SCHEDULE OF BENEFITS - nib

| MediGap 2010
16
Item No Benefit Item No Benefit Item No Benefit Item No Benefit
30497 $891.75 30563 $756.60 30641 $518.20 31266 $234.60
30499 $1,060.65 30564 $982.10 30644 $662.85 31267 $234.60
30500 $1,135.70 30565 $1,108.00 30653 $59.10 31268 $234.60
30502 $1,253.50 30566 $1,230.80 30656 $137.50 31270 $328.45
30503 $1,403.65 30568 $923.30 30659 $190.40 31271 $328.45
30505 $701.75 30569 $470.80 30660 $236.05 31272 $328.45
30506 $1,228.10 30571 $566.40 30663 $183.50 31273 $328.45
30508 $1,292.75 30572 $566.40 30666 $60.30 31275 $380.50
30509 $1,292.75 30574 $156.75 30672 $566.40 31276 $380.50
30511 $1,080.30 30575 $652.00 30675 $380.80 31277 $380.50
30512 $1,329.40 30577 $1,385.05 30676 $482.00 31278 $380.50
30514 $1,957.25 30578 $1,458.90 30679 $122.45 31280 $198.15
30515 $895.65 30580 $1,329.40 30680 $1,487.90 31281 $198.90
30517 $1,172.70 30581 $969.50 30682 $1,487.90 31282 $198.90
30518 $1,255.80 30583 $1,518.70 30684 $1,831.00 31283 $198.90
30520 $858.80 30584 $2,241.70 30686 $1,831.00 31285 $270.80
30521 $1,837.45 30586 $891.75 30688 $464.05 31286 $270.80
30523 $1,920.40 30587 $923.30 30690 $716.30 31287 $270.80
30524 $2,114.35 30589 $1,591.00 30692 $464.05 31288 $270.80
30526 $2,742.20 30590 $1,754.30 30694 $716.30 31290 $312.65
30527 $1,108.00 30593 $2,400.65 30710 $663.30 31291 $312.65
30529 $1,661.95 30594 $2,770.10 31000 $738.65 31292 $312.65
30530 $997.25 30596 $1,141.05 31001 $923.30 31293 $312.65
30532 $1,145.00 30597 $915.85 31002 $1,108.00 31295 $372.40
30533 $1,362.00 30599 $1,661.95 31200 $43.20 31300 $406.80
30535 $2,157.55 30600 $988.20 31205 $121.30 31305 $500.40
30536 $2,188.45 30601 $1,217.40 31210 $156.55 31310 $354.35
30538 $1,514.35 30602 $1,975.80 31215 $182.50 31315 $448.25
30539 $1,108.00 30603 $2,086.70 31220 $272.80 31320 $500.40
30541 $1,929.75 30605 $2,372.90 31225 $484.85 31325 $344.05
30542 $1,311.15 30606 $1,412.60 31230 $213.65 31330 $406.80
30544 $960.30 30609 $590.65 31235 $182.50 31335 $469.20
30545 $2,336.20 30612 $453.15 31240 $213.65 31340 DERIVED
30547 $1,606.60 30614 $590.65 31245 $469.20 31345 $268.25
30548 $1,200.20 30615 $662.85 31250 $469.20 31346 $268.25
30550 $2,622.45 30616 $337.35 31255 $281.45 31350 $551.00
30551 $1,809.75 30617 $453.15 31256 $281.45 31355 $908.55
30553 $1,338.60 30620 $380.80 31257 $281.45 31400 $332.00
30554 $2,917.80 30621 $518.20 31258 $281.45 31403 $383.20
30556 $2,012.85 30628 $45.25 31260 $401.40 31406 $638.60
30557 $1,486.55 30631 $300.95 31261 $401.40 31409 $1,984.00
30559 $1,080.30 30634 $298.90 31262 $401.40 31412 $2,443.80
30560 $1,200.20 30635 $371.05 31263 $401.40 31420 $233.80
30562 $756.60 30638 $380.80 31265 $234.60 31423 $510.85
30497 to 31423