1801 Watermark Drive, Suite 100, P.O. Box 159019, Columbus, OH 43215
(614) 487-9680 • Toll-free: (800) 848-0123 • Fax: (614) 487-9675
Visit our web site at www.uct.org
Outline of Medicare Supplement Coverage – Cover Page: 1 of 2
Benefit Plans A, B, C, D, F and G
See Outlines of Coverage sections for details about ALL plans.
Basic Benefits for Plans A-J:
Hospitalization: Part A coinsurance plus coverage for 365 additional days after Medicare benefits end.
Medical Expenses: Part B coinsurance (generally 20% of Medicare-approved expenses) or copayments for hospital outpatient services.
Blood: First three pints of blood each year.
A / B / C / D / E / F / F* / G / H / I / J / J*Basic Benefits / Basic Benefits / Basic Benefits / Basic Benefits / Basic Benefits / Basic Benefits / Basic Benefits / Basic Benefits / Basic Benefits / Basic Benefits
Skilled Nursing
Facility Coinsurance / Skilled Nursing
Facility
Coinsurance / Skilled Nursing
Facility
Coinsurance / Skilled Nursing
Facility
Coinsurance / Skilled Nursing
Facility
Coinsurance / Skilled Nursing
Facility
Coinsurance / Skilled Nursing
Facility
Coinsurance / Skilled Nursing
Facility
Coinsurance
Part A Deductible / Part A Deductible / Part A Deductible / Part A Deductible / Part A Deductible / Part A Deductible / Part A Deductible / Part A Deductible / Part A Deductible
Part B Deductible / Part B Deductible / Part B Deductible
Part B Excess (100%) / Part B Excess
(80%) / Part B Excess (100%) / Part B Excess (100%)
Foreign Travel Emergency / Foreign Travel Emergency / Foreign Travel Emergency / Foreign Travel Emergency / Foreign Travel Emergency / Foreign Travel Emergency / Foreign Travel Emergency / Foreign Travel Emergency
At-Home Recovery / At-Home Recovery / At-Home Recovery / At-Home Recovery
Preventive Care NOT covered by Medicare / Preventive Care NOT covered by Medicare
* Plans F and J also have an option called a high deductible Plan F and a high deductible Plan J. These high deductible plans pay the same or offer the same benefits as Plans F and J after one has paid a calendar year $2,000 deductible. Benefits from high deductible Plans F and J will not begin until out-of-pocket expenses are $2,000. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy. These expenses include the Medicare Deductibles for Part A and Part B, but does not include, in Plan J, the plan’s separate prescription drug deductible or, in Plans F and J, the plan’s separate foreign emergency deductible.
Outline of Medicare Supplement Coverage – Cover Page 2
Basic Benefits for Plans K and L include similar services as plans A-J, but cost-sharing for the basic benefits is at different levels.
J / K** / L**Basic Benefits / 100% of Part A Hospitalization Coinsurance plus coverage for 365 Days after Medicare Benefits End
50% Hospice cost-sharing
50% of Medicare-eligible expenses for the first three pints of blood
50% Part B Coinsurance, except 100% Coinsurance for Part B Preventive Services / 100% of Part A Hospitalization Coinsurance plus coverage for 365 Days after Medicare Benefits End
75% Hospice cost-sharing
75% of Medicare-eligible expenses for the first three pints of blood
75% Part B Coinsurance, except 100% Coinsurance for Part B Preventive Services
Skilled Nursing Coinsurance / 50% Skilled Nursing Facility Coinsurance / 75% Skilled Nursing Facility Coinsurance
Part A Deductible / 50% Part A Deductible / 75% Part A Deductible
Part B Deductible
Part B Excess (100%)
Foreign Travel Emergency
At-Home Recovery
Preventative Care NOT covered by Medicare
$4,620 Out of Pocket Annual Limit *** / $2,310 Out of Policy Annual Limit ***
** Plans K and L provide for different cost-sharing for items and services than Plans A-J.
Once you reach the annual limit, the plans pays 100% of the Medicare copayments, coinsurances, and deductibles for the rest of the calendar year. The out-of-pocket annual limit does NOT include charges from your provider that exceed Medicare-approved amounts, called “Excess Charges.” You will be responsible for paying excess charges.
*** The out-of-pocket annual limit will increase each year for inflation.
See Outlines of Coverage for details and exceptions.
Page 2
MSA OC 10 IN Effective 1-1-10
/ Home Office:1801 Watermark Drive, Suite 100, P.O. Box 159019, Columbus, OH 43215
(614) 487-9680 • Toll-free: (800) 848-0123 • Fax: (614) 487-9675
Visit our web site at www.uct.org
Annual Non-Smoker Premium Rates
For Use In Indiana Zip Codes
46400-46499
Attained Age / Plan A / Plan B / Plan C / Plan D / Plan F / Plan GFemale / Male / Female / Male / Female / Male / Female / Male / Female / Male / Female / Male
65 / $1,213.73 / $1,395.81 / $1,566.31 / $1,801.25 / $1,878.35 / $2,160.10 / $1,719.21 / $1,977.10 / $1,929.83 / $2,219.29 / $1,563.16 / $1,797.63
66 / $1,273.03 / $1,463.99 / $1,645.89 / $1,892.78 / $1,967.26 / $2,262.37 / $1,809.70 / $2,081.16 / $2,020.32 / $2,323.36 / $1,636.44 / $1,881.92
67 / $1,330.75 / $1,530.36 / $1,725.44 / $1,984.28 / $2,054.64 / $2,362.84 / $1,898.62 / $2,183.43 / $2,110.81 / $2,427.42 / $1,709.74 / $1,966.21
68 / $1,390.03 / $1,598.54 / $1,805.02 / $2,075.78 / $2,142.00 / $2,463.31 / $1,987.55 / $2,285.69 / $2,201.28 / $2,531.50 / $1,783.03 / $2,050.50
69 / $1,447.76 / $1,664.93 / $1,884.58 / $2,167.28 / $2,230.93 / $2,565.59 / $2,076.49 / $2,387.97 / $2,291.76 / $2,635.52 / $1,856.34 / $2,134.77
70 / $1,503.93 / $1,729.51 / $1,962.59 / $2,256.98 / $2,316.73 / $2,664.24 / $2,165.42 / $2,490.23 / $2,380.69 / $2,737.80 / $1,928.36 / $2,217.61
71 / $1,558.52 / $1,792.30 / $2,039.05 / $2,344.91 / $2,402.54 / $2,762.93 / $2,251.20 / $2,588.88 / $2,469.61 / $2,840.05 / $2,000.39 / $2,300.45
72 / $1,611.56 / $1,853.30 / $2,113.92 / $2,431.01 / $2,486.78 / $2,859.82 / $2,337.02 / $2,687.57 / $2,555.42 / $2,938.76 / $2,069.89 / $2,380.38
73 / $1,661.49 / $1,910.72 / $2,187.26 / $2,515.34 / $2,569.47 / $2,954.90 / $2,419.71 / $2,782.66 / $2,639.69 / $3,035.64 / $2,138.13 / $2,458.87
74 / $1,709.86 / $1,966.32 / $2,257.45 / $2,596.07 / $2,649.03 / $3,046.38 / $2,499.26 / $2,874.14 / $2,722.35 / $3,130.71 / $2,205.12 / $2,535.87
75 / $1,755.11 / $2,018.37 / $2,324.54 / $2,673.23 / $2,725.48 / $3,134.31 / $2,575.72 / $2,962.08 / $2,800.38 / $3,220.44 / $2,268.30 / $2,608.54
76 / $1,798.77 / $2,068.59 / $2,388.49 / $2,746.77 / $2,798.80 / $3,218.63 / $2,649.03 / $3,046.38 / $2,875.25 / $3,306.54 / $2,328.95 / $2,678.28
77 / $1,837.78 / $2,113.45 / $2,447.78 / $2,814.95 / $2,867.45 / $3,297.56 / $2,717.70 / $3,125.35 / $2,947.01 / $3,389.06 / $2,387.09 / $2,745.15
78 / $1,872.11 / $2,152.92 / $2,503.96 / $2,879.55 / $2,932.96 / $3,372.93 / $2,781.64 / $3,198.89 / $3,012.54 / $3,464.42 / $2,440.17 / $2,806.19
79 / $1,903.31 / $2,188.81 / $2,555.42 / $2,938.76 / $2,992.26 / $3,441.12 / $2,840.94 / $3,267.09 / $3,074.95 / $3,536.18 / $2,490.71 / $2,864.31
80 / $1,931.38 / $2,221.09 / $2,600.66 / $2,990.77 / $3,048.43 / $3,505.68 / $2,895.53 / $3,329.87 / $3,131.13 / $3,600.80 / $2,536.19 / $2,916.63
81 / $1,953.23 / $2,246.22 / $2,642.79 / $3,039.22 / $3,098.34 / $3,563.11 / $2,943.91 / $3,385.50 / $3,182.59 / $3,659.99 / $2,577.90 / $2,964.58
82 / $1,976.64 / $2,273.14 / $2,683.36 / $3,085.88 / $3,146.73 / $3,618.75 / $2,992.26 / $3,441.12 / $3,232.51 / $3,717.40 / $2,618.32 / $3,011.08
83 / $2,000.04 / $2,300.03 / $2,722.35 / $3,130.71 / $3,195.06 / $3,674.32 / $3,039.06 / $3,494.91 / $3,282.43 / $3,774.81 / $2,658.77 / $3,057.59
84 / $2,021.87 / $2,325.17 / $2,761.35 / $3,175.56 / $3,241.88 / $3,728.16 / $3,084.30 / $3,546.95 / $3,330.81 / $3,830.43 / $2,697.97 / $3,102.66
85 / $2,045.29 / $2,352.09 / $2,800.38 / $3,220.44 / $3,287.12 / $3,780.19 / $3,128.00 / $3,597.20 / $3,377.61 / $3,884.24 / $2,735.85 / $3,146.23
86 / $2,068.68 / $2,378.98 / $2,836.24 / $3,261.69 / $3,332.37 / $3,832.23 / $3,166.98 / $3,642.04 / $3,424.41 / $3,938.08 / $2,773.78 / $3,189.84
87 / $2,092.07 / $2,405.90 / $2,873.68 / $3,304.75 / $3,376.05 / $3,882.46 / $3,202.87 / $3,683.31 / $3,468.09 / $3,988.29 / $2,809.14 / $3,230.54
88 / $2,113.92 / $2,431.01 / $2,908.01 / $3,344.22 / $3,416.61 / $3,929.11 / $3,237.19 / $3,722.77 / $3,511.79 / $4,038.55 / $2,844.53 / $3,271.21
89 / $2,137.30 / $2,457.91 / $2,940.77 / $3,381.88 / $3,457.17 / $3,975.74 / $3,271.52 / $3,762.26 / $3,552.35 / $4,085.20 / $2,877.40 / $3,309.00
90 / $2,160.72 / $2,484.82 / $2,973.55 / $3,419.58 / $3,496.18 / $4,020.59 / $3,302.73 / $3,798.13 / $3,591.34 / $4,130.05 / $2,908.97 / $3,345.32
91 / $2,182.56 / $2,509.96 / $3,004.75 / $3,455.45 / $3,532.04 / $4,061.86 / $3,332.37 / $3,832.23 / $3,628.77 / $4,173.09 / $2,939.32 / $3,380.20
92 / $2,205.97 / $2,536.86 / $3,034.38 / $3,489.53 / $3,566.38 / $4,101.34 / $3,358.89 / $3,862.72 / $3,664.66 / $4,214.36 / $2,968.38 / $3,413.64
93 / $2,229.36 / $2,563.77 / $3,062.46 / $3,521.85 / $3,600.69 / $4,140.78 / $3,385.41 / $3,893.22 / $3,698.99 / $4,253.84 / $2,996.17 / $3,445.60
94 / $2,251.20 / $2,588.88 / $3,088.99 / $3,552.34 / $3,630.34 / $4,174.90 / $3,408.79 / $3,920.11 / $3,730.19 / $4,289.72 / $3,021.46 / $3,474.68
95 / $2,274.60 / $2,615.79 / $3,115.52 / $3,582.86 / $3,659.98 / $4,208.97 / $3,430.64 / $3,945.25 / $3,759.84 / $4,323.81 / $3,045.46 / $3,502.28
96 / $2,296.47 / $2,640.93 / $3,140.47 / $3,611.56 / $3,689.62 / $4,243.07 / $3,450.93 / $3,968.58 / $3,791.04 / $4,359.70 / $3,070.75 / $3,531.35
97 / $2,319.85 / $2,667.84 / $3,166.98 / $3,642.04 / $3,719.28 / $4,277.16 / $3,472.77 / $3,993.71 / $3,820.67 / $4,393.78 / $3,094.73 / $3,558.95
98 / $2,343.27 / $2,694.76 / $3,193.53 / $3,672.56 / $3,748.90 / $4,311.24 / $3,494.62 / $4,018.81 / $3,851.87 / $4,429.65 / $3,120.01 / $3,588.03
99 / $2,366.67 / $2,721.68 / $3,218.47 / $3,701.24 / $3,780.11 / $4,347.12 / $3,518.02 / $4,045.72 / $3,883.08 / $4,465.53 / $3,145.28 / $3,617.09
MODAL FACTORS
Semi Annual – 0.51500 Quarterly – 0.26250 Direct Monthly – 0.10000 Monthly EFT – 0.08333
Annual Non-Smoker Premium Rates
For Use In Indiana Zip Codes
46000-46399, 47100-47199, 47800-47899
Attained Age / Plan A / Plan B / Plan C / Plan D / Plan F / Plan GFemale / Male / Female / Male / Female / Male / Female / Male / Female / Male / Female / Male
65 / $1,092.36 / $1,256.23 / $1,409.68 / $1,621.13 / $1,690.52 / $1,944.09 / $1,547.29 / $1,779.39 / $1,736.85 / $1,997.36 / $1,406.84 / $1,617.87
66 / $1,145.73 / $1,317.59 / $1,481.30 / $1,703.50 / $1,770.53 / $2,036.13 / $1,628.73 / $1,873.04 / $1,818.29 / $2,091.02 / $1,472.80 / $1,693.73
67 / $1,197.68 / $1,377.32 / $1,552.90 / $1,785.85 / $1,849.18 / $2,126.56 / $1,708.76 / $1,965.09 / $1,899.73 / $2,184.68 / $1,538.77 / $1,769.59
68 / $1,251.03 / $1,438.69 / $1,624.52 / $1,868.20 / $1,927.80 / $2,216.98 / $1,788.80 / $2,057.12 / $1,981.15 / $2,278.35 / $1,604.73 / $1,845.45
69 / $1,302.98 / $1,498.44 / $1,696.12 / $1,950.55 / $2,007.84 / $2,309.03 / $1,868.84 / $2,149.17 / $2,062.58 / $2,371.97 / $1,670.71 / $1,921.29
70 / $1,353.54 / $1,556.56 / $1,766.33 / $2,031.28 / $2,085.06 / $2,397.82 / $1,948.88 / $2,241.21 / $2,142.62 / $2,464.02 / $1,735.52 / $1,995.85
71 / $1,402.67 / $1,613.07 / $1,835.15 / $2,110.42 / $2,162.29 / $2,486.64 / $2,026.08 / $2,329.99 / $2,222.65 / $2,556.05 / $1,800.35 / $2,070.41
72 / $1,450.40 / $1,667.97 / $1,902.53 / $2,187.91 / $2,238.10 / $2,573.84 / $2,103.32 / $2,418.81 / $2,299.88 / $2,644.88 / $1,862.90 / $2,142.34
73 / $1,495.34 / $1,719.65 / $1,968.53 / $2,263.81 / $2,312.52 / $2,659.41 / $2,177.74 / $2,504.39 / $2,375.72 / $2,732.08 / $1,924.32 / $2,212.98
74 / $1,538.87 / $1,769.69 / $2,031.71 / $2,336.46 / $2,384.13 / $2,741.74 / $2,249.33 / $2,586.73 / $2,450.12 / $2,817.64 / $1,984.61 / $2,282.28
75 / $1,579.60 / $1,816.53 / $2,092.09 / $2,405.91 / $2,452.93 / $2,820.88 / $2,318.15 / $2,665.87 / $2,520.34 / $2,898.40 / $2,041.47 / $2,347.69
76 / $1,618.89 / $1,861.73 / $2,149.64 / $2,472.09 / $2,518.92 / $2,896.77 / $2,384.13 / $2,741.74 / $2,587.73 / $2,975.89 / $2,096.06 / $2,410.45
77 / $1,654.00 / $1,902.11 / $2,203.00 / $2,533.46 / $2,580.71 / $2,967.80 / $2,445.93 / $2,812.82 / $2,652.31 / $3,050.15 / $2,148.38 / $2,470.64
78 / $1,684.90 / $1,937.63 / $2,253.56 / $2,591.60 / $2,639.66 / $3,035.64 / $2,503.48 / $2,879.00 / $2,711.29 / $3,117.98 / $2,196.15 / $2,525.57
79 / $1,712.98 / $1,969.93 / $2,299.88 / $2,644.88 / $2,693.03 / $3,097.01 / $2,556.85 / $2,940.38 / $2,767.46 / $3,182.56 / $2,241.64 / $2,577.88
80 / $1,738.24 / $1,998.98 / $2,340.59 / $2,691.69 / $2,743.59 / $3,155.11 / $2,605.98 / $2,996.88 / $2,818.02 / $3,240.72 / $2,282.57 / $2,624.97
81 / $1,757.91 / $2,021.60 / $2,378.51 / $2,735.30 / $2,788.51 / $3,206.80 / $2,649.52 / $3,046.95 / $2,864.33 / $3,293.99 / $2,320.11 / $2,668.12
82 / $1,778.98 / $2,045.83 / $2,415.02 / $2,777.29 / $2,832.06 / $3,256.88 / $2,693.03 / $3,097.01 / $2,909.26 / $3,345.66 / $2,356.49 / $2,709.97
83 / $1,800.04 / $2,070.03 / $2,450.12 / $2,817.64 / $2,875.55 / $3,306.89 / $2,735.15 / $3,145.42 / $2,954.19 / $3,397.33 / $2,392.89 / $2,751.83
84 / $1,819.68 / $2,092.65 / $2,485.22 / $2,858.00 / $2,917.69 / $3,355.34 / $2,775.87 / $3,192.26 / $2,997.73 / $3,447.39 / $2,428.17 / $2,792.39
85 / $1,840.76 / $2,116.88 / $2,520.34 / $2,898.40 / $2,958.41 / $3,402.17 / $2,815.20 / $3,237.48 / $3,039.85 / $3,495.82 / $2,462.27 / $2,831.61
86 / $1,861.81 / $2,141.08 / $2,552.62 / $2,935.52 / $2,999.13 / $3,449.01 / $2,850.28 / $3,277.84 / $3,081.97 / $3,544.27 / $2,496.40 / $2,870.86
87 / $1,882.86 / $2,165.31 / $2,586.31 / $2,974.28 / $3,038.45 / $3,494.21 / $2,882.58 / $3,314.98 / $3,121.28 / $3,589.46 / $2,528.23 / $2,907.49
88 / $1,902.53 / $2,187.91 / $2,617.21 / $3,009.80 / $3,074.95 / $3,536.20 / $2,913.47 / $3,350.49 / $3,160.61 / $3,634.70 / $2,560.08 / $2,944.09
89 / $1,923.57 / $2,212.12 / $2,646.69 / $3,043.69 / $3,111.45 / $3,578.17 / $2,944.37 / $3,386.03 / $3,197.12 / $3,676.68 / $2,589.66 / $2,978.10
90 / $1,944.65 / $2,236.34 / $2,676.20 / $3,077.62 / $3,146.56 / $3,618.53 / $2,972.46 / $3,418.32 / $3,232.21 / $3,717.05 / $2,618.07 / $3,010.79
91 / $1,964.30 / $2,258.96 / $2,704.28 / $3,109.91 / $3,178.84 / $3,655.67 / $2,999.13 / $3,449.01 / $3,265.89 / $3,755.78 / $2,645.39 / $3,042.18
92 / $1,985.37 / $2,283.17 / $2,730.94 / $3,140.58 / $3,209.74 / $3,691.21 / $3,023.00 / $3,476.45 / $3,298.19 / $3,792.92 / $2,671.54 / $3,072.28
93 / $2,006.42 / $2,307.39 / $2,756.21 / $3,169.67 / $3,240.62 / $3,726.70 / $3,046.87 / $3,503.90 / $3,329.09 / $3,828.46 / $2,696.55 / $3,101.04
94 / $2,026.08 / $2,329.99 / $2,780.09 / $3,197.11 / $3,267.31 / $3,757.41 / $3,067.91 / $3,528.10 / $3,357.17 / $3,860.75 / $2,719.31 / $3,127.21
95 / $2,047.14 / $2,354.21 / $2,803.97 / $3,224.57 / $3,293.98 / $3,788.07 / $3,087.58 / $3,550.73 / $3,383.86 / $3,891.43 / $2,740.91 / $3,152.05
96 / $2,066.82 / $2,376.84 / $2,826.42 / $3,250.40 / $3,320.66 / $3,818.76 / $3,105.84 / $3,571.72 / $3,411.94 / $3,923.73 / $2,763.68 / $3,178.22
97 / $2,087.87 / $2,401.06 / $2,850.28 / $3,277.84 / $3,347.35 / $3,849.44 / $3,125.49 / $3,594.34 / $3,438.60 / $3,954.40 / $2,785.26 / $3,203.06
98 / $2,108.94 / $2,425.28 / $2,874.18 / $3,305.30 / $3,374.01 / $3,880.12 / $3,145.16 / $3,616.93 / $3,466.68 / $3,986.69 / $2,808.01 / $3,229.23
99 / $2,130.00 / $2,449.51 / $2,896.62 / $3,331.12 / $3,402.10 / $3,912.41 / $3,166.22 / $3,641.15 / $3,494.77 / $4,018.98 / $2,830.75 / $3,255.38
MODAL FACTORS
Semi Annual – 0.51500 Quarterly – 0.26250 Direct Monthly – 0.10000 Monthly EFT – 0.08333
Annual Non-Smoker Premium Rates