Texas

1 Texas medicare supplement Life Application Booklet Insurance Policy: L030TX-Plan A L035TX-Plan F L036TX-Plan G L037TX-High Deductible Plan F L038TX-High Deductible Plan G XXKX-0120C030-TX (Rev. 01/23) -1-Physicians Life Insurance Company Benefit Chart of medicare supplement Plans Sold on or after January 1, 2020 This chart shows the benefits included in each of the standard medicare supplement plans. Every Company must make Plan A available. Some plans may not be available. Only applicants first eligible for medicare before 2020 may purchase Plans C, F, and High Deductible F. We currently offer Plan A, Plan F, and Plan G, including all high deductible options. All Physicians Life medicare supplement plans except Plan A provide innovative benefits not contained in standardized medicare supplement plans, including Preventive Health Care and Hearing Loss Testing, subject to plan limitations. Note: A means 100% of the benefit is paid. 1 Plans F and G also have a high deductible option which require first paying a plan deductible of $2,700 before the plan begins to pay.

2 Once the plan deductible is met, the plan pays 100% of covered services for the rest of the calendar year. High Deductible Plan G does not cover the medicare Part B deductible. However, High Deductible Plans F and G count your payment of the medicare Part B deductible toward meeting the plan deductible. Physicians Life also offers Deductible Discount Riders to add to Plan F or Plan G. The addition of the rider will provide the same benefits as a High Deductible Plan G or High Deductible Plan F from the effective date of the policy until the Deductible Elimination Date as defined on the Policy Schedule. On or after the Deductible Elimination Date, the benefits provided will be Plan F or Plan G benefits. 2 Plans K and L pay 100% of covered services for the rest of the calendar year once you meet the out-of-pocket yearly limit. 3 Plan N pays 100% of the Part B coinsurance, except for a co-payment of up to $20 for some office visits and up to a $50 co-payment for emergency room visits that do not result in an inpatient admission.

3 Benefits Plans Available to All Applicants medicare first eligible before 2020 only A B D G1 K L M N C F1 medicare Part A coinsurance and hospital coverage (up to an additional 365 days after medicare benefits are used up) medicare Part B coinsurance or copayment 50% 75% copays apply3 Blood (first three pints) 50% 75% Part A hospice care coinsurance or copayment 50% 75% Skilled nursing facility coinsurance 50% 75% medicare Part A deductible 50% 75% 50% medicare Part B deductible medicare Part B excess charges Foreign travel emergency (up to plan limits) Out-of-pocket limit in 20232$6,9402$3,4702 Non-Tobacco Automatic Bank Withdrawal Rates ZIP Code: 750 753, 757, 773 774, 776 777, 782 Female Attained Age Premiums Male Attained Age Premiums Age Plan F Plan F w/Rider* High Ded. Plan F Plan G Plan G w/Rider* High Ded. Plan G Age Plan F Plan F w/Rider* High Ded.

4 Plan F Plan G Plan G w/Rider* High Ded. Plan G 65-68 $ $ $ $ $ $ 65-68 $ $ $ $ $ $ 69 $ $ $ $ $ $ 69 $ $ $ $ $ $ 70 $ $ $ $ $ $ 70 $ $ $ $ $ $ 71 $ $ $ $ $ $ 71 $ $ $ $ $ $ 72 $ $ $ $ $ $ 72 $ $ $ $ $ $ 73 $ $ $ $ $ $ 73 $ $ $ $ $ $ 74 $ $ $ $ $ $ 74 $ $ $ $ $ $ 75 $ $ $ $ $ $ 75 $ $ $ $ $ $ 76 $ $ $ $ $ $ 76 $ $ $ $ $ $ 77 $ $ $ $ $ $ 77 $ $ $ $ $ $ 78 $ $ $ $ $ $ 78 $ $ $ $ $ $ 79 $ $ $ $ $ $ 79 $ $ $ $ $ $ 80 $ $ $ $ $ $ 80 $ $ $ $ $ $ 81 $ $ $ $ $ $ 81 $ $ $ $ $ $ 82 $ $ $ $ $ $

5 82 $ $ $ $ $ $ 83 $ $ $ $ $ $ 83 $ $ $ $ $ $ 84 $ $ $ $ $ $ 84 $ $ $ $ $ $ 85+ $ $ $ $ $ $ 85+ $ $ $ $ $ $ Female Issue Age Premiums Male Issue Age Premiums Age Plan F Plan F w/Rider* High Ded. Plan F Plan G Plan G w/Rider* High Ded. Plan G Age Plan F Plan F w/Rider* High Ded. Plan F Plan G Plan G w/Rider* High Ded. Plan G 65-68 $ $ $ $ $ $ 65-68 $ $ $ $ $ $ 69-71 $ $ $ $ $ $ 69-71 $ $ $ $ $ $ 72-74 $ $ $ $ $ $ 72-74 $ $ $ $ $ $ 75-77 $ $ $ $ $ $ 75-77 $ $ $ $ $ $ 78-80 $ $ $ $ $ $ 78-80 $ $ $ $ $ $ 81-84 $ $ $ $ $ $ 81-84 $ $ $ $ $ $ 85+ $ $ $ $ $ $ 85+ $ $ $ $ $ $ See Premium Information regarding eligibility for the Household Discount (10%).

6 To calculate other modal premiums, first apply Household Discount, if eligible, and then for monthly premiums add $ to the premium, or for other modes, multiply the premium by the following factors: Annual-12, Semiannual-6, Quarterly-3. *Rider is the optional Deductible Discount Rider, only available with Plan F or Plan (Rev. 01/23) -2-Tobacco Automatic Bank Withdrawal Rates ZIP Code: 750 753, 757, 773 774, 776 777, 782 Female Attained Age Premiums Male Attained Age Premiums Age Plan F Plan F w/Rider* High Ded. Plan F Plan G Plan G w/Rider* High Ded. Plan G Age Plan F Plan F w/Rider* High Ded. Plan F Plan G Plan G w/Rider* High Ded. Plan G 65-68 $ $ $ $ $ $ 65-68 $ $ $ $ $ $ 69 $ $ $ $ $ $ 69 $ $ $ $ $ $ 70 $ $ $ $ $ $ 70 $ $ $ $ $ $ 71 $ $ $ $ $ $ 71 $ $ $ $ $ $ 72 $ $ $ $ $ $ 72 $ $ $ $ $ $ 73 $ $ $ $ $ $ 73 $ $ $ $ $ $ 74 $ $ $ $ $ $ 74 $ $ $ $ $ $ 75 $ $ $ $ $ $ 75 $ $ $ $ $ $ 76 $ $ $ $ $ $ 76 $ $ $ $ $ $ 77 $ $ $ $ $ $ 77 $ $ $ $ $ $ 78 $ $ $ $ $ $ 78 $ $ $ $ $ $ 79 $ $ $ $ $ $ 79 $ $ $ $ $ $ 80 $ $ $ $ $ $ 80 $ $ $ $ $ $ 81 $ $ $ $ $ $ 81 $ $ $ $ $ $ 82 $ $ $ $ $ $ 82 $ $ $

7 $ $ $ 83 $ $ $ $ $ $ 83 $ $ $ $ $ $ 84 $ $ $ $ $ $ 84 $ $ $ $ $ $ 85+ $ $ $ $ $ $ 85+ $ $ $ $ $ $ Female Issue Age Premiums Male Issue Age Premiums Age Plan F Plan F w/Rider* High Ded. Plan F Plan G Plan G w/Rider* High Ded. Plan G Age Plan F Plan F w/Rider* High Ded. Plan F Plan G Plan G w/Rider* High Ded. Plan G 65-68 $ $ $ $ $ $ 65-68 $ $ $ $ $ $ 69-71 $ $ $ $ $ $ 69-71 $ $ $ $ $ $ 72-74 $ $ $ $ $ $ 72-74 $ $ $ $ $ $ 75-77 $ $ $ $ $ $ 75-77 $ $ $ $ $ $ 78-80 $ $ $ $ $ $ 78-80 $ $ $ $ $ $ 81-84 $ $ $ $ $ $ 81-84 $ $ $ $ $ $ 85+ $ $ $ $ $ $ 85+ $ $ $ $ $ $ See Premium Information regarding eligibility for the Household Discount (10%).

8 To calculate other modal premiums, first apply Household Discount, if eligible, and then for monthly premiums add $ to the premium, or for other modes, multiply the premium by the following factors: Annual-12, Semiannual-6, Quarterly-3. *Rider is the optional Deductible Discount Rider, only available with Plan F or Plan (Rev. 01/23) -3-Non-Tobacco Automatic Bank Withdrawal Rates ZIP Code: 754 756, 758 765, 778 781, 783 789, 793 Female Attained Age Premiums Male Attained Age Premiums Age Plan F Plan F w/Rider* High Ded. Plan F Plan G Plan G w/Rider* High Ded. Plan G Age Plan F Plan F w/Rider* High Ded. Plan F Plan G Plan G w/Rider* High Ded. Plan G 65-68 $ $ $ $ $ $ 65-68 $ $ $ $ $ $ 69 $ $ $ $ $ $ 69 $ $ $ $ $ $ 70 $ $ $ $ $ $ 70 $ $ $ $ $ $ 71 $ $ $ $ $ $ 71 $ $ $ $ $ $ 72 $ $ $ $ $ $ 72 $ $ $ $ $ $ 73 $ $ $ $ $ $ 73 $ $ $ $ $ $ 74 $ $ $ $ $ $ 74 $ $ $ $ $ $ 75 $ $ $ $ $ $ 75 $ $ $ $ $ $ 76 $ $ $ $ $ $ 76 $ $ $ $ $ $ 77 $ $ $ $ $ $ 77 $ $ $ $ $ $ 78 $ $ $ $ $ $ 78 $ $ $ $ $ $ 79 $ $ $ $ $ $ 79 $ $ $ $ $ $ 80 $ $ $ $ $ $ 80 $ $ $ $ $ $ 81 $ $ $ $ $ $ 81 $ $ $ $ $ $ 82 $ $ $ $ $

9 $ 82 $ $ $ $ $ $ 83 $ $ $ $ $ $ 83 $ $ $ $ $ $ 84 $ $ $ $ $ $ 84 $ $ $ $ $ $ 85+ $ $ $ $ $ $ 85+ $ $ $ $ $ $ Female Issue Age Premiums Male Issue Age Premiums Age Plan F Plan F w/Rider* High Ded. Plan F Plan G Plan G w/Rider* High Ded. Plan G Age Plan F Plan F w/Rider* High Ded. Plan F Plan G Plan G w/Rider* High Ded. Plan G 65-68 $ $ $ $ $ $ 65-68 $ $ $ $ $ $ 69-71 $ $ $ $ $ $ 69-71 $ $ $ $ $ $ 72-74 $ $ $ $ $ $ 72-74 $ $ $ $ $ $ 75-77 $ $ $ $ $ $ 75-77 $ $ $ $ $ $ 78-80 $ $ $ $ $ $ 78-80 $ $ $ $ $ $ 81-84 $ $ $ $ $ $ 81-84 $ $ $ $ $ $ 85+ $ $ $ $ $ $ 85+ $ $ $ $ $ $ See Premium Information regarding eligibility for the Household Discount (10%).

10 To calculate other modal premiums, first apply Household Discount, if eligible, and then for monthly premiums add $ to the premium, or for other modes, multiply the premium by the following factors: Annual-12, Semiannual-6, Quarterly-3. *Rider is the optional Deductible Discount Rider, only available with Plan F or Plan (Rev. 01/23) -4-Tobacco Automatic Bank Withdrawal Rates ZIP Code: 754 756, 758 765, 778 781, 783 789, 793 Female Attained Age Premiums Male Attained Age Premiums Age Plan F Plan F w/Rider* High Ded. Plan F Plan G Plan G w/Rider* High Ded. Plan G Age Plan F Plan F w/Rider* High Ded. Plan F Plan G Plan G w/Rider* High Ded. Plan G 65-68 $ $ $ $ $ $ 65-68 $ $ $ $ $ $ 69 $ $ $ $ $ $ 69 $ $ $ $ $ $ 70 $ $ $ $ $ $ 70 $ $ $ $ $ $ 71 $ $ $ $ $ $ 71 $ $ $ $ $ $ 72 $ $ $ $ $ $ 72 $ $ $ $ $ $ 73 $ $ $ $ $ $ 73 $ $ $ $ $ $ 74 $ $ $ $ $ $ 74 $ $ $ $ $ $ 75 $ $ $ $ $ $ 75 $ $ $ $ $ $ 76 $ $ $ $ $ $ 76 $ $ $ $ $ $ 77 $ $ $ $ $ $ 77 $ $ $ $ $ $ 78 $ $ $ $ $ $ 78 $ $ $ $ $ $ 79 $ $ $ $ $ $ 79 $ $ $ $ $ $ 80 $ $ $ $ $ $ 80 $ $ $ $ $ $ 81 $ $ $ $ $ $ 81 $ $ $ $ $ $ 82 $ $ $ $ $ $ 82 $