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 OK 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 Oklahoma Zip Codes
73000-73199, 73900-74199, 74400-74499, 74700-74799
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
0-64 / $2,206.14 / $2,537.08 / N/A / N/A / N/A / N/A / N/A / N/A / N/A / N/A / N/A / N/A
65 / $1,309.19 / $1,505.58 / $1,689.51 / $1,942.94 / $2,026.05 / $2,329.99 / $1,854.44 / $2,132.60 / $2,081.61 / $2,393.86 / $1,831.82 / $2,106.59
66 / $1,373.16 / $1,579.13 / $1,775.35 / $2,041.64 / $2,121.99 / $2,440.29 / $1,952.02 / $2,244.83 / $2,179.22 / $2,506.10 / $1,917.70 / $2,205.36
67 / $1,435.41 / $1,650.74 / $1,861.16 / $2,140.34 / $2,216.23 / $2,548.68 / $2,047.95 / $2,355.16 / $2,276.83 / $2,618.33 / $2,003.60 / $2,304.14
68 / $1,499.37 / $1,724.29 / $1,947.00 / $2,239.06 / $2,310.48 / $2,657.07 / $2,143.87 / $2,465.47 / $2,374.41 / $2,730.56 / $2,089.47 / $2,402.89
69 / $1,561.61 / $1,795.86 / $2,032.81 / $2,337.74 / $2,406.38 / $2,767.35 / $2,239.79 / $2,575.76 / $2,472.02 / $2,842.84 / $2,175.37 / $2,501.69
70 / $1,622.20 / $1,865.53 / $2,116.94 / $2,434.52 / $2,498.95 / $2,873.79 / $2,335.69 / $2,686.05 / $2,567.94 / $2,953.13 / $2,259.80 / $2,598.77
71 / $1,681.12 / $1,933.28 / $2,199.42 / $2,529.34 / $2,591.51 / $2,980.22 / $2,428.25 / $2,792.50 / $2,663.87 / $3,063.46 / $2,344.21 / $2,695.85
72 / $1,738.33 / $1,999.08 / $2,280.19 / $2,622.20 / $2,682.35 / $3,084.71 / $2,520.83 / $2,898.95 / $2,756.40 / $3,169.85 / $2,425.64 / $2,789.50
73 / $1,792.17 / $2,061.00 / $2,359.29 / $2,713.19 / $2,771.57 / $3,187.31 / $2,610.01 / $3,001.53 / $2,847.28 / $3,274.36 / $2,505.59 / $2,881.42
74 / $1,844.34 / $2,120.98 / $2,435.00 / $2,800.26 / $2,857.38 / $3,286.01 / $2,695.84 / $3,100.21 / $2,936.48 / $3,376.93 / $2,584.10 / $2,971.72
75 / $1,893.15 / $2,177.12 / $2,507.37 / $2,883.47 / $2,939.84 / $3,380.83 / $2,778.31 / $3,195.06 / $3,020.62 / $3,473.70 / $2,658.15 / $3,056.88
76 / $1,940.27 / $2,231.32 / $2,576.37 / $2,962.85 / $3,018.93 / $3,471.77 / $2,857.38 / $3,286.01 / $3,101.39 / $3,566.59 / $2,729.22 / $3,138.61
77 / $1,982.33 / $2,279.68 / $2,640.31 / $3,036.36 / $3,092.97 / $3,556.92 / $2,931.42 / $3,371.15 / $3,178.80 / $3,655.62 / $2,797.34 / $3,216.95
78 / $2,019.34 / $2,322.24 / $2,700.88 / $3,106.02 / $3,163.64 / $3,638.19 / $3,000.42 / $3,450.48 / $3,249.49 / $3,736.92 / $2,859.53 / $3,288.47
79 / $2,053.01 / $2,360.96 / $2,756.40 / $3,169.85 / $3,227.60 / $3,711.74 / $3,064.37 / $3,524.02 / $3,316.80 / $3,814.33 / $2,918.78 / $3,356.60
80 / $2,083.27 / $2,395.77 / $2,805.21 / $3,226.01 / $3,288.19 / $3,781.40 / $3,123.27 / $3,591.78 / $3,377.38 / $3,884.00 / $2,972.11 / $3,417.91
81 / $2,106.86 / $2,422.88 / $2,850.64 / $3,278.25 / $3,342.02 / $3,843.30 / $3,175.42 / $3,651.75 / $3,432.92 / $3,947.84 / $3,020.94 / $3,474.11
82 / $2,132.10 / $2,451.92 / $2,894.40 / $3,328.54 / $3,394.20 / $3,903.33 / $3,227.60 / $3,711.74 / $3,486.74 / $4,009.77 / $3,068.33 / $3,528.58
83 / $2,157.35 / $2,480.97 / $2,936.48 / $3,376.93 / $3,446.36 / $3,963.31 / $3,278.08 / $3,769.80 / $3,540.60 / $4,071.69 / $3,115.70 / $3,583.07
84 / $2,180.88 / $2,508.01 / $2,978.53 / $3,425.32 / $3,496.84 / $4,021.37 / $3,326.90 / $3,825.93 / $3,592.77 / $4,131.68 / $3,161.65 / $3,635.89
85 / $2,206.14 / $2,537.08 / $3,020.62 / $3,473.70 / $3,545.67 / $4,077.51 / $3,373.99 / $3,880.10 / $3,643.27 / $4,189.77 / $3,206.07 / $3,686.98
86 / $2,231.36 / $2,566.07 / $3,059.32 / $3,518.22 / $3,594.46 / $4,133.62 / $3,416.06 / $3,928.48 / $3,693.76 / $4,247.82 / $3,250.50 / $3,738.06
87 / $2,256.63 / $2,595.13 / $3,099.70 / $3,564.67 / $3,641.58 / $4,187.81 / $3,454.78 / $3,973.00 / $3,740.84 / $4,301.98 / $3,291.95 / $3,785.76
88 / $2,280.19 / $2,622.20 / $3,136.74 / $3,607.26 / $3,685.32 / $4,238.14 / $3,491.82 / $4,015.59 / $3,787.99 / $4,356.19 / $3,333.41 / $3,833.42
89 / $2,305.43 / $2,651.24 / $3,172.07 / $3,647.88 / $3,729.07 / $4,288.46 / $3,528.83 / $4,058.16 / $3,831.72 / $4,406.49 / $3,371.91 / $3,877.70
90 / $2,330.67 / $2,680.27 / $3,207.40 / $3,688.52 / $3,771.14 / $4,336.84 / $3,562.48 / $4,096.86 / $3,873.80 / $4,454.87 / $3,408.93 / $3,920.29
91 / $2,354.24 / $2,707.36 / $3,241.06 / $3,727.22 / $3,809.84 / $4,381.33 / $3,594.46 / $4,133.62 / $3,914.17 / $4,501.31 / $3,444.48 / $3,961.15
92 / $2,379.46 / $2,736.39 / $3,273.03 / $3,763.99 / $3,846.87 / $4,423.90 / $3,623.06 / $4,166.53 / $3,952.91 / $4,545.84 / $3,478.55 / $4,000.35
93 / $2,404.70 / $2,765.41 / $3,303.32 / $3,798.84 / $3,883.90 / $4,466.48 / $3,651.67 / $4,199.40 / $3,989.93 / $4,588.42 / $3,511.13 / $4,037.80
94 / $2,428.25 / $2,792.50 / $3,331.93 / $3,831.71 / $3,915.86 / $4,503.26 / $3,676.91 / $4,228.43 / $4,023.57 / $4,627.11 / $3,540.72 / $4,071.85
95 / $2,453.52 / $2,821.54 / $3,360.54 / $3,864.63 / $3,947.84 / $4,540.01 / $3,700.48 / $4,255.53 / $4,055.53 / $4,663.85 / $3,568.87 / $4,104.19
96 / $2,477.04 / $2,848.62 / $3,387.48 / $3,895.60 / $3,979.82 / $4,576.80 / $3,722.34 / $4,280.71 / $4,089.19 / $4,702.57 / $3,598.50 / $4,138.28
97 / $2,502.32 / $2,877.65 / $3,416.06 / $3,928.48 / $4,011.79 / $4,613.55 / $3,745.91 / $4,307.81 / $4,121.18 / $4,739.34 / $3,626.63 / $4,170.62
98 / $2,527.54 / $2,906.69 / $3,444.70 / $3,961.40 / $4,043.78 / $4,650.35 / $3,769.47 / $4,334.88 / $4,154.82 / $4,778.06 / $3,656.25 / $4,204.69
99 / $2,552.80 / $2,935.72 / $3,471.61 / $3,992.36 / $4,077.41 / $4,689.03 / $3,708.83 / $4,265.16 / $4,188.47 / $4,816.76 / $3,685.85 / $4,238.74
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 Oklahoma Zip Codes
All Other Zip Codes
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
0-64 / $1,961.02 / $2,255.18 / N/A / N/A / N/A / N/A / N/A / N/A / N/A / N/A / N/A / N/A
65 / $1,163.72 / $1,338.30 / $1,501.78 / $1,727.06 / $1,800.94 / $2,071.10 / $1,648.39 / $1,895.65 / $1,850.32 / $2,127.87 / $1,628.29 / $1,872.53
66 / $1,220.58 / $1,403.67 / $1,578.09 / $1,814.79 / $1,886.22 / $2,169.14 / $1,735.13 / $1,995.41 / $1,937.09 / $2,227.65 / $1,704.62 / $1,960.32
67 / $1,275.92 / $1,467.32 / $1,654.37 / $1,902.53 / $1,969.98 / $2,265.50 / $1,820.40 / $2,093.47 / $2,023.85 / $2,327.41 / $1,780.98 / $2,048.12
68 / $1,332.78 / $1,532.70 / $1,730.66 / $1,990.27 / $2,053.76 / $2,361.84 / $1,905.66 / $2,191.53 / $2,110.58 / $2,427.17 / $1,857.30 / $2,135.90
69 / $1,388.10 / $1,596.32 / $1,806.94 / $2,077.99 / $2,139.01 / $2,459.86 / $1,990.93 / $2,289.56 / $2,197.35 / $2,526.97 / $1,933.66 / $2,223.73
70 / $1,441.95 / $1,658.25 / $1,881.73 / $2,164.02 / $2,221.29 / $2,554.48 / $2,076.17 / $2,387.60 / $2,282.62 / $2,625.00 / $2,008.71 / $2,310.02
71 / $1,494.33 / $1,718.47 / $1,955.04 / $2,248.30 / $2,303.57 / $2,649.09 / $2,158.44 / $2,482.22 / $2,367.88 / $2,723.07 / $2,083.74 / $2,396.31
72 / $1,545.18 / $1,776.96 / $2,026.83 / $2,330.85 / $2,384.31 / $2,741.97 / $2,240.74 / $2,576.85 / $2,450.14 / $2,817.65 / $2,156.12 / $2,479.55
73 / $1,593.04 / $1,832.00 / $2,097.14 / $2,411.72 / $2,463.62 / $2,833.17 / $2,320.01 / $2,668.02 / $2,530.91 / $2,910.54 / $2,227.19 / $2,561.26
74 / $1,639.42 / $1,885.31 / $2,164.45 / $2,489.12 / $2,539.90 / $2,920.90 / $2,396.30 / $2,755.74 / $2,610.21 / $3,001.71 / $2,296.98 / $2,641.53
75 / $1,682.80 / $1,935.22 / $2,228.78 / $2,563.09 / $2,613.19 / $3,005.18 / $2,469.61 / $2,840.06 / $2,684.99 / $3,087.74 / $2,362.80 / $2,717.22
76 / $1,724.68 / $1,983.39 / $2,290.10 / $2,633.65 / $2,683.50 / $3,086.02 / $2,539.90 / $2,920.90 / $2,756.79 / $3,170.30 / $2,425.98 / $2,789.87
77 / $1,762.07 / $2,026.38 / $2,346.94 / $2,698.98 / $2,749.30 / $3,161.70 / $2,605.70 / $2,996.58 / $2,825.60 / $3,249.44 / $2,486.52 / $2,859.51
78 / $1,794.97 / $2,064.22 / $2,400.78 / $2,760.90 / $2,812.13 / $3,233.94 / $2,667.04 / $3,067.10 / $2,888.43 / $3,321.70 / $2,541.81 / $2,923.09
79 / $1,824.90 / $2,098.63 / $2,450.14 / $2,817.65 / $2,868.98 / $3,299.32 / $2,723.88 / $3,132.46 / $2,948.26 / $3,390.51 / $2,594.47 / $2,983.65
80 / $1,851.79 / $2,129.58 / $2,493.52 / $2,867.56 / $2,922.83 / $3,361.25 / $2,776.24 / $3,192.70 / $3,002.11 / $3,452.44 / $2,641.87 / $3,038.14
81 / $1,872.76 / $2,153.67 / $2,533.90 / $2,914.00 / $2,970.69 / $3,416.26 / $2,822.59 / $3,246.00 / $3,051.48 / $3,509.19 / $2,685.28 / $3,088.10
82 / $1,895.20 / $2,179.48 / $2,572.80 / $2,958.70 / $3,017.06 / $3,469.62 / $2,868.98 / $3,299.32 / $3,099.33 / $3,564.24 / $2,727.40 / $3,136.51
83 / $1,917.64 / $2,205.30 / $2,610.21 / $3,001.71 / $3,063.43 / $3,522.94 / $2,913.85 / $3,350.94 / $3,147.20 / $3,619.28 / $2,769.51 / $3,184.95
84 / $1,938.56 / $2,229.34 / $2,647.58 / $3,044.73 / $3,108.30 / $3,574.55 / $2,957.25 / $3,400.82 / $3,193.58 / $3,672.61 / $2,810.35 / $3,231.90
85 / $1,961.02 / $2,255.18 / $2,684.99 / $3,087.74 / $3,151.70 / $3,624.46 / $2,999.10 / $3,448.98 / $3,238.46 / $3,724.24 / $2,849.84 / $3,277.31
86 / $1,983.43 / $2,280.95 / $2,719.39 / $3,127.30 / $3,195.07 / $3,674.33 / $3,036.50 / $3,491.98 / $3,283.34 / $3,775.84 / $2,889.34 / $3,322.72
87 / $2,005.90 / $2,306.78 / $2,755.29 / $3,168.59 / $3,236.96 / $3,722.50 / $3,070.91 / $3,531.55 / $3,325.19 / $3,823.98 / $2,926.18 / $3,365.12
88 / $2,026.83 / $2,330.85 / $2,788.22 / $3,206.46 / $3,275.84 / $3,767.23 / $3,103.84 / $3,569.42 / $3,367.10 / $3,872.17 / $2,963.03 / $3,407.49
89 / $2,049.27 / $2,356.66 / $2,819.62 / $3,242.56 / $3,314.73 / $3,811.96 / $3,136.74 / $3,607.26 / $3,405.98 / $3,916.88 / $2,997.26 / $3,446.85
90 / $2,071.70 / $2,382.46 / $2,851.02 / $3,278.69 / $3,352.13 / $3,854.97 / $3,166.65 / $3,641.66 / $3,443.38 / $3,959.88 / $3,030.16 / $3,484.70
91 / $2,092.66 / $2,406.54 / $2,880.94 / $3,313.08 / $3,386.53 / $3,894.51 / $3,195.07 / $3,674.33 / $3,479.26 / $4,001.17 / $3,061.76 / $3,521.02
92 / $2,115.07 / $2,432.34 / $2,909.36 / $3,345.77 / $3,419.44 / $3,932.35 / $3,220.50 / $3,703.58 / $3,513.70 / $4,040.74 / $3,092.04 / $3,555.86
93 / $2,137.51 / $2,458.14 / $2,936.29 / $3,376.74 / $3,452.35 / $3,970.21 / $3,245.93 / $3,732.80 / $3,546.60 / $4,078.59 / $3,121.00 / $3,589.15
94 / $2,158.44 / $2,482.22 / $2,961.71 / $3,405.97 / $3,480.77 / $4,002.90 / $3,268.36 / $3,758.61 / $3,576.50 / $4,112.98 / $3,147.30 / $3,619.42
95 / $2,180.90 / $2,508.03 / $2,987.14 / $3,435.22 / $3,509.19 / $4,035.57 / $3,289.31 / $3,782.70 / $3,604.91 / $4,145.65 / $3,172.33 / $3,648.17
96 / $2,201.82 / $2,532.10 / $3,011.10 / $3,462.75 / $3,537.62 / $4,068.26 / $3,308.74 / $3,805.07 / $3,634.83 / $4,180.06 / $3,198.66 / $3,678.47
97 / $2,224.28 / $2,557.91 / $3,036.50 / $3,491.98 / $3,566.03 / $4,100.94 / $3,329.70 / $3,829.16 / $3,663.27 / $4,212.74 / $3,223.67 / $3,707.22
98 / $2,246.70 / $2,583.72 / $3,061.95 / $3,521.25 / $3,594.47 / $4,133.64 / $3,350.64 / $3,853.22 / $3,693.18 / $4,247.16 / $3,250.00 / $3,737.50
99 / $2,269.15 / $2,609.53 / $3,085.87 / $3,548.76 / $3,624.37 / $4,168.02 / $3,296.74 / $3,791.26 / $3,723.09 / $4,281.56 / $3,276.31 / $3,767.77
MODAL FACTORS
Semi Annual – 0.51500 Quarterly – 0.26250 Direct Monthly – 0.10000 Monthly EFT – 0.08333
Annual Smoker Premium Rates