benefits designed to cover cost sharing amounts under Medicare will be changed automatically in your policy to
coincide with any changes in the applicable Medicare deductible, co-payment, or coinsurance amounts.
Premiums may be modified to correspond with such changes.
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DEFINITIONS
Shown below are the defined terms used in your policy. These terms are capitalized wherever they appear in the
policy.
ACCIDENT means accidental bodily Injury or Injuries causing Loss under this policy. Such Injuries must be caused
directly and independent of disease or bodily infirmity.
BENEFIT PERIOD means a Benefit Period as defined by Medicare.
COMPANY OFFICER means the President or Secretary.
EFFECTIVE DATE means the date your policy coverage begins at 12:01 A.M. where you live. Your policy Effective
Date is listed on the policy schedule page.
HOSPITAL means a legally operated Hospital as defined by Medicare.
INPATIENT HOSPITAL DEDUCTIBLE means the initial amount of Hospital expenses you incur in a Medicare
Benefit Period as a resident bed patient under Medicare Part A. Medicare establishes the amount of the
Inpatient Hospital Deductible. Medicare does not pay this amount.
INJURY or INJURIES means bodily Injury caused by an Accident and resulting independent of disease or bodily
infirmity.
LIFETIME INPATIENT RESERVE DAYS means additional days that Medicare will pay for when you are confined to
a Hospital for more than 90 days in a Benefit Period.
LOSS means the incurring of Medicare Eligible Expenses while this policy is in force.
MATERIAL INFORMATION means a condition or combination of conditions you were requested to disclose on
the application were not disclosed and which, if disclosed, would have required a different premium or caused
us to deny issuing your policy.
MEDICALLY NECESSARY means that the service or supply is recognized by Medicare as necessary to diagnose or
treat an Injury or Sickness and must:
1. Be prescribed by a Physician;
2. Be consistent with the diagnosis and treatment of such Injury or Sickness;
3. Be in accordance with the generally accepted standards of medical practice; and
4. Not be solely for the convenience of the Insured or the Physician.
MEDICAID means the Health Insurance for the Aged Act, Title XIX of the Social Security Amendment of 1965, as
amended.
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MEDICARE means the Health Insurance for the Aged Act, Title XVIII of the Social Security Amendment of 1965 as
then constituted or later amended.
MEDICARE COINSURANCE means the portion of charges covered but not reimbursed by Medicare, excluding the
Medicare deductibles, for which you are responsible.
MEDICARE ELIGIBLE EXPENSES means health care expenses of the kinds covered by Medicare Parts A and B, to
the extent recognized as reasonable and Medically Necessary by Medicare.
MEDICARE PART B DEDUCTIBLE means the amount you must pay each calendar year before benefits will be
paid under Medicare Part B. Medicare establishes the amount of the Part B Deductible. Medicare does not pay
this amount. A calendar year begins on January 1 and ends on December 31.
PHYSICIAN means a Physician as defined by Medicare.
PREMIUM DUE DATE means the month and day your policy’s premium payment is due. The frequency of the
Premium Due Date can vary depending on whether your premiums are paid on a monthly, quarterly,
semiannual, or annual basis.
RESPITE CARE means treatment that meets Medicare’s definition of respite care.
SICKNESS means illness or disease.
SKILLED NURSING FACILITY means a Skilled Nursing Facility as defined by Medicare.
WRITTEN NOTIFICATION means written notice that you are currently receiving medical assistance or that your
medical assistance received has terminated. This notification should include: Insured’s name, policy number,
copy of the document which indicates the date you became eligible for medical assistance or a copy of the
document which indicates the date medical assistance terminated.
Notice must be given by or on behalf of the Insured or the beneficiary to the Medicare Supplement
Administrative Office, Attn: Policyholders Service Department, or to any authorized agent of the Company.
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BENEFIT PROVISIONS
BASIC (“CORE”) BENEFITS

TO SUPPLEMENT BENEFITS UNDER PART A OF MEDICARE:
1. We will pay all Part A Medicare Coinsurance for inpatient Hospital confinement to the extent not
covered by Medicare from the 61st day through 90th day in any Medicare Benefit Period.
2. We will pay all Part A Medicare Coinsurance incurred for each Lifetime Inpatient Reserve Day to the
extent not covered by Medicare Lifetime Inpatient Reserve Days are nonrenewable and limited to 60
days during your lifetime.
3. Upon exhaustion of the Medicare Hospital inpatient coverage, including the Lifetime Inpatient Reserve
Days, we will pay one hundred percent (100%) of the Part A Medicare Eligible Expenses for inpatient
Hospital confinement. Benefits are payable at the same rate Medicare would have paid had Medicare
Part A Hospital days not been exhausted. Medicare exhaustion benefits are limited to a lifetime
maximum of 365 days of inpatient Hospital confinement.
4. We will pay under Medicare Part A the reasonable cost of the first three (3) pints of blood (or equivalent
quantities of packed red blood cells, as defined under federal regulations) unless replaced in accordance
with federal regulations. We will pay $0 in additional amounts following the first three pints of blood.
5. We will pay the co-payment/coinsurance amount for all Part A Medicare Eligible Expenses for hospice
care and Respite Care.
TO SUPPLEMENT BENEFITS UNDER PART B OF MEDICARE:
1. We will pay all of the Medicare Coinsurance amount, or in the case of hospital outpatient department
services, paid under a prospective payment system, the copayment amount of Medicare Part B Eligible
Expenses regardless of Hospital confinement, subject to the Medicare Part B Deductible.
2. We will pay under Medicare Part B the reasonable cost of the first three (3) pints of blood (or equivalent
quantities of packed red blood cells, as defined under federal regulations) unless replaced in accordance
with federal regulations. We will pay one hundred percent (100%) of the Medicare Coinsurance amount
for additional pints of blood.
ADDITIONAL BENEFITS
TO SUPPLEMENT BENEFITS UNDER PART A OF MEDICARE:
1. We will pay one hundred percent (100%) of the Medicare Part A Inpatient Hospital Deductible amount
per Benefit Period.
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2. We will pay for the actual billed charges up to the Medicare Coinsurance amount from the 21st day
through the 100th day in a Medicare Benefit Period for post-hospital Skilled Nursing Facility care eligible
under Medicare Part A. Such confinement must:
a. begin on or after the Effective Date and while your coverage is in force;
b. begin within 30 days following a Hospital confinement of 3 days or more;
c. be for the same Injury or Sickness which required the Hospital confinement; and
d. be under the direct and personal supervision of a Physician.
TO SUPPLEMENT BENEFITS UNDER PART B OF MEDICARE:
1. Insured will pay:
a. the lesser of twenty dollars ($20) or the Medicare Part B coinsurance or co-payment for each
covered health care provider office visit (including visits to medical specialists); and
b. the lesser of fifty dollars ($50) or the Medicare Part B coinsurance or co-payment for each
covered emergency room visit, however, this co-payment shall be waived if you are admitted to
any Hospital and the emergency visit is subsequently covered as a Medicare Part A expense.
2. We will pay, to the extent not covered by Medicare, 80% of the billed charges for Medicare Eligible
Expenses for Medically Necessary emergency hospital, physician and medical care received in a foreign
country, which care would have been covered by Medicare if provided in the United States and which
care began during the first 60 consecutive days of each trip outside the United States, subject to a
calendar year deductible of $250, and a lifetime maximum benefit of $50,000. For purposes of this
benefit “emergency care” shall mean care needed immediately because of an Injury or Sickness of
sudden and unexpected onset.
EXCLUSIONS
We will not pay for:

1. Loss incurred while your policy is not in force, except as provided in the Extension of Benefits section of
your policy;
2. Hospital or Skilled Nursing Facility confinement incurred during a Medicare Part A Benefit Period that
begins while this policy is not in force;
3. That portion of any Loss incurred which is paid for by Medicare;
4. Services for non-Medicare Eligible Expenses, including, but not limited to, routine exams, take-home
drugs and eye refractions;
5. Services for which a charge is not normally made in the absence of insurance;
6. Loss that is payable under any other Medicare supplement insurance policy or certificate; or
7. Loss that is payable under any other insurance which paid benefits for the same Loss on an expense
incurred basis.
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RECEIPT OF MEDICAL ASSISTANCE
Benefits and premium(s) under this policy shall be suspended upon your request for any period, (that may be
provided by law), in which you have applied for and qualified for the receipt of medical assistance under Title
XIX of the Social Security Act (Medicaid), but only if you notify us within ninety (90) days after the date you
became entitled to such assistance.
If such suspension occurs and if you lose entitlement to such medical assistance, this policy shall be
automatically reinstituted, effective as of the date of termination of such entitlement, if you provide Written
Notification of loss of such entitlement within ninety (90) days after the date of such loss of entitlement and pay
the premium attributable to this period, effective as of the date of termination of such entitlement.
Benefits and premiums under the policy shall be suspended (for any period that may be provided by federal
regulation) at your request if you are entitled to benefits under Section 226(b) of the Social Security Act and are
covered under a group health plan (as defined in Section 1862(b)(1)(A)(v) of the Social Security Act). If
suspension occurs and if you lose coverage under the group health plan, the policy shall be automatically
reinstituted (effective as of the date of loss of coverage) if you provide notice of loss of coverage within 90 days
after the date of loss.
If such reinstitution occurs:
1. Your policy shall not provide for any waiting period with respect to treatment of Pre-Existing Conditions;
2. Your benefits provided under the reinstitution will be substantially the same as the benefits in effect
before the date of such suspension; and
3. Your premium classification terms provided under the reinstitution will be at least as favorable to you as
the premium terms that would have applied had this policy not been suspended.
POLICY TERMINATION
Your policy will terminate on the earliest of:

1. The date we receive your written request to cancel your policy (in which case the grace period will not
apply);
2. The date your policy is replaced by another Medicare supplement or Medicare Select policy or by a Part
C Medicare Advantage plan (in which case the grace period will not apply);
3. The Premium Due Date, if sufficient premium has not been paid by the end of the grace period; or
4. The date and time of your death.
In the event of cancellation or death, we will promptly return the unearned portion of any premium paid in
accordance with the laws in your state of residence.
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POLICY PROVISIONS
ENTIRE CONTRACT; CHANGES: This policy, the application and any attached papers constitute the entire
contract. No one has the authority to change this policy or to waive any of its provisions unless the change is
approved in writing by a Company Officer. The approval must be written on or attached to this policy.
CANCELLATION BY INSURED: The insured may cancel this policy at any time by written notice delivered or
mailed to the insurer, effective upon receipt of such notice or on such late date as may be specified in such
notice. In the event of cancellation or death of the insured, the insurer will promptly return the unearned
portion of any premium paid. The earned premium shall be computed by the use of the pro-rata method.
Cancellation shall be without prejudice to any claim originating prior to the effective date of cancellation.
TIME LIMIT ON CERTAIN DEFENSES:
1. Misstatement in your application: We issued your policy based on information you provided in your
application. Any incorrect or omitted Material Information in your application may cause your policy to
be rescinded (voided) back to the Effective Date of your policy or a claim to be denied.
2. Time limit on certain defenses:
a. We may rescind (void) this policy or deny a claim for Loss incurred within 2 years from your
policy Effective Date because of misstatement in your application.
b. We may rescind (void) your policy or deny a claim for Loss incurred any time after 2 years from
your policy’s Effective Date only for fraudulent misstatement in your application.
GRACE PERIOD: A grace period of 31 days from your Premium Due Date will be allowed for late payment of
premium. During such grace period, this policy will not lapse as long as you pay your full premium before the
end of the grace period.
REINSTATEMENT: If any premium is not paid within the time your payment is due, a subsequent acceptance of
premium by us or by any agent authorized by us to accept such premium, without requiring an application for
reinstatement, shall reinstate your policy. However, if we or our agent requires an application for reinstatement
and issues a conditional receipt for the premium tendered, your policy will be reinstated only upon approval of
the application by us or, lacking such approval, upon the 45th day following the date of the conditional receipt,
unless we have previously notified you in writing of our disapproval of your application. If the application for
reinstatement is disapproved, any premium received will be returned to you. If the application for reinstatement
is approved, the reinstated policy will cover only Loss resulting from Injury or Sickness sustained after the
Effective Date of reinstatement. In all other respects you and the Company shall have the same rights under this
policy as were in effect before it lapsed, subject to the provisions of any rider which may be attached in
connection with the reinstatement.
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NOTICE OF CLAIM: Written notice of claim must be given to the Company within twenty days after the
beginning of any Loss covered by this policy. If notice cannot be given within that period, it must be given as
soon as is reasonably possible. The notice will be considered sufficient if it identifies you and is given to the
Company at its Medicare Supplement Administrative Office or to any authorized agent of the Company.
CLAIM FORMS: The Company, after receiving notice of claim, will furnish to the claimant forms for filing proof of
Loss. If forms are not furnished within 15 days after the giving of such notice, the claimant will be considered to
have met the requirements of this policy for proof of Loss if the Company is furnished proof of Loss as stated
below.
TIME OF PAYMENT OF CLAIMS: Benefits payable under this policy will be paid immediately after the Company
receives suitable written proof of Loss. We will notify providers of any deficiencies in a submitted claim not
more than 30 days after receipt if the claim is filed electronically or 45 days if the claim is filed on paper.
PROOF OF LOSS: Written proof of Loss must be sent to the Company at its Medicare Supplement Administrative
Office within 90 days after the date of Loss. Failure to furnish proof within 90 days shall not invalidate nor
reduce any claim if it was not reasonably possible to give proof within such time, provided such proof is
furnished as soon as reasonably possible and in no event, except in the absence of legal capacity, later than one
year from the time proof is otherwise required.
PAYMENT OF CLAIMS: All benefits are payable to you unless we receive proof of an assignment of benefits to
pay your health care provider. At your death, any accrued benefits unpaid, and which are not assigned, or
unearned premium will be paid to your estate.
PHYSICAL EXAMINATIONS AND AUTOPSY: We, at our expense, shall have the right and opportunity to have a
Physician examine you when and as often as we may reasonably require while a claim is pending under your
policy, and to request an autopsy in case of death where it is not prohibited by law.
LEGAL ACTION: No action at law or in equity can be brought to recover on this policy until 60 days after written
proof of Loss has been given to the Company. No action can be brought after 3 years from the date written
proof of Loss is required.
CONFORMITY WITH STATE STATUTES: Any provision of this policy which, on its Effective Date, is in conflict with
the statutes of the state in which you reside on such date is automatically changed to meet the minimum
requirements of such statutes.
ASSIGNMENT: No assignment of interest under this policy will be binding upon the Company unless notice of
the assignment is received at the Medicare Supplement Administrative Office of the Company. The Company
does not assume any responsibility for the assignment’s validity.
CHANGE IN BENEFICIARY: The right to change of beneficiary is reserved to the insured and the consent of the
beneficiary or beneficiaries shall not be requisite to surrender or assignment of this policy or to any change of
beneficiary or beneficiaries, or to any other changes in this policy.
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MISSTATEMENT OF AGE OR GENDER: If your age or gender has been misstated in your application for this
policy, your premium will be adjusted based on your correct age or gender upon reasonable notice to you. If
based on your true age this policy would not have been issued, we will be liable only for the refund of premiums
paid for this policy.
UNPAID PREMIUMS: When benefits are paid for a claim under this policy, any premium due and unpaid may be
deducted, at our option, from the benefits payable.
EXTENSION OF BENEFITS: Termination of your policy shall be without prejudice to any continuous Loss which
commenced while your policy was in force, but the extension of benefits beyond the period that your policy was
in force is: (a) subject to your continuous total disability; (b) limited to the duration of the Medicare Benefit
Period or, if none is applicable, payment of the maximum benefits; and (c) limited to the covered Injury or
Sickness causing the continuous Loss beginning while your policy was in force. Receipt of Medicare Part D
benefits will not be considered in determining a continuous Loss.
TERM OF COVERAGE: Your coverage starts on the Effective Date at 12:01 A.M. where you live. It ends at 12:01
A.M. where you live on the termination date as described in the Policy Termination section.
IN WITNESS WHEREOF, Accendo Insurance Company has caused this policy to be signed and attested by its
authorized Company Officers.
President Secretary
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MEDICARE SUPPLEMENT ADMINISTRATIVE OFFICE

1021 Reams Fleming Blvd
Franklin, TN 37064
800 264.4000
MEDICARE SUPPLEMENT POLICY
THIS IS A PLAN “N”
If you need information or have any questions regarding your policy, please contact:
Policyholder Services
P.O. Box 14770
800 264.4000
NOTICE: Questions regarding Your Policy or coverage should be directed to:
Accendo Insurance Company, contact number 800 264.4000
If You need the assistance of the governmental agency that regulates insurance
or have a complaint You have been unable to resolve with Your insurer
You may contact the Department of Insurance by mail, telephone or email:
State of Indiana Department of Insurance Consumer Services Division

311 West Washington Street, Suite 300
Indianapolis, Indiana 46204
Consumer Hotline: (800) 622-4461; (317) 232-2395
Complaints can be filed electronically at www.in.gov/idoi
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Notice of Privacy Practices

Accendo Insurance Company is part of the CVS Health® family of companies and Aetna affiliate.
This notice describes how medical information about you may be used and
disclosed and how you can get access to this information.
Please review it carefully.
Para recibir esta notificación en español por favor llamar al número gratuito de Member Services
(Servicios a Miembros) que figura en su tarjeta de identificación.
To receive this notice in Spanish, please call the toll-free Member Services number on your ID card.
This Notice of Privacy Practices applies to Aetna’s insured health benefit plans. It does not apply to
any plans that are self-funded by an employer. If you receive benefits through a group health
insurance plan, your employer will be able to tell you if your plan is insured or self-funded. If your
plan is self-funded, you may want to ask for a copy of your employer’s privacy notice.
Aetna1 considers personal information to be confidential. We protect the privacy of that information in
accordance with federal and state privacy laws, as well as our own company privacy policies.
This notice describes how we may use and disclose information about you in administering your
benefits, and it explains your legal rights regarding the information.
When we use the term “personal information,” we mean information that identifies you as an individual,
such as your name and Social Security Number, as well as financial, health and other information about
you that is nonpublic, and that we obtain so we can provide you with insurance coverage. By “health
information,” we mean information that identifies you and relates to your medical history (i.e., the health
care you receive or the amounts paid for that care).
This notice became effective on March 9, 2020.
How Aetna Uses and Discloses Personal Information

In order to provide you with insurance coverage, we need personal information about you, and we
obtain that information from many different sources – particularly you, your employer or benefits plan
sponsor if applicable, other insurers, HMOs or third-party administrators (TPAs), and health care
providers. In administering your health benefits, we may use and disclose personal information about
you in various ways, including:
Health Care Operations: We may use and disclose personal information during the course of running
our health business – that is, during operational activities such as quality assessment and
improvement; licensing; accreditation by independent organizations; performance measurement and
outcomes assessment; health services research; and preventive health, disease management, case
management and care coordination. For example, we may use the information to provide disease
management programs for members with specific conditions, such as diabetes, asthma or heart failure.
Other operational activities requiring use and disclosure include administration of reinsurance and stop
loss; underwriting and rating; detection and investigation of fraud; administration of pharmaceutical
programs and payments; transfer of policies or contracts from and to other health plans; facilitation of a
sale, transfer, merger or consolidation of all or part of Aetna with another entity (including due diligence
related to such activity); and other general administrative activities, including data and information
systems management, and customer service.
1
Coverage underwritten by Accendo Insurance Company, a licensed insurer and affiliate of Aetna Inc.
For purposes of this notice, “Aetna” and the pronouns “we”, “us” and “our” refer to all of the licensed
insurer subsidiaries and affiliates. These entities have been designated as a single affiliated covered
entity for federal privacy purposes.
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Payment: To help pay for your covered services, we may use and disclose personal information in a
number of ways – in conducting utilization and medical necessity reviews; coordinating care;
determining eligibility; determining formulary compliance; collecting premiums; calculating cost-sharing
amounts; and responding to complaints, appeals and requests for external review. For example, we
may use your medical history and other health information about you to decide whether a particular
treatment is medically necessary and what the payment should be – and during the process, we may
disclose information to your provider. We also mail Explanation of Benefits forms and other information
to the address we have on record for the subscriber (i.e., the primary insured). In addition, we make
claims information contained on our secure member website and telephonic claims status sites
available to the subscriber and all covered dependents. We also use personal information to obtain
payment for any mail order pharmacy services provided to you.
Treatment: We may disclose information to doctors, dentists, pharmacies, hospitals and other health
care providers who take care of you. For example, doctors may request medical information from us to
supplement their own records. We also may use personal information in providing mail order pharmacy
services and by sending certain information to doctors for patient safety or other treatment-related
reasons.
Disclosures to Other Covered Entities: We may disclose personal information to other covered
entities, or business associates of those entities for treatment, payment and certain health care
operations purposes. For example, if you receive benefits through a group health insurance plan, we
may disclose personal information to other health plans maintained by your employer if it has been
arranged for us to do so in order to have certain expenses reimbursed.
Additional Reasons for Disclosure
We may use or disclose personal information about you in providing you with treatment alternatives,
treatment reminders, or other health-related benefits and services. We also may disclose such
information in support of:
 Plan Administration (Group Plans)– to your employer, as applicable, when we have
been informed that appropriate language has been included in your plan documents, or
when summary data is disclosed to assist in bidding or amending a group health plan.
 Research – to researchers, provided measures are taken to protect your privacy.
 Business Associates – to persons who provide services to us and assure us they will
protect the information.
 Industry Regulation – to Government agencies that regulate us (different countries and
U.S. state insurance departments).
 Workers’ Compensation – to comply with workers’ compensation laws.
 Law Enforcement – to Government law enforcement officials.
 Legal Proceedings – in response to a court order or other lawful process.
 Public Welfare – to address matters of public interest as required or permitted by law
(e.g., child abuse and neglect, threats to public health and safety, and national security).
 As Required by Law – to comply with legal obligations and requirements.
 Decedents – to a coroner or medical examiner for the purpose of identifying a deceased
person, determining a cause of death, or as authorized by law; and to funeral directors
as necessary to carry out their duties.
 Organ Procurement – to respond to organ donation groups for the purpose of
facilitating donation and transplantation.
Required Disclosures: We must use and disclose your personal information in the following manner:
 To you or someone who has the legal right to act for you (your personal representative)
in order to administer your rights as described in this notice; and
 To the Secretary of the Department of Health and Human Services, as necessary, for
HIPAA compliance and enforcement purposes.
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Disclosure to Others Involved in Your Health Care

We may disclose health information about you to a relative, a friend, the subscriber of your health
benefits plan or any other person you identify, provided the information is directly relevant to that
person’s involvement with your health care or payment for that care. For example, if a family member
or a caregiver calls us with prior knowledge of a claim, we may confirm whether or not the claim has
been received and paid. You have the right to stop or limit this kind of disclosure by calling the toll-free
Member Services number on your ID card.
If you are a minor, you also may have the right to block parental access to your health information in
certain circumstances, if permitted by state law. You can contact us using the toll-free Member
Services number on your ID card – or have your provider contact us.
Uses and Disclosures Requiring Your Written Authorization
In all situations other than those described above, we will ask for your written authorization before using
or disclosing personal information about you. For example, we will get your authorization:
 for marketing purposes that are unrelated to your benefit plan(s),
 before disclosing any psychotherapy notes,
 related to the sale of your health information, and
 for other reasons as required by law.
If you have given us an authorization, you may revoke it in writing at any time, if we have not already
acted on it. If you have questions regarding authorizations, please call the toll-free Member Services
number on your ID card.
Your Legal Rights
The federal privacy regulations give you several rights regarding your health information:
 You have the right to ask us to communicate with you in a certain way or at a certain location.
For example, if you are covered as an adult dependent, you might want us to send health
information (e.g. Explanation of benefits (EOB) and other claim information) to a different
address from that of your subscriber. We will accommodate reasonable requests.
 You have the right to ask us to restrict the way we use or disclose health information about you
in connection with health care operations, payment and treatment. We will consider, but may not
agree to, such requests. You also have the right to ask us to restrict disclosures to persons
involved in your health care.
 You have the right to ask us to obtain a copy of health information that is contained in a
“designated record set” – medical records and other records maintained and used in making
enrollment, payment, claims adjudication, medical management and other decisions. We may
ask you to make your request in writing, may charge a reasonable fee for producing and mailing
the copies and, in certain cases, may deny the request.
 You have the right to ask us to amend health information that is in a “designated record set.”
Your request must be in writing and must include the reason for the request. If we deny the
request, you may file a written statement of disagreement.
 You have the right to ask us to provide a list of certain disclosures we have made about you,
such as disclosures of health information to government agencies that license us. Your request
must be in writing. If you request such an accounting more than once in a 12-month period, we
may charge a reasonable fee.
 You have the right to be notified following a breach involving your health information.
 You have the right to know the reasons for an unfavorable underwriting decision. Previous
unfavorable underwriting decisions may not be used as the basis for future underwriting
decisions unless we make an independent evaluation of the basic facts. Your genetic
information cannot be used for underwriting purposes.
 You have the right with very limited exceptions, not to be subjected to pretext interviews.1
1
Aetna does not participate in pretext interviews
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You may make any of the requests described above (if applicable), may request a paper copy of this
notice, or ask questions regarding this notice by calling the toll-free Member Services number on your
ID card.
You also have the right to file a complaint if you think your privacy rights have been violated. To do so,
please send your inquiry to the following address:
HIPAA Member Rights Team
P.O. Box 14079
You may stop the paper mailing of your EOB and other claim information by visiting www.aetna.com
and click “Log In/Register”. Follow the prompts to complete the one-time registration. Then you can
log in any time to view past copies of EOBs and other claim information.
You also may write to the Secretary of the U.S. Department of Health and Human Services. You will
not be penalized for filing a complaint.
Aetna’s Legal Obligations

The federal privacy regulations require us to keep personal information about you private, to give you
notice of our legal duties and privacy practices, and to follow the terms of the notice currently in effect.
Safeguarding Your Information

We guard your information with administrative, technical, and physical safeguards to protect it against
unauthorized access and against threats and hazards to its security and integrity. We comply with all
applicable state and federal law pertaining to the security and confidentiality of personal information.
This Notice is Subject to Change

We may change the terms of this notice and our privacy policies at any time. If we do, the new terms
and policies will be effective for all of the information that we already have about you, as well as any
information that we may receive or hold in the future.
Please note that we do not destroy personal information about you when you terminate your coverage
with us. It may be necessary to use and disclose this information for the purposes described above
even after your coverage terminates, although policies and procedures will remain in place to protect
against inappropriate use or disclosure.
Coverage underwritten by Accendo Insurance Company and administered by Aetna Life Insurance Company and its affiliates.
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NOTICE OF PROTECTION PROVIDED BY THE

INDIANA LIFE AND HEALTH INSURANCE GUARANTY ASSOCIATION
This Notice provides a brief summary of the Indiana Life and Health Insurance Guaranty Association
("ILHIGA") and the protection it provides for policyholders. This safety net was created under Indiana law,
which determines who and what is covered and the amounts of coverage.
ILHIGA was established to provide protection to policyholders in the unlikely event that your life, annuity
or health insurance company becomes financially unable to meet its obligations and is taken over by its
insurance department. If this should happen, ILHIGA will typically arrange to continue coverage and pay
claims, in accordance with Indiana law, with funding from assessments paid by other insurance companies.
(For the purposes of this Notice, the terms "insurance company" and "insurer" mean and include health
maintenance organizations ("HMOs")).
Basic Protections Currently Provided by ILHIGA
Generally, an individual is covered by ILHIGA if the insurer was a member of ILHIGA and the individual
lives in Indiana at the time the insurer is ordered into liquidation with a finding of insolvency. The coverage
limits below apply only for companies placed in rehabilitation or liquidation on or after July 1, 2018. The
benefits that ILHIGA is obligated to cover are not to exceed the lesser of (a) the contractual obligations for
which the member insurer is liable or would have been liable if the member insurer were not an insolvent
insurer, or (b) the limits indicated below:
Life Insurance
• $300,000 in death benefits
• $100,000 in net cash surrender or net cash withdrawal values
Health Insurance
• $500,000 for health plan benefits (see definition below)
• $300,000 in disability income and long-term care insurance benefits
• $100,000 in other types of health insurance benefits
Annuities
• $250,000 in present value of annuity benefits (including net cash surrender and net cash withdrawal
values)
The maximum amount of protection for each individual, regardless of the number of policies or contracts,
is $300,000. Special rules may apply with regard to health benefit plans and covered unallocated
annuities.
"Health benefit plan" is defined in IC 27-8-8-2(o), and generally includes hospital or medical expense
policies, certificates, HMO subscriber contracts or certificates or other similar health contracts that provide
comprehensive forms of coverage for hospitalization or medical services, but excludes policies that provide
coverages for limited benefits (such as accident-only, credit, dental-only or vision-only insurance), Medicare
Supplement insurance, disability income insurance and long-term care insurance.
The protections listed above apply only to the extent that benefits are payable under covered policy(s). In
no event will the ILHIGA provide benefits greater than the contractual obligations in the life, annuity or
health insurance policy or contract. The statutory limits on ILHIGA coverage have changed over the years and
coverage in prior years may not be the same as that set forth in this Notice.
Proprietary
IN GUAR 1 06/2019
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Note: Certain policies and contracts may not be covered or fully covered. For example,
coverage does not extend to any portion(s) of a policy or contract that the insurer does not guarantee,
such as certain investment additions to the account value of a variable life insurance policy or
variable annuity contract.
Benefits provided by a long-term care (LTC) rider to a life insurance policy or annuity contract shall
be considered the same type of benefits as the base life insurance policy or annuity to which it
relates.
To learn more about the protections provided by ILHIGA, please visit the ILHIGA website at
www.inlifega.org or contact:
Indiana Life & Health Insurance
Guaranty Association
3502 Woodview Trace, Suite 100
Indianapolis, IN 46268
(317) 636-8204
Indiana Department of Insurance
311 W. Washington Street, Suite 103
Indianapolis, IN 46204
(317) 232-2385
The policy or contract that this Notice accompanies might not be fully covered by
ILHIGA and even if coverage is currently provided, coverage is (a) subject to substantial
limitations and exclusions (some of which are described above), (b) generally conditioned
on continued residence in Indiana, and (c) subject to possible change as a result of future
amendments to Indiana law and court decisions.
Complaints to allege a violation of any provision of the Indiana Life and Health
Insurance Guaranty Association Act must be filed with the Indiana Department of
Insurance, 311 W. Washington Street, Suite 103, Indianapolis, IN 46204; (telephone) 317-
232-2385.
Insurance companies and agents are not allowed by Indiana law to use the existence of
ILHIGA or its coverage to encourage you to purchase any form of insurance or HMO
coverage. (IC 27-8-8-18(a)). When selecting an insurance company, you should not rely
on ILHIGA coverage. If there is any inconsistency between this Notice and Indiana law,
Indiana law will control.
Questions regarding the financial condition of a company or your life, health insurance
policy or annuity should be directed to your insurance company or agent.
IN GUAR 2 06/2019
Proprietary
388950
Application for
Medicare Supplement
Insurance
part of the CVS Health family of companies and Aetna affiliate
®
Policy administered by Aetna Life Insurance Company and its affiliates
Indiana
ACCMS05297IN
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388950
Application for Medicare Supplement Insurance

Page 1 of 13
• If only one applicant, just complete applicant A information. • Complete all required sections of the application. Any
• Mail application and check in the provided business incomplete or missing information could result in delay
reply envelope. or closure of your application.
Section 1a. Applicant A information

Applicant A name (as appears on Medicare card*) Phone
• JIMMY L BOYD JR • 574-360-9585
Residential address Apt/suite number

• 1752 Kessler Blvd •
City State Zip

• South Bend • IN • 46616
Mailing address (if different than residential address) Apt/suite number
• P. O. Box 11212 , •
City State Zip

• South Bend • IN • 46634
E-mail Social Security Number
• • XXX-XX-8151
Birth date (mm/dd/yyyy) Age ■ Male

□ Height (feet and inches) Weight (pounds)
• 03/13/1956 • 65 □ Female • •
Are you a legal resident of the United States? ■ Yes

□ □ No
Have you used any form of tobacco in the past 12 months? (Including vaping and e-cigarettes) □ Yes ■ No
□
Medicare card number * Effective date: Medicare Part A Medicare Part B
• 6GW1YX0UY95 • 03/01/2021 • 06/01/2021
*Please provide complete Medicare number and a copy of card if possible.

If applicant has not received a Medicare card yet, leave blank.
Section 1b. Applicant B information

Applicant B name (as appears on Medicare card*) Phone
• •
Residential address Apt/suite number

• •
City State Zip

• • •
Mailing address (if different than residential address) Apt/suite number
• •
City State Zip

• • •
E-mail Social Security Number
• •
Birth date (mm/dd/yyyy) Age □ Male Height (feet and inches) Weight (pounds)
• • □ Female • •
Are you a legal resident of the United States? □ Yes □ No

Have you used any form of tobacco in the past 12 months? (Including vaping and e-cigarettes) □ Yes □ No
Medicare card number * Effective date: Medicare Part A Medicare Part B
• • •
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Section 2a. Household premium discount information
Household premium discount eligibility information

You may be eligible for a policy with a lower premium rate based on your answers to the questions in this section.
(1) Do you currently live with your spouse, including validly recognized civil union and domestic partners, or do you
currently have a household resident (at least one, no more than three) with whom you have continuously resided for
the last 12 months?
□
■ Yes □ No
(2) If you answered "Yes" to question 1 above, please fill out the following information about the household resident,
unless both applicants are applying for coverage on this application.
Name Policy number

• Annette Boyd •
Upon verification of eligibility and approval of your application, you will qualify for the discount.
Payment modes
You have a choice among several payment options or modes for paying your premium: annual, semi-annual,
quarterly and monthly electronic funds transfer (EFT). Each payment mode, other than annual and monthly electronic
funds transfer, results in higher total yearly premium costs. Reasons for higher costs include added collection and
administrative costs, time value of money considerations and lapse rates. The annual and monthly electronic funds
transfer modes have the same and lowest total yearly premium costs. As a result, there is a time value of money
advantage to you for paying monthly versus annually. However, there may be other advantages to you for choosing
an annual payment based on your preferences. Your agent can explain the differences in modes and help you decide
which is best for you. You may change your payment mode, among the modes available, during the life of your policy.
Mail policy(ies) to: ■ Applicant(s)

□ □ Agent
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Section 2b. Plan and premium information - applicant A
Applicant A Plan selected Requested Medicare Supplement effective date (mm/dd/yyyy)

• Plan N •06/01/2021
Modal premium Modal premium with discount Policy fee* Total initial premium collected/draft
$ 94.30 $ 81.10 $ 25.00 $ 106.10
Initial premium
□
■ Draft initial premium upon policy approval □ Draft initial premium on policy effective date
Subsequent draft date** Payment mode

• 1 □ Annually □ Quarterly □ Semi-annually □
■ Monthly EFT
Payment method
□ Check ■□ EFT □ List bill Billing file identifier:
If applying for household discount, provide the discounted and non-discounted premium amounts.
*This one-time fee will be refunded, along with your premium, if the
policy is not issued or you return it during your 30-day free look.
**Draft date cannot be on the 29th, 30th or 31st of the month. Requesting to have a draft
date more than 15 days greater than the policy's paid to date will draft a month in advance.
Section 2b. Plan and premium information - applicant B
Applicant B Plan selected Requested Medicare Supplement effective date (mm/dd/yyyy)

• •
Modal premium Modal premium with discount Policy fee* Total initial premium collected/draft
$ $ $ $
Initial premium
□ Draft initial premium upon policy approval □ Draft initial premium on policy effective date
Subsequent draft date** Payment mode

• □ Annually □ Quarterly □ Semi-annually □ Monthly EFT
Payment method
□ Check □ EFT □ List bill Billing file identifier:
Section 3. Eligibility questions
To the best of your knowledge: Applicant:

A B
1. Did you turn age 65 in the last 6 months? ■ Yes □ No
□ □ Yes □ No
i. Did you enroll in Medicare Part B in the last 6 months? □ Yes □

■ No □ Yes □ No
ii. If yes, what is the effective date? (mm/dd/yyyy)
Applicant A effective date Applicant B effective date
A • 06/01/2021 B •
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Section 3. Eligibility questions continued
Applicant:
NOTE: If you are participating in a "Spend-Down Program" and have A B
not met your "share of cost," please answer no to question 2.
2. Are you covered for medical assistance through the state Medicaid program? □ Yes ■
□ No □ Yes □ No
i. If yes, will Medicaid pay your premiums for this Medicare Supplement policy? □ Yes □ No □ Yes □ No
ii. Do you receive any benefits from Medicaid other than payments toward
your Medicare Part B premium? □ Yes □ No □ Yes □ No
3. If you had coverage from any Medicare plan other than original Medicare within
the past 63 days (for example, a Medicare Advantage plan, or a Medicare HMO
or PPO), fill in your start and end dates below. If you are still covered under this
plan, leave "End date" blank.
Applicant A start date Applicant B start date
• •
A B
End date End date
• •
i. If you are still covered under the Medicare plan, do you intend to replace your
current coverage with this new Medicare Supplement policy? □ Yes □ No □ Yes □ No
ii. Was this your first time in this type of Medicare plan? □ Yes □ No □ Yes □ No
iii. Did you drop a Medicare Supplement policy to enroll in the Medicare plan? □ Yes □ No □ Yes □ No
4. Do you have another Medicare Supplement policy in force? □ Yes □

■ No □ Yes □ No
i. If so for applicant A, with what company, and what plan do you have?
A
Company Plan
• •
If so for applicant B, with what company, and what plan do you have?
B Company Plan
• •
ii. If so, do you intend to replace your current Medicare Supplement policy
with this policy? □ Yes □ No □ Yes □ No
iii. Are you replacing an Accendo Insurance Company Medicare Supplement policy? □ Yes □ No □ Yes □ No
If yes, list policy number:

A Applicant A B Applicant B
• •
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Section 3. Eligibility questions continued
If you lost, or are losing, other health insurance coverage and received a notice from your prior insurer saying
you were eligible for guaranteed issue of a Medicare Supplement insurance policy, or that you had certain rights
to buy such a policy, you may be guaranteed acceptance in one or more of our Medicare Supplement plans.
Please include a copy of the notice from your prior insurer with your application.
Applicant:
5. Have you had coverage under any other health insurance within the A B
past 63 days? (For example, an employer, union, or individual plan) ■ Yes □ No
□ □ Yes □ No
i. If so for applicant A, with what company, and what plan do you have?
Company Plan
• Anthem • Employer Health
A ii. What are your start and end dates of coverage under the other policy?
(If you are still covered under the other policy, leave "End date" blank.)
Applicant A start date End date
• 05/01/2021 •
i. If so for applicant B, with what company, and what plan do you have?
Company Plan
• •
B
ii. What are your start and end dates of coverage under the other policy?
(If you are still covered under the other policy, leave "End date" blank.)
Applicant B start date End date
• •
For agent use only
Check if application is for:

Applicant A □
■ Open Enrollment □ Guaranteed Issue □ Underwritten
Applicant B □ Open Enrollment □ Guaranteed Issue □ Underwritten
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Page 6 of 13
Section 4. Health questions
Answer these questions only if you're applying for underwritten coverage. Do not answer these questions for
an Open Enrollment or Guaranteed Issue application. If any health questions are answered "yes" in section 4, the
applicant(s) will not qualify for this insurance with us.
Applicant:
A B
1. Are you dependent on a wheelchair or any motorized mobility device? □ Yes □ No □ Yes □ No
2. Do any of the following apply to you?

Currently hospitalized, confined to a bed, in a nursing facility or assisted living □ Yes □ No □ Yes □ No
facility, receiving home health care or physical therapy
3. At any time, have you been medically diagnosed, treated, or had surgery
for any of the following?
A. congestive heart failure, unoperated aneurysm, defibrillator □ Yes □ No □ Yes □ No
B. leukemia, lymphoma, multiple myeloma, cirrhosis □ Yes □ No □ Yes □ No
C. Parkinson's Disease, Lou Gehrig's Disease, Alzheimer's Disease, dementia
multiple sclerosis, muscular dystrophy, cerebral palsy □ Yes □ No □ Yes □ No
D. chronic kidney disease, kidney failure, kidney disease requiring dialysis,
renal insufficiency, Addison's Disease □ Yes □ No □ Yes □ No
E. any condition requiring a bone marrow transplant or stem cell transplant, any
condition requiring an organ transplant □ Yes □ No □ Yes □ No
F. Acquired Immune Deficiency Syndrome (AIDS), AIDS Related Complex (ARC),
tested positive for the Human Immunodeficiency Virus (HIV) □ Yes □ No □ Yes □ No
4. Have you been medically diagnosed or treated by a member of the

medical profession for diabetes?
A. that requires use of insulin □ Yes □ No □ Yes □ No
B. with complications including retinopathy, neuropathy, peripheral
vascular or arterial disease or heart artery blockage □ Yes □ No □ Yes □ No
C. with history of heart attack or stroke (at any time) □ Yes □ No □ Yes □ No
D. treated with medication that has been changed or adjusted in the past 12
months because of uncontrolled blood sugar □ Yes □ No □ Yes □ No
5. Within the past 36 months, have you been medically diagnosed, treated,
or had surgery for any of the following?
A. alcoholism, drug abuse □ Yes □ No □ Yes □ No
B. cardiomyopathy, atrial fibrillation, anemia requiring repeated blood
transfusions, any other blood disorder □ Yes □ No □ Yes □ No
C. internal cancer, melanoma, Hodgkin's Disease □ Yes □ No □ Yes □ No
D. hepatitis, disorder of the pancreas □ Yes □ No □ Yes □ No
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Page 7 of 13
Section 4. Health questions continued
Applicant:
6. Within the past 24 months, have you been medically diagnosed, treated, A B
or had surgery for any of the following?
A. enlarged heart, transient ischemic attack (TIA), stroke, peripheral vascular
or arterial disease, neuropathy, amputation caused by disease □ Yes □ No □ Yes □ No
B. myasthenia gravis, systemic lupus or connective tissue disorder □ Yes □ No □ Yes □ No
C. osteoporosis with fractures, Paget's Disease, arthritis that restricts mobility
or the activities of daily living □ Yes □ No □ Yes □ No
D. any lung or respiratory disorder requiring the use of a nebulizer or oxygen,
or 3 or more medications for lung or respiratory disorder □ Yes □ No □ Yes □ No
E. any lung or respiratory disorder and currently use tobacco products □ Yes □ No □ Yes □ No
7. Within the past 12 months, have you been advised by a medical professional
to have treatment, further evaluation, diagnostic testing, or surgery that
has not been performed or do you have pending test results? □ Yes □ No □ Yes □ No
8. Within the past 12 months, have you been medically diagnosed or, treated,
or had surgery for a heart attack, artery blockage, or heart valve disorder? □ Yes □ No □ Yes □ No
9. Within the past 12 months, have you been medically diagnosed with wet
macular degeneration and have taken or are currently receiving injections? □ Yes □ No □ Yes □ No
10. Within the past 12 months, do any of the following apply to you?
A. had a pacemaker implanted □ Yes □ No □ Yes □ No
B. had a PSA blood test greater than 4.5, under age 70, with no history of
prostate cancer □ Yes □ No □ Yes □ No
C. had a PSA blood test greater than 6.5, age 70 or older, with no history of
prostate cancer □ Yes □ No □ Yes □ No
D. had a seizure □ Yes □ No □ Yes □ No
11. Was your last blood pressure reading higher than 175 systolic or higher
than 100 diastolic? □ Yes □ No □ Yes □ No
Systolic is the upper number and diastolic is

the bottom number of a blood pressure reading.
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Page 8 of 13
Section 5. Health history - applicant A
If this is an Open Enrollment or Guaranteed Issue application, do not answer questions in this section.
Applicant A
Within the past 24 months if you have been medically diagnosed, treated, or had surgery for any brain, mental or
nervous disorder, provide reason and diagnosis:
Within the past five years if you have been hospitalized, treated at an outpatient facility, or emergency room,
provide reason and diagnosis:
List the name of any medications you are taking and the reason why, if known.
Use an additional sheet of paper if needed for explanation.
Section 5. Health history - applicant B
Applicant B
Within the past 24 months if you have been medically diagnosed, treated, or had surgery for any brain, mental or
nervous disorder, provide reason and diagnosis:
Within the past five years if you have been hospitalized, treated at an outpatient facility, or emergency room,
provide reason and diagnosis:
List the name of any medications you are taking and the reason why, if known.
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Section 6. Physician information - applicant A
If this is an Open Enrollment or Guaranteed Issue application, do not answer questions in this section.
Applicant A primary physician Phone

• •
Physician's office name

•
City State
• •
Specialist seen in the past 24 months Specialty

• •
Reason for seeing (diagnosis)

•

• •

•

• •

•
Have you seen any additional physicians other than those listed
above in the past 24 months? □ Yes □ No
Section 6. Physician information - applicant B
Applicant B primary physician Phone

• •
Physician's office name

•
City State
• •

• •

•

• •

•

• •

•
Have you seen any additional physicians other than those listed
above in the past 24 months? □ Yes □ No
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Page 10 of 13
Section 7. Important statements
1. You do not need more than one Medicare Supplement 5. If you are eligible for, and have enrolled in a Medicare
policy. Supplement policy by reason of disability and you
later become covered by an employer or union-based
2. If you purchase this policy, you may want to evaluate your group health plan, the benefits and premiums under
existing health coverage and decide if you need multiple your Medicare Supplement policy can be suspended,
coverages. if requested, while you are covered under the employer
or union-based group health plan. If you suspend your
3. You may be eligible for benefits under Medicaid and may
Medicare Supplement policy under these circumstances,
not need a Medicare Supplement policy.
and later lose your employer or union-based group health
4. If, after purchasing this policy, you become eligible plan, your suspended Medicare Supplement policy (or,
for Medicaid, the benefits and premiums under your if that is no longer available, a substantially equivalent
Medicare Supplement policy can be suspended, if policy) will be reinstituted if requested within 90 days of
requested, during your entitlement to benefits un- losing your employer or union-based group health plan.
der Medicaid for 24 months. You must request this If the Medicare Supplement policy provided coverage
suspension within 90 days of becoming eligible for for outpatient prescription drugs and you enrolled in
Medicaid. If you are no longer entitled to Medicaid, your Medicare Part D while your policy was suspended, the
suspended Medicare Supplement policy (or, if that is reinstituted policy will not have outpatient prescription
no longer available, a substantially equivalent policy) drug coverage, but will otherwise be substantially equiva-
will be reinstituted if requested within 90 days of losing lent to your coverage before the date of suspension.
Medicaid eligibility. If the Medicare Supplement policy
6. Counseling services may be available in your state to
provided coverage for outpatient prescription drugs and
provide advice concerning your purchase of Medicare
you enrolled in Medicare Part D while your policy was
Supplement insurance and concerning medical assis-
suspended, the reinstituted policy will not have outpa-
tance through the state Medicaid program, including
tient prescription drug coverage, but will otherwise be
benefits as a Qualified Medicare Beneficiary (QMB) and
substantially equivalent to your coverage before the date
a Specified Low-Income Medicare Beneficiary (SLMB).
of the suspension.
Section 8. Producer compensation
When you purchase insurance from us, we pay Some agents and/or their intermediaries may also receive
compensation to the licensed agent. Intermediaries through discounts on their own policy premiums and bonuses. We
whom the licensed agent works may also receive compensa- may also offer incentive trips or prizes associated with sales
tion. contests based on sales criteria. Types of sales criteria
The agent or intermediary represents us by simply taking include overall sales volume of an agent or intermediary
your insurance application, collecting your initial premiums with our companies or percentage of completed sales.
and delivering your policy. Intermediaries may also pay compensation directly to the
Agent compensation may vary depending on the type of licensed agent. If the licensed insurance agent can sell
insurance plan you purchase or the specific options included insurance policies from other insurance carriers, those
with your policy. The agent can receive compensation by: carriers may pay compensation that differs from ours.
• Commissions when a policy is purchased or renewed

• Fees for marketing and administrative services
• Educational opportunities
ACCMS05297IN
(012120)
388950
Page 11 of 13
Section 9. Applicant(s) agreement
This agreement is to acknowledge that I am applying for an I understand and agree that this application and any
insurance policy from Accendo Insurance Company that policy issued will be the entire contract of insurance. The
will be issued based on my answers to the questions on this Company will not be bound by any statements, promises, or
application. I have read, or had read to me, and understand information made or given by any agent or other person at
all statements and answers and acknowledge that to the any time unless it is in writing, submitted to the Company’s
best of my knowledge and belief, they are all accurate, administrative office, and made a part of the contract of
complete and correctly documented. I understand that I will insurance. An Officer of the Company is the only one who
receive a copy of the signed application. I acknowledge that can make, modify or discharge contracts or waive any of the
I have received an outline of coverage for the policy that I Company's rights or requirements; and any modifications
applied for, along with a copy of Choosing a Medigap Policy: must be documented in writing.
A Guide to Health Insurance for People with Medicare.
I also understand that I do not have coverage until this
I acknowledge and agree that if there is more than one application is approved, the first premium is paid, there has
applicant on this application, all information provided been no change in my health as stated in the application,
may be reviewed or shared with the other applicant. and a policy has been issued by the Company.
I understand that upon acceptance of the completed
application, each applicant will receive a separate policy I understand and agree that, if I choose to pay my premium
with a copy of this application attached. by electronic funds transfer (EFT) from my checking or
savings account, I am accepting the terms and conditions
of the EFT authorization attached to this application.
I understand that if any answers on this application are incorrect, incomplete or untrue,
Accendo Insurance Company has the right to adjust my premium or cancel this policy.
Applicant A signature Date signed 05/07/2021
X In Person JIMMY BOYD JR •
Applicant B signature Date signed
X •
Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit
or who knowingly presents false information in an application for insurance is guilty of a crime and
may be subject to restitution fines or confinement in prison, or any combination thereof.
ACCMS05297IN
(012120)
388950
Page 12 of 13
Section 10. Account information - applicant A
Complete this section if you are requesting electronic funds transfer (EFT) for premium payment.
Include a voided check with the application.
Applicant A name Account owner name (if different than proposed insured's)
• JIMMY L BOYD JR •
Account owner relationship to proposed insured

□ Business owned by proposed insured □ Living trust □ Employer
□ Power of Attorney □ Conservator/guardian □ Family member; please specify:
Financial institution name Account type

• COMMUNITYWIDE FED CR UN ■ Checking
□ □ Savings
Routing number Account number
•271291855 •XXXXXX4809
Section 10. Account information - applicant B
Applicant B name Account owner name (if different than proposed insured's)
• •
Account owner relationship to proposed insured

□ Business owned by proposed insured □ Living trust □ Employer
□ Power of Attorney □ Conservator/guardian □ Family member; please specify:
Financial institution name Account type

• □ Checking □ Savings
Routing number Account number
• •
Section 11. Electronic funds transfer (EFT) authorization
I understand and accept these terms and conditions: • Information as to each EFT charge will be provided by entry
on your account statement or by any other means provided
• We are authorized to withdraw funds periodically from your by your financial institution. You will not receive premium
account to pay insurance premiums for the insured. notices from us.
• If your financial institution does not honor an EFT • If you want to cancel or change this authorization, you
request, we will NOT consider your premium paid. must contact us at least three business days before a
• If your financial institution does not honor an EFT scheduled withdrawal.
request, we may make a second attempt within five • Any refund of unearned premium will be made to the
business days. policy owner or the policy owner's estate.
• We have the right to end EFT payments at any time and
bill you directly either quarterly or less frequently for premi- Signature only required if the account owner
ums due. is different than the proposed insured.
Account owner signature - applicant A Date signed
X •
Account owner signature - applicant B Date signed
X •
ACCMS05297IN
(012120)
388950
Page 13 of 13
Section 12. Agent information
Please list any other medical or health insurance policies sold to applicant A.
1) List policies sold which are still in force

•
2) List policies sold in the past 5 years which are no longer in force
•
Please list any other medical or health insurance policies sold to applicant B.
1) List policies sold which are still in force

•
2) List policies sold in the past 5 years which are no longer in force
•
I certify that:
1. I have truly and accurately recorded the information 3. I have provided an outline of coverage for the policy(ies)
supplied by the applicant(s). applied for and A Guide to Health Insurance for People
with Medicare to applicant(s) prior to completing the
2. The application was provided to the applicant(s) to application.
review and the applicant(s) has been advised that any false
statement or misrepresentation in the application may All information must be completed. The writing
result in an adjustment of premium, reduction of number reflects where commissions will be paid.
benefits or rescission of the policy(ies).
Agent name (printed) Agent signature KENNEYL@SJRMC.COM

• Lory Kenney X Lory Kenney
Writing number (agent or company) State license ID number (for FL only)
• GNW2039385 •
Phone Email
• (574) 335-7948 • KENNEYL@SJRMC.COM
Section 13. Agent request to split commissions
If this application results in an issued policy through Accendo Insurance Company (ACC), the agents listed below have
agreed to split the commissions earned on the policy.
• Both agents must be properly licensed and appointed with • The percentage of the premium split can be for any amount
ACC in the policy’s state of issue. but must be stated in whole numbers and total 100%. (For
• Split commissions are calculated as a percentage of example, the percentage for the premium split can be from
commissionable premium and will apply while the policy 1% to 99% but cannot be 0% or 100%.)
remains in force. • Calculation of each agent’s commissions are based on
their respective ACC commission schedule.
Writing agent name (printed) Percentage
• Lory Kenney • 100.00 %
Writing agent signature KENNEYL@SJRMC.COM
X Lory Kenney
Secondary agent Writing number Percentage
• • • %
This section must be completed with this application in order to split commissions. By signing this form,
the writing agent agrees to split his/her commission with the secondary agent as indicated above.
ACCMS05297IN
(012120)
388950
Applicant receipt
Thank you for choosing Accendo Insurance Company
part of the CVS Health family of companies and Aetna affiliate
®
Policy administered by Aetna Life Insurance Company and its affiliates
• Payment will be refunded for any coverage not issued.

• All premium payments must be made payable to Accendo Insurance Company.
• DO NOT make any check payable to the agent and DO NOT leave the payee blank on the check.
• A recorded interview may be required as part of the underwriting on your application for insurance.
Applicant A name (printed) Date of application

• JIMMY L BOYD JR • 05/07/2021
Initial payment collected (if applicable) Payment type
$ 106.10 □ Check □ Money order
EFT draft amount EFT draft date

$ 106.10 • 1
Applicant B name (printed) Date of application

• •
Initial payment collected (if applicable) Payment type

$ □ Check □ Money order
EFT draft amount EFT draft date

$ •
This acknowledges receipt of your application for an Accendo Insurance Company Medicare Supplement insurance
policy.
Agent name (printed) Agent signature KENNEYL@SJRMC.COM
• Lory Kenney X Lory Kenney

Phone Email
• (574) 335-7948 • KENNEYL@SJRMC.COM
©2020 CVS Health

388950
Applicant A JIMMY L BOYD JR
Additional Eligibility Questions#2 - Is this a voluntary termination? -
Additional Eligibility Questions#3 - Was your Medicare Supplement policy with Aetna/Accendo?-
Additional Eligibility Questions#3 - Is this a voluntary termination? -
Additional Eligibility Questions#5 - Are you currently covered or are you losing COBRA coverage?- N
Additional Eligibility Questions#5 - Is this a voluntary termination?- Y
Receive policy electronically - N
Secure question -
Secure question response -
Application type override to -
Applicant B
Additional Eligibility Question#2 - Is this a voluntary termination? -
Additional Eligibility Question#3 - Was your Medicare Supplement policy with Aetna/Accendo?-
Additional Eligibility Question#3 - Is this a voluntary termination? -
Additional Eligibility Question#5 - Are you currently covered or are you losing COBRA coverage?-
Additional Eligibility Question#5 - Is this a voluntary termination?-
Receive policy electronically -
Secure question -
Secure question response -
Application type override to -

X In Person JIMMY BOYD JR
Writing Agent Signature KENNEYL@SJRMC.COM Date signed 05/07/2021
X Lory Kenney
388950
Applicant A JIMMY L BOYD JR
Prescribed medications Reason for medications (diagnosis)

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X Lory Kenney
388950
Applicant B
Prescribed medications Reason for medications (diagnosis)

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X Lory Kenney
388950
Applicant A physician information JIMMY L BOYD JR

▪ ▪

▪

▪ ▪

▪

▪ ▪

▪

▪ ▪

▪

▪ ▪

▪

▪ ▪

▪

▪ ▪

▪

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▪

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▪
X Lory Kenney
388950
Applicant B physician information

▪ ▪

▪

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▪

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▪

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▪

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X Lory Kenney
388950
Applicant A:
Is mailing address different? Y

Address: P. O. Box 11212 ,
City: South Bend
State: IN
Zip Code: 46634
Applicant B:
Is mailing address different?

Address:
City:
State:
Zip Code:
AgentName Writing number Percentage
AgentNotes A
AgentNotes B
SOS A
SOS B
Send Policy Document(Applicant B):
O Agent
O Applicant
388950
Applicant A:
EQ 1. Will you turn 65 in the next 6 months?
EQ1-A. Will you be enrolling in Medicare Part B in the next 6 months, If WI,
then in the next 90 days?
Applicant B:
EQ 1. Will you turn 65 in the next 6 months?
EQ1-A. Will you be enrolling in Medicare Part B in the next 6 months, If WI,
then in the next 90 days?
388950
388950
388950
388950
Underwritten by

part of the CVS Health family of companies and Aetna affiliate
®
aetnaseniorproducts.com
Policy administered by Aetna Life Insurance Company and its affiliates
Not connected with or endorsed

by the U.S. Government or the
Federal Medicare Program.
©2020 CVS Health

388950
Discounts and programs available to

Aetna Senior Supplemental
Members
18.02.448.1 T (12/19)
388950
Discounts Hearing
You can take care of your hearing and save money
with Hearing Care Solutions.
As a member of an Aetna
Hearing Care Solutions has over 2,000 providers at
Insurance Plan, you can get more than 1,800 locations and offers you:
discounts on eyeglasses and • Annual hearing exam at no charge.
more. You can save money on • A discounted rate of $42 for hearing exams.
products and services that fit • Hundreds of hearing aid models at low prices.
Save up to 63 percent.
your life. • A three-year supply of batteries (up to 240 cells
per ear). After that, you can join a discount battery
At home products mail-order program.
• Free in-office service of hearing aids for one year
Omron Healthcare after purchase.
Get discounts on blood pressure monitors, • Free routine services (cleanings, checks and
pedometers and activity trackers, electrotherapy battery door replacements) for one year after
TENS (transcutaneous electrical nerve stimulation) purchase from the original provider.
units, and many other Omron products.
How to get your discount
Receive 10% off when you use code AETNA10. This
is a savings of up to 60% off retail price. Offer • To schedule an appointment, call Hearing Care
excludes AliveCor and subscription products Solutions at 1-866-344-7756.
• Before your appointment, you will receive a
How to get your Omron discount welcome packet that includes:
• Visit Omron’s website (omronhealthcare.com/ • Information on hearing loss
aetna) and use the promotion code AETNA10 at • Information on hearing aids
checkout.
• What to expect at your first appointment
• Call 1-877-216-1333 to order by phone or to
speak with an Omron customer service
representative to get more information. Mention
the promotion code AETNA10 to get the discount
Aetna is the brand name used for products and services provided by one or more of the Aetna group
of subsidiary companies, including Aetna Life Insurance Company and its affiliates (Aetna). Aetna
insurance plans are underwritten by Aetna Life Insurance Company, American Continental Insurance
Company, Continental Life Insurance Company of Brentwood, Tennessee, Aetna Health Insurance
Company, Aetna Health and Life Insurance Company, First Health Life and Health Insurance Company,
and Coventry Health and Life Insurance Company.
2
388950
Vision Ready for LASIK?
You can take care of your vision and save You pay one low package price for LASIK screening,
with EyeMed Vision Care. surgery and follow-up care. And your first
consultation is free, even if you decide not to have
Get discounts on: surgery.
• Eye exams Call U.S. Laser Network Customer Service at
• Eyeglass frames and lenses 1-800-422-6600 (Mon-Fri, 8 a.m. - 9 p.m. ET and
• Non-disposable contact lenses and solutions Sat, 9 a.m. - 6 p.m. ET) to get started. You can get
• LASIK eye surgery help finding a doctor, get a referral, learn about
costs and set up a surgery date.
• Sunglasses (prescription and non-prescription)
• And more! Need to replace lost contact lenses?
Aetna and EyeMed Vision Care bring you a It’s easy. If you have a current prescription and
nationwide network of eye care providers at the need replacement contact lenses, you can get extra
following retail chains: pairs shipped to your home easily and quickly.
• LensCrafters® Here’s how:
• Pearle Vision® • Buy your first pair of prescription lenses through
• Target Optical® your doctor’s office.
• Sears Optical® locations • Then call 1-844-5LENSES (1-844-553-6737)
(Mon-Fri, 8 a.m. - 8 p.m. ET and Sat 9 a.m. - 5 p.m.
You also can use any of the thousands of
ET) and use your current prescription to place
participating independent eye care providers who
your order for your replacement lenses.
have doctors of optometry practicing at their
location or nearby.
Coupons vs. discounts
You can get these discounts even if you have other
• In no event shall a member be required to pay
vision benefit coverage. If you do have coverage,
more for any service(s) or materials than such
check your plan requirements first.
member would have paid, had the member taken
advantage of a coupon or other sales promotion
Vision savings snapshot (provided the member complies with the terms of
Discounted prices on eye care services and the coupon or other sales promotion).
eyewear products through the vision discounts • Members may not combine any coupon or sales
participating providers are listed on the next page. promotion with any reduced fee service discount.
Keep this chart handy - it’s a listing of savings
available to you.
Find a participating provider
• Call 1-800-793-8616 (Mon-Sat, 8 a.m. - 11 p.m. ET
and Sun, 11 a.m. - 8 p.m. ET) to find a participating
provider.
• Call the provider’s office to schedule an
appointment.
• Show your Aetna discount program membership
card (on page 8 of this brochure) to get your
discount.
3
388950
Vision*
PRODUCT OR SERVICE DISCOUNTED FEE
Eye exam
Exam for eyeglasses $42
Exam for standard contact lenses fit and $40 (plus $42 exam fee)
follow-up
$10 off standard fee (plus $42 exam fee)
Exam for specialty contact lenses fit and
follow-up (toric, bifocal, gas permeable)
Lenses per pair (uncoated plastic)
Single vision $40

Bifocal $60
Trifocal $80
Standard progressive (no-line bifocal) $120
Eyeglass frames* 35% off retail price
Lens options per pair (add to lens price listed above)
Polycarbonate (includes UV $40

and scratch-resistant coating)
Scratch-resistant coating $15
UV coating $15
Solid or gradient tint $15
Standard anti-reflective coating $45
Glass 20% off retail price
Photochromatic glass 20% off retail price
Non-disposable contact lenses 15% discount off retail price**
Mail-order contact lenses Call 1-844-553-6737 to order replacement
contact lenses
Additional vision-related items 20% discount off retail price
LASIK procedure 15% off standard prices or 5% off promotional
prices for LASIK services obtained through the
U.S. Laser Network. Members must call before
scheduling an appointment.
*
EyeMed Services and Compensation Schedule, 01/15. Prices are subject to change. Certain brands impose
a no-discount policy
**
Discount does not apply to disposable contact lenses.
4
388950
The little card for

BIG eye care savings
Vision Discounts
Get on-the-spot savings with your membership!
Simply sign the card below, then present at any participating location before you
buy eyewear or other vision services.
Plan #: 46543
Expires: 12/31/20
Vision discounts Membership card

Member signature
For location details call 1-800-793-8616

Monday – Saturday, 8 a.m. – 11 p.m.
Sunday, 11 a.m. – 8 p.m. ET
Vision discounts
Exam and Eyewear: 1-800-793-8616
LASIK Customer Service: 1-800-422-6600
Contacts Direct: 1-844-553-6737
Vision discounts provide access to discounted
services and are not part of an insured plan or policy.
They are rate-access offers and may be in addition
to any plan benefits. Aetna does not endorse any
vendor, product or service associated with these
discount offers. Vendors are independent of Aetna,
not agents or employees thereof. No eligibility
verification required, process sale under 46543.
Aetna is the brand name used for products and services provided by one or more of the Aetna group
of subsidiary companies, including Aetna Life Insurance Company and its affiliates (Aetna).
Health benefits and health insurance plans contain exclusions and limitations. Information is believed to
be accurate as of the production date; however, it is subject to change. For more information about
Aetna plans, refer to www.aetna.com.
©2017 Aetna Inc.

10.11.301.1 E (10/17)
5
388950
Programs AETNA VITAL DENTAL SAVINGS DENTAL

DISCOUNT PROGRAM
The discounts described earlier in this
brochure are automatically available to all For instant savings on dental, join the Aetna Vital
Aetna members with no additional fee. The Dental Savings program. Your Aetna Vital Dental
following programs are available at an Savings discount card can also earn you discounts
additional fee and may require that you enroll on eye care, fitness services and a whole lot more.
in the program. In most instances, you can save 15 percent - 50
percent.*
LIFESTATION® EMERGENCY RESPONSE
Start smiling - Join us online or call us! We’ve made
SYSTEM the sign-up process quick and easy. Join us online at
LifeStation is a leader in medical alert systems www.vitalsavings.com and use promotion code
providing seniors with 24/7 emergency help at the VS4YOU or call 1-877-698-4825.
push of a button. Medical alert systems provide Sign up now and we’ll waive the $15 sign-up fee.
piece of mind to seniors and their loved ones,
allowing seniors to remain in their own homes with $75 for an individual. $105 for a family.
the knowledge that help is always available. Now you can keep your smile looking good and
Medical alert systems are offered to members have a reason to show it off.
through the use of a medical alert console and
wireless help button that can be worn as a pendant
or bracelet. In the event of an emergency, members
press the help button and are immediately
connected with Care Specialists at LifeStation’s
Underwriters Laboratory (UL) Listed Monitoring
Center who will assess the situation and contact
EMS and the member’s emergency contact list, if
necessary.
LifeStation Medical Alert Systems - special offer of
$21.95 per month (less than 75 cents per day), a
more than 25% discount off of current retail price
of $29.95 per month for medical alert equipment
and 24/7 monitoring from their UL Listed
Monitoring Center.
Members can call LifeStation’s Aetna member line
1-866-665-5288 or visit the Aetna member landing
page www.lifestation.com/aetna for more
information or to purchase the service. To receive
the Aetna member pricing you must either call the
Aetna member line at 1-866-665-5288 or enroll
online at www.lifestation.com/aetna. Members
can use promotion code AM21.
*
Actual costs and savings vary by provider and geographic area.
6
388950
Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary
companies, including Aetna Life Insurance Company and its affiliates (Aetna). Aetna insurance plans are
underwritten by Aetna Life Insurance Company, American Continental Insurance Company, Continental Life
Insurance Company of Brentwood, Tennessee, Aetna Health Insurance Company, Aetna Health and Life Insurance
Company, First Health Life and Health Insurance Company, and Coventry Health and Life Insurance Company.
This material contains only a partial, general description and does not constitute a contract. Health information
programs provide general health information and are not substitutes for diagnosis or treatment by a physician or
other health care professional. Discount offers are available to people who have health benefits plans that are
issued by, administered by, or serviced by Aetna or our affiliates.
Discount offers provide access to discounted services and are not part of an insured plan or policy. Discount
offers are rate-access offers and may be in addition to any plan benefits. Check any insurance benefits you have
before using these discount offers, as those benefits may result in lower costs to you than using these discounts.
Discount offers are not guaranteed and may be discontinued at any time. Aetna makes no payment to the
discount vendor. The member is responsible for the full cost of the discounted services.
Aetna does not endorse any vendor, product or service associated with this program. Vendors are independent
of Aetna, not agents of employees thereof. Programs, products and services may not be available at all times.
Certain offers may not be available in some states. Products may be subject to a warranty from the manufacturer.
Aetna makes no representations or warranties, and disclaims all product warranties.
The discount offers have no liability for providing or guaranteeing service and assumes no liability for the quality
of service rendered. Aetna may receive a percentage of the fee paid to a discount vendor. While this material is
believed to be accurate as of the production date, it is subject to change.
Oral health care discounts: Aetna does not provide dental products or treatment, and therefore cannot
guarantee any results or outcomes.
Vision discounts: LASIK surgery discounts are offered by the U.S. Laser Network. Providers are independent
surgeons and are not agents or representatives of EyeMed, Aetna Health Inc. or their affiliates.
The Aetna Vital Dental Savings program (the “Program”) is not insurance. This program does not meet the
Minimum Creditable Coverage requirements in Massachusetts. The Program provides members with access to
discounted fees pursuant to schedules negotiated by Aetna Life Insurance Company for the Aetna Vital Dental
Savings discount program. The range of discounts provided under the Program will vary depending on the type
of provider and type of service received. The Program does not make payments directly to the participating
providers. Each member must pay for all services or products but will receive a discount from the providers
who have contracted with the Discount Medical Plan Organization to participate in the Program. Aetna may
receive a percentage of the fee you pay to the discount provider. Aetna Life Insurance Company, 151 Farmington
Avenue, Hartford, CT 06156. 1-877-698-4825, is the Discount Medical Plan Organization.
©2019 Aetna Inc. aetnaseniorproducts.com

18.02.448.1 T (12/19)
388950

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388950

Accendo Insurance Company

Enclosed is your policy. Keep it in a handy place for future reference.

Accendo Insurance Company is committed to providing outstanding service to our

Thank you for trusting us with your insurance coverage.

Medicare Supplement Insurance

ACCENDO INSURANCE COMPANY

PREMIUMS ARE SUBJECT TO CHANGE

RIGHT TO EXAMINE POLICY FOR THIRTY (30) DAYS .................................................................................1

ACCENDO INSURANCE COMPANY

Insured: JIMMY BOYD JR Age: 65 Gender: M

Address: PO BOX 11212 Policy Number: ACC6365374

Initial Premium: $81.09 Premium Mode: Monthly

Policy Effective Date: 06/01/2021

To Inquire About Your Coverage, or to Express a Concern, Call us Toll-Free at:

Policyholder Services: 800 264.4000

Claims Customer Service: 800 264.4000

POLICY SCHEDULE (CONT’D)

MEDICARE (PART A) – HOSPITAL SERVICES THIS POLICY PAYS

DAILY BENEFIT NOT COVERED BY MEDICARE:

HOME HEALTH CARE, MEDICARE APPROVED SERVICES:

CHANGES IN MEDICARE COINSURANCE AND DEDUCTIBLES

BENEFIT PERIOD means a Benefit Period as defined by Medicare.

COMPANY OFFICER means the President or Secretary.

HOSPITAL means a legally operated Hospital as defined by Medicare.

PHYSICIAN means a Physician as defined by Medicare.

SICKNESS means illness or disease.

SKILLED NURSING FACILITY means a Skilled Nursing Facility as defined by Medicare.

BASIC (“CORE”) BENEFITS

TO SUPPLEMENT BENEFITS UNDER PART B OF MEDICARE:

TO SUPPLEMENT BENEFITS UNDER PART B OF MEDICARE:

1. Insured will pay:

We will not pay for:

RECEIPT OF MEDICAL ASSISTANCE

If such reinstitution occurs:

Your policy will terminate on the earliest of:

TIME LIMIT ON CERTAIN DEFENSES:

2. Time limit on certain defenses:

ACCENDO INSURANCE COMPANY

MEDICARE SUPPLEMENT ADMINISTRATIVE OFFICE

MEDICARE SUPPLEMENT POLICY

THIS IS A PLAN “N”

NOTICE: Questions regarding Your Policy or coverage should be directed to:

Accendo Insurance Company, contact number 800 264.4000

State of Indiana Department of Insurance Consumer Services Division

Notice of Privacy Practices

How Aetna Uses and Discloses Personal Information

GR-67806-11 (3-20) Accendo 1

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Disclosure to Others Involved in Your Health Care

Aetna’s Legal Obligations

Safeguarding Your Information

This Notice is Subject to Change

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NOTICE OF PROTECTION PROVIDED BY THE

Basic Protections Currently Provided by ILHIGA

• $300,000 in death benefits

• $100,000 in net cash surrender or net cash withdrawal values

• $500,000 for health plan benefits (see definition below)

• $300,000 in disability income and long-term care insurance benefits

• $100,000 in other types of health insurance benefits

Indiana Life & Health Insurance

3502 Woodview Trace, Suite 100