Philadelphia American Life Insurance Company
P.O. BOX 4884 Houston, TX 77210-4884
Plan Form Standard Plan A MS.A.PAL.PA
The Insurance Plans of Choice for
Medicare Supplemental Coverage
W
hen it comes to Medicare, it’s important that you know both sides of the story, the advantages and disadvantages of relying only on Medicare to provide for your health care needs.Before Medicare pays for any of the medical services you want or need, you must first pay the Medicare deductibles. There are health care costs that Medicare either does not cover in full or does not pay at all. This can result in significant out-of-pocket expenses for you.
Medicare supplement plans help pay your medical expenses and provide you with protection from the ever-increasing gaps in Medicare. Philadelphia American Life Insurance Company (Philadelphia American) has affordable Medicare supplement plans.
Plus, you receive the following benefits:
Your right to use the doctor of your choice. You may see any doctor accepting Medicare patients.
Medicare supplement plans are guaranteed renewable.
Your Medicare supplement policy is portable. If you move to another state, your coverage goes with you.
No annual maximums for Medicare-covered services.
Philadelphia American provides accurate and speedy claim payments.
Philadelphia American’s toll-free dedicated customer service phone number:
1-800-552-7879
FREEDOM OF CHOICE
You’ve earned the right to choose your own doctor or hospital. You can use any Medicare-participating physician and any Medicare-approved hospital in the United States.
PROTECTION AGAINST EXCESS CHARGES
Under Part B of Medicare, you may have out-of-pocket costs if your physician or medical supplier does not accept assignment of your Medicare claim and charges more than Medicare’s approved amount. The difference to be paid is called the ‘excess charge’ and that amount may not exceed any charge limitations established by Medicare. With some plans, your doctor’s charges for Medicare’s covered services are paid in full, including the Medicare Part B deductible.
OPEN ENROLLMENT
Acceptance of your application is guaranteed if you apply during your Open Enrollment. Open Enrollment is the 6 month period beginning on the 1st day of the month in which you are enrolled in Medicare Part B. If you are on Medicare under age 65, you will also have a 6 month open enrollment period when you reach age 65.
You must already be enrolled in both Parts A and B of Medicare to apply for these plans.
Home Office MUST receive your application no later than 5 working days PRIOR to your requested effective date.
The amount of the premium submitted depends on the payment mode you have selected. After your policy is issued, Philadelphia American will bill you according to the payment mode you have selected or payment will be withdrawn from your bank account accordingly.
A one-time, non-refundable application fee should be included with each application.
Philadelphia American reserves the right to reject your application. If your application is rejected, you will be notified in writing and any premium submitted will be refunded.
With the Philadelphia American monthly Checking Account Deduction Program, you can have your monthly Philadelphia American premium withdrawn directly from your checking account. When you receive your bank statement, your Philadelphia American monthly checking account deduction will be included. To find out more about this convenient service, contact your Philadelphia American Authorized Agent, or call us toll-free at:
1-800-552-7879
GUARANTEED RENEWABLE
Philadelphia American Medicare supplement policies are guaranteed renewable.
After the first modal premium payment, the term of this coverage is for the modal duration.
You have the option to pay premium on monthly bank draft, quarterly, semi-annually or annually.
Coverage renews automatically, subject to the right of Philadelphia American to change rates on a class basis.
We will not cancel your coverage, except for the reasons listed below:
If we discover any concealment of material facts upon enrollment
If you do not pay your premiums, your coverage will end after your 31 day grace period has expired
You cease to be covered under both Parts A and B of Medicare
If you notify us of your enrollment in a Medicare Advantage plan.
which will describe these changes and the changes in your Medicare supplement coverage.
GRIEVANCE PROCEDURE
We are certain that you will be completely satisfied with your Philadelphia American plan, but if you should ever have a complaint or problem, please call us toll free:
1-800-552-7879 Or you can write to us:
P.O. Box 4884
Houston, TX 77210-4884 QUESTIONS
After you receive your policy, please feel free to contact your Philadelphia American Authorized Agent, or call us toll-free:
1-800-552-7879
NOTICE OF 30 DAY RIGHT TO EXAMINE THE POLICY: If you are not satisfied with your policy for any reason, the policy may be returned to us within the first 30 days after you receive it, for a full refund of all premium paid. If the policy is returned, it shall be void from the effective date. To return the Policy, simply mail or deliver it to us at our mailing address:
P.O. Box 4884, Houston, TX 77210-4884.
To learn more about this coverage, please see the accompanying outline of coverage.
PHILADELPHIA AMERICAN LIFE INSURANCE COMPANY
BENEFIT CHART OF MEDICARE SUPPLEMENT PLANS SOLD ON OR AFTER JUNE 1, 2010
This chart shows the benefits included in each of the Medicare supplement plans. Every company must make Plan “A, B and C or F” available. Some plans may not be available in your state.
BASIC BENEFITS
Hospitalization - Part A co-insurance plus coverage for 365 additional days after Medicare benefits end.
Medical Expenses - Part B co-insurance (generally, 20% of Medicare-approved expenses), or, co-payments for hospital outpatient services. Plans K, L, and N require insureds to pay a portion of Part B coinsurance or co-payments.
Blood - First three pints of blood each year.
Hospice - Part A coinsurance.
SHADED PLANS ARE AVAILABLE IN YOUR STATE
A B C D F F* G K L M N
Basic, including 100%
Part B co- insurance
Basic, including 100% Part B co- insurance
Basic, including 100% Part B co-insurance
Basic, including 100% Part B co-insurance
Basic, including 100% Part B co- insurance*
Basic, including 100% Part B co-insurance
Hospitalization and preventive care paid at 100%; other basic benefits paid at 50%
Hospitalization and preventive care paid at 100%; other basic benefits paid at 75%
Basic, including 100% Part B co- insurance
Basic, including 100%
Part B co-insurance, except up to $20 co- payment for office visit, and up to $50 co- payment for ER Skilled
Nursing Facility Co-insurance
Skilled Nursing Facility Co-insurance
Skilled Nursing Facility Co-insurance
Skilled Nursing Facility Co-insurance
50% Skilled Nursing Facility Co-insurance
75% Skilled Nursing Facility Co-insurance
Skilled Nursing Facility Co-insurance
Skilled Nursing Facility Co-insurance
Part A
Ded. Part A Ded. Part A Ded. Part A Ded. Part A Ded. 50% Part A Ded. 75% Part A Ded. 50% Part A
Ded. Part A Ded.
Part B Ded. Part B Ded.
Part B Excess
(100%) Part B
Excess (100%)
Attained
Age MNTU MTU FNTU FTU Attained
Age MNTU MTU FNTU FTU Attained
Age MNTU MTU FNTU FTU Attained
Age MNTU MTU FNTU FTU
< 65 369.17 406.07 335.60 369.17 < 65 321.02 353.10 291.83 321.02 < 65 298.62 328.47 271.47 298.62 < 65 253.71 279.08 230.64 253.71 65 155.47 171.05 141.36 155.47 65 135.20 148.73 122.92 135.20 65 125.77 138.36 114.35 125.77 65 106.86 117.55 97.15 106.86 66 156.35 171.98 142.15 156.35 66 135.95 149.55 123.61 135.95 66 126.47 139.11 114.99 126.47 66 107.46 118.20 97.69 107.46 67 157.10 172.80 142.80 157.10 67 136.61 150.26 124.17 136.61 67 127.07 139.78 115.51 127.07 67 107.96 118.76 98.14 107.96 68 157.64 173.41 143.30 157.64 68 137.08 150.79 124.61 137.08 68 127.51 140.27 115.92 127.51 68 108.34 119.18 98.49 108.34 69 158.08 173.90 143.70 158.08 69 137.46 151.22 124.96 137.46 69 127.87 140.67 116.25 127.87 69 108.64 119.51 98.76 108.64 70 158.33 174.15 143.94 158.33 70 137.68 151.44 125.17 137.68 70 128.07 140.88 116.43 128.07 70 108.81 119.69 98.92 108.81 71 160.53 176.59 145.94 160.53 71 139.60 153.55 126.90 139.60 71 129.85 142.84 118.05 129.85 71 110.32 121.36 100.30 110.32 72 165.84 182.44 150.77 165.84 72 144.21 158.64 131.10 144.21 72 134.15 147.58 121.96 134.15 72 113.98 125.38 103.61 113.98 73 171.44 188.59 155.86 171.44 73 149.08 163.99 135.53 149.08 73 138.67 152.54 126.07 138.67 73 117.82 129.60 107.11 117.82 74 177.33 195.07 161.23 177.33 74 154.20 169.63 140.20 154.20 74 143.44 157.79 130.41 143.44 74 121.87 134.06 110.80 121.87 75 182.03 200.22 165.48 182.03 75 158.29 174.11 143.89 158.29 75 147.24 161.96 133.85 147.24 75 125.10 137.60 113.73 125.10 76 187.58 206.35 170.53 187.58 76 163.12 179.43 148.29 163.12 76 151.74 166.92 137.95 151.74 76 128.92 141.81 117.20 128.92 77 193.34 212.67 175.76 193.34 77 168.12 184.93 152.84 168.12 77 156.39 172.02 142.17 156.39 77 132.87 146.15 120.79 132.87 78 199.27 219.19 181.16 199.27 78 173.28 190.60 157.53 173.28 78 161.20 177.30 146.54 161.20 78 136.95 150.64 124.50 136.95 79 205.36 225.89 186.69 205.36 79 178.57 196.42 162.34 178.57 79 166.11 182.72 151.01 166.11 79 141.13 155.24 128.30 141.13 80 215.61 237.16 196.01 215.61 80 187.49 206.23 170.45 187.49 80 174.41 191.85 158.55 174.41 80 148.18 162.99 134.70 148.18 81 227.60 250.36 206.91 227.60 81 197.91 217.71 179.93 197.91 81 184.11 202.51 167.37 184.11 81 156.42 172.06 142.20 156.42 82 240.20 264.21 218.37 240.20 82 208.87 229.75 189.88 208.87 82 194.29 213.72 176.63 194.29 82 165.07 181.58 150.07 165.07 83 253.41 278.75 230.37 253.41 83 220.35 242.39 200.32 220.35 83 204.98 225.48 186.34 204.98 83 174.15 191.57 158.32 174.15 84 264.58 291.04 240.53 264.58 84 230.07 253.08 209.16 230.07 84 214.01 235.42 194.57 214.01 84 181.83 200.01 165.30 181.83 85 276.13 303.74 251.02 276.13 85 240.11 264.13 218.28 240.11 85 223.37 245.70 203.06 223.37 85 189.78 208.75 172.53 189.78 86 288.12 316.93 261.92 288.12 86 250.54 275.59 227.76 250.54 86 233.06 256.37 211.87 233.06 86 198.01 217.81 180.01 198.01 87 300.48 330.53 273.16 300.48 87 261.28 287.42 237.53 261.28 87 243.05 267.36 220.96 243.05 87 206.50 227.16 187.73 206.50 88 313.26 344.59 284.78 313.26 88 272.40 299.64 247.63 272.40 88 253.40 278.73 230.36 253.40 88 215.29 236.82 195.72 215.29 89 326.43 359.09 296.77 326.43 89 283.86 312.25 258.06 283.86 89 264.05 290.46 240.05 264.05 89 224.34 246.78 203.95 224.34 90+ 340.00 374.00 309.10 340.00 90+ 295.65 325.22 268.78 295.65 90+ 275.03 302.53 250.03 275.03 90+ 233.67 257.03 212.43 233.67
< 65 (open enrollee)
155.47 141.36
< 65 (open enrollee)
135.20 122.92
< 65 (open enrollee)
125.77 114.35
< 65 (open enrollee)
106.86 97.15
STANDARD PLAN A FORM NUMBER: MS.A.PAL.PA
Area 1 Area 2 Area 3 Area 4
Attained
Age MNTU MTU FNTU FTU Attained Age MNTU MTU FNTU FTU Attained Age MNTU MTU FNTU FTU Attained Age MNTU MTU FNTU FTU
< 65 452.17 497.37 411.05 452.17 < 65 393.19 432.50 357.44 393.19 < 65 365.76 402.32 332.50 365.76 < 65 310.75 341.82 282.49 310.75 65 190.45 209.51 173.13 190.45 65 165.61 182.18 150.55 165.61 65 154.05 169.46 140.05 154.05 65 130.88 143.98 118.99 130.88 66 190.45 209.51 173.13 190.45 66 165.61 182.18 150.55 165.61 66 154.05 169.46 140.05 154.05 66 130.88 143.98 118.99 130.88 67 190.45 209.51 173.13 190.45 67 165.61 182.18 150.55 165.61 67 154.05 169.46 140.05 154.05 67 130.88 143.98 118.99 130.88 68 195.13 214.64 177.39 195.13 68 169.68 186.65 154.25 169.68 68 157.84 173.63 143.48 157.84 68 134.11 147.51 121.92 134.11 69 199.83 219.81 181.66 199.83 69 173.76 191.14 157.96 173.76 69 161.65 177.81 146.95 161.65 69 137.33 151.07 124.85 137.33 70 204.52 224.96 185.93 204.52 70 177.85 195.62 161.69 177.85 70 165.44 181.98 150.40 165.44 70 140.56 154.61 127.79 140.56 71 208.17 228.98 189.24 208.17 71 181.02 199.12 164.56 181.02 71 168.39 185.22 153.08 168.39 71 143.07 157.37 130.06 143.07 72 215.92 237.49 196.29 215.92 72 187.75 206.51 170.68 187.75 72 174.65 192.11 158.77 174.65 72 148.39 163.22 134.89 148.39 73 224.12 246.53 203.74 224.12 73 194.89 214.37 177.17 194.89 73 181.29 199.42 164.81 181.29 73 154.02 169.43 140.03 154.02 74 232.77 256.04 211.62 232.77 74 202.41 222.64 184.01 202.41 74 188.29 207.11 171.17 188.29 74 159.97 175.97 145.43 159.97 75 239.94 263.93 218.13 239.94 75 208.64 229.50 189.67 208.64 75 194.08 213.49 176.44 194.08 75 164.89 181.38 149.90 164.89 76 245.67 270.25 223.34 245.67 76 213.63 235.00 194.21 213.63 76 198.72 218.60 180.66 198.72 76 168.84 185.72 153.50 168.84 77 251.59 276.75 228.71 251.59 77 218.77 240.65 198.88 218.77 77 203.51 223.86 185.00 203.51 77 172.90 190.20 157.19 172.90 78 257.59 283.32 234.18 257.59 78 223.99 246.37 203.64 223.99 78 208.35 229.18 189.42 208.35 78 177.02 194.72 160.93 177.02 79 263.69 290.05 239.72 263.69 79 229.29 252.22 208.45 229.29 79 213.30 234.63 193.90 213.30 79 181.22 199.35 164.75 181.22 80 274.97 302.46 249.98 274.97 80 239.12 263.01 217.38 239.12 80 222.43 244.67 202.21 222.43 80 188.98 207.88 171.80 188.98 81 290.27 319.28 263.87 290.27 81 252.41 277.64 229.45 252.41 81 234.80 258.27 213.44 234.80 81 199.49 219.43 181.35 199.49 82 306.32 336.96 278.47 306.32 82 266.37 293.00 242.14 266.37 82 247.78 272.56 225.25 247.78 82 210.51 231.57 191.37 210.51 83 323.17 355.48 293.78 323.17 83 281.02 309.11 255.47 281.02 83 261.41 287.54 237.64 261.41 83 222.10 244.30 201.89 222.10 84 337.43 371.16 306.75 337.43 84 293.41 322.76 266.73 293.41 84 272.94 300.24 248.13 272.94 84 231.89 255.09 210.81 231.89 85 352.18 387.42 320.17 352.18 85 306.24 336.88 278.41 306.24 85 284.89 313.37 258.98 284.89 85 242.04 266.25 220.04 242.04 86 367.44 404.19 334.04 367.44 86 319.52 351.47 290.47 319.52 86 297.22 326.95 270.21 297.22 86 252.53 277.78 229.57 252.53 87 383.22 421.54 348.37 383.22 87 333.24 366.57 302.94 333.24 87 309.99 340.99 281.80 309.99 87 263.37 289.71 239.42 263.37 88 399.53 439.48 363.21 399.53 88 347.41 382.15 315.83 347.41 88 323.17 355.49 293.79 323.17 88 274.58 302.02 249.62 274.58 89 416.31 457.95 378.47 416.31 89 362.01 398.21 329.10 362.01 89 336.76 370.44 306.14 336.76 89 286.11 314.73 260.11 286.11 90+ 433.62 476.98 394.20 433.62 90+ 377.07 414.77 342.78 377.07 90+ 350.75 385.82 318.86 350.75 90+ 298.00 327.80 270.91 298.00
< 65 (open enrollee)
190.45 173.13
< 65 (open enrollee)
165.61 150.55
< 65 (open enrollee)
154.05 140.05
< 65 (open enrollee)
130.88 118.99
STANDARD PLAN B FORM NUMBER: MS.B.PAL.PA
Area 1 Area 2 Area 3 Area 4
Attained
Age MNTU MTU FNTU FTU Attained Age MNTU MTU FNTU FTU Attained Age MNTU MTU FNTU FTU Attained Age MNTU MTU FNTU FTU
< 65 530.78 583.84 482.54 530.78 < 65 461.55 507.70 419.59 461.55 < 65 429.35 472.28 390.33 429.35 < 65 364.78 401.26 331.62 364.78 65 223.57 245.92 203.23 223.57 65 194.41 213.84 176.73 194.41 65 180.84 198.93 164.40 180.84 65 153.65 169.01 139.68 153.65 66 223.57 245.92 203.23 223.57 66 194.41 213.84 176.73 194.41 66 180.84 198.93 164.40 180.84 66 153.65 169.01 139.68 153.65 67 227.30 250.03 206.64 227.30 67 197.66 217.42 179.69 197.66 67 183.87 202.25 167.15 183.87 67 156.22 171.84 142.01 156.22 68 230.96 254.06 209.95 230.96 68 200.83 220.91 182.56 200.83 68 186.82 205.50 169.84 186.82 68 158.72 174.59 144.29 158.72 69 234.47 257.91 213.16 234.47 69 203.89 224.27 185.36 203.89 69 189.67 208.62 172.42 189.67 69 161.14 177.25 146.50 161.14 70 237.94 261.73 216.30 237.94 70 206.90 227.60 188.09 206.90 70 192.47 211.71 174.97 192.47 70 163.53 179.88 148.66 163.53 71 241.22 265.34 219.27 241.22 71 209.75 230.73 190.68 209.75 71 195.11 214.63 177.37 195.11 71 165.77 182.35 150.70 165.77 72 249.10 274.01 226.46 249.10 72 216.62 238.28 196.93 216.62 72 201.50 221.66 183.18 201.50 72 171.19 188.32 155.63 171.19 73 257.46 283.21 234.06 257.46 73 223.88 246.26 203.52 223.88 73 208.26 229.08 189.33 208.26 73 176.94 194.63 160.85 176.94 74 266.25 292.86 242.04 266.25 74 231.51 254.66 210.47 231.51 74 215.37 236.89 195.78 215.37 74 182.97 201.26 166.34 182.97 75 273.21 300.53 248.39 273.21 75 237.57 261.33 215.99 237.57 75 220.99 243.10 200.92 220.99 75 187.76 206.54 170.70 187.76 76 279.88 307.87 254.44 279.88 76 243.37 267.71 221.25 243.37 76 226.39 249.03 205.81 226.39 76 192.35 211.58 174.87 192.35 77 286.72 315.42 260.66 286.72 77 249.32 274.27 226.66 249.32 77 231.93 255.14 210.85 231.93 77 197.05 216.76 179.15 197.05 78 293.70 323.09 267.00 293.70 78 255.39 280.95 232.19 255.39 78 237.57 261.35 215.99 237.57 78 201.85 222.03 183.50 201.85 79 300.83 330.90 273.46 300.83 79 261.58 287.73 237.79 261.58 79 243.33 267.67 221.20 243.33 79 206.73 227.41 187.94 206.73 80 313.82 345.22 285.31 313.82 80 272.88 300.18 248.08 272.88 80 253.85 279.24 230.78 253.85 80 215.68 237.25 196.07 215.68 81 331.28 364.39 301.16 331.28 81 288.07 316.87 261.88 288.07 81 267.97 294.76 243.61 267.97 81 227.67 250.44 206.98 227.67 82 349.61 384.55 317.82 349.61 82 304.01 334.39 276.37 304.01 82 282.80 311.07 257.09 282.80 82 240.27 264.30 218.43 240.27 83 368.83 405.73 335.30 368.83 83 320.72 352.81 291.57 320.72 83 298.35 328.19 271.23 298.35 83 253.48 278.84 230.43 253.48 84 385.09 423.60 350.08 385.09 84 334.86 368.35 304.42 334.86 84 311.49 342.65 283.19 311.49 84 264.65 291.12 240.60 264.65 85 401.95 442.13 365.40 401.95 85 349.52 384.46 317.74 349.52 85 325.13 357.64 295.58 325.13 85 276.23 303.86 251.12 276.23 86 419.38 461.30 381.23 419.38 86 364.68 401.13 331.51 364.68 86 339.23 373.15 308.37 339.23 86 288.21 317.04 262.01 288.21 87 437.37 481.11 397.61 437.37 87 380.32 418.36 345.74 380.32 87 353.79 389.17 321.63 353.79 87 300.58 330.65 273.25 300.58 88 455.96 501.56 414.51 455.96 88 396.50 436.14 360.44 396.50 88 368.83 405.72 335.30 368.83 88 313.37 344.70 284.88 313.37 89 475.15 522.65 431.95 475.15 89 413.18 454.48 375.62 413.18 89 384.34 422.77 349.41 384.34 89 326.55 359.19 296.86 326.55 90+ 494.92 544.40 449.93 494.92 90+ 430.36 473.40 391.24 430.36 90+ 400.34 440.37 363.94 400.34 90+ 340.14 374.15 309.21 340.14
< 65 (open enrollee)
223.57 203.23
< 65 (open enrollee)
194.41 176.73
< 65 (open enrollee)
180.84 164.40
< 65 (open enrollee)
153.65 139.68
STANDARD PLAN C FORM NUMBER: MS.C.PAL.PA
Area 1 Area 2 Area 3 Area 4
Attained
Age MNTU MTU FNTU FTU Attained Age MNTU MTU FNTU FTU Attained Age MNTU MTU FNTU FTU Attained
Age MNTU MTU FNTU FTU
< 65 536.14 589.74 487.41 536.14 < 65 466.21 512.82 423.83 466.21 < 65 433.68 477.05 394.26 433.68 < 65 368.47 405.31 334.97 368.47 65 225.82 248.41 205.29 225.82 65 196.37 216.01 178.51 196.37 65 182.67 200.94 166.06 182.67 65 155.20 170.72 141.09 155.20 66 225.82 248.41 205.29 225.82 66 196.37 216.01 178.51 196.37 66 182.67 200.94 166.06 182.67 66 155.20 170.72 141.09 155.20 67 229.60 252.56 208.73 229.60 67 199.66 219.62 181.50 199.66 67 185.72 204.30 168.84 185.72 67 157.79 173.58 143.45 157.79 68 233.29 256.62 212.07 233.29 68 202.86 223.15 184.41 202.86 68 188.71 207.57 171.55 188.71 68 160.32 176.36 145.75 160.32 69 236.84 260.52 215.31 236.84 69 205.95 226.54 187.23 205.95 69 191.58 210.74 174.16 191.58 69 162.77 179.05 147.98 162.77 70 240.35 264.38 218.48 240.35 70 208.99 229.90 189.99 208.99 70 194.41 213.85 176.74 194.41 70 165.18 181.69 150.16 165.18 71 243.65 268.01 221.49 243.65 71 211.87 233.06 192.60 211.87 71 197.09 216.79 179.16 197.09 71 167.44 184.19 152.22 167.44 72 251.62 276.78 228.75 251.62 72 218.80 240.68 198.91 218.80 72 203.53 223.89 185.03 203.53 72 172.92 190.22 157.21 172.92 73 260.06 286.06 236.42 260.06 73 226.14 248.75 205.58 226.14 73 210.36 231.39 191.24 210.36 73 178.72 196.59 162.48 178.72 74 268.94 295.82 244.48 268.94 74 233.86 257.23 212.59 233.86 74 217.54 239.28 197.76 217.54 74 184.82 203.30 168.02 184.82 75 275.97 303.57 250.90 275.97 75 239.98 263.97 218.17 239.98 75 223.23 245.55 202.94 223.23 75 189.66 208.62 172.42 189.66 76 282.70 310.98 257.01 282.70 76 245.83 270.42 223.48 245.83 76 228.68 251.55 207.89 228.68 76 194.29 213.72 176.63 194.29 77 289.62 318.60 263.30 289.62 77 251.84 277.04 228.95 251.84 77 234.28 257.71 212.98 234.28 77 199.05 218.96 180.96 199.05 78 296.67 326.35 269.70 296.67 78 257.97 283.78 234.53 257.97 78 239.98 263.98 218.17 239.98 78 203.89 224.28 185.36 203.89 79 303.86 334.24 276.22 303.86 79 264.22 290.64 240.20 264.22 79 245.78 270.36 223.44 245.78 79 208.82 229.71 189.84 208.82 80 317.00 348.71 288.18 317.00 80 275.65 303.22 250.59 275.65 80 256.41 282.06 233.11 256.41 80 217.85 239.64 198.05 217.85 81 334.62 368.08 304.21 334.62 81 290.98 320.07 264.53 290.98 81 270.68 297.74 246.07 270.68 81 229.97 252.97 209.07 229.97 82 353.14 388.44 321.04 353.14 82 307.07 337.77 279.16 307.07 82 285.65 314.21 259.69 285.65 82 242.70 266.96 220.64 242.70 83 372.56 409.83 338.69 372.56 83 323.97 356.37 294.51 323.97 83 301.36 331.51 273.97 301.36 83 256.04 281.65 232.76 256.04 84 388.97 427.88 353.62 388.97 84 338.24 372.07 307.49 338.24 84 314.64 346.11 286.04 314.64 84 267.33 294.06 243.02 267.33 85 406.01 446.60 369.10 406.01 85 353.05 388.34 320.95 353.05 85 328.42 361.25 298.56 328.42 85 279.03 306.93 253.66 279.03 86 423.61 465.96 385.09 423.61 86 368.36 405.18 334.86 368.36 86 342.66 376.92 311.49 342.66 86 291.12 320.24 264.65 291.12 87 441.79 485.97 401.63 441.79 87 384.16 422.58 349.24 384.16 87 357.36 393.10 324.87 357.36 87 303.62 333.98 276.01 303.62 88 460.57 506.64 418.70 460.57 88 400.50 440.55 364.09 400.50 88 372.56 409.82 338.69 372.56 88 316.53 348.19 287.75 316.53 89 479.94 527.93 436.32 479.94 89 417.34 459.07 379.41 417.34 89 388.23 427.05 352.94 388.23 89 329.85 362.83 299.86 329.85 90+ 499.92 549.91 454.47 499.92 90+ 434.71 478.18 395.19 434.71 90+ 404.39 444.82 367.62 404.39 90+ 343.57 377.93 312.33 343.57
< 65 (open enrollee)
225.82 205.29
< 65 (open enrollee)
196.37 178.51
< 65 (open enrollee)
182.67 166.06
< 65 (open enrollee)
155.20 141.09
STANDARD PLAN F FORM NUMBER: MS.F.PAL.PA
Area 1 Area 2 Area 3 Area 4
Attained
Age MNTU MTU FNTU FTU Attained Age MNTU MTU FNTU FTU Attained Age MNTU MTU FNTU FTU Attained
Age MNTU MTU FNTU FTU
< 65 154.94 170.43 140.84 154.94 < 65 134.73 148.20 122.47 134.73 < 65 125.33 137.86 113.93 125.33 < 65 106.48 117.13 96.80 106.48
65 65.26 71.79 59.33 65.26 65 56.75 62.43 51.59 56.75 65 52.79 58.07 47.99 52.79 65 44.85 49.34 40.77 44.85
66 66.93 73.63 60.85 66.93 66 58.20 64.03 52.91 58.20 66 54.14 59.56 49.22 54.14 66 46.00 50.60 41.82 46.00
67 68.64 75.52 62.41 68.64 67 59.69 65.67 54.27 59.69 67 55.53 61.09 50.48 55.53 67 47.18 51.90 42.89 47.18
68 70.36 77.40 63.95 70.36 68 61.18 67.30 55.61 61.18 68 56.91 62.60 51.73 56.91 68 48.35 53.19 43.95 48.35
69 72.02 79.24 65.48 72.02 69 62.63 68.90 56.94 62.63 69 58.26 64.09 52.97 58.26 69 49.50 54.45 45.00 49.50
70 73.74 81.12 67.03 73.74 70 64.12 70.54 58.29 64.12 70 59.65 65.62 54.22 59.65 70 50.68 55.75 46.07 50.68
71 75.42 82.95 68.56 75.42 71 65.58 72.13 59.62 65.58 71 61.00 67.10 55.46 61.00 71 51.83 57.01 47.12 51.83
72 78.61 86.48 71.47 78.61 72 68.36 75.20 62.15 68.36 72 63.59 69.95 57.81 63.59 72 54.03 59.43 49.12 54.03
73 82.02 90.21 74.55 82.02 73 71.32 78.44 64.83 71.32 73 66.34 72.97 60.31 66.34 73 56.36 62.00 51.24 56.36
74 85.59 94.15 77.82 85.59 74 74.43 81.87 67.67 74.43 74 69.24 76.16 62.95 69.24 74 58.83 64.71 53.48 58.83
75 88.69 97.57 80.63 88.69 75 77.12 84.84 70.11 77.12 75 71.74 78.92 65.22 71.74 75 60.95 67.05 55.41 60.95
76 91.91 101.10 83.55 91.91 76 79.92 87.91 72.65 79.92 76 74.34 81.78 67.58 74.34 76 63.16 69.48 57.42 63.16
77 95.25 104.79 86.58 95.25 77 82.83 91.12 75.29 82.83 77 77.05 84.76 70.04 77.05 77 65.46 72.01 59.51 65.46
78 98.74 108.62 89.77 98.74 78 85.86 94.45 78.06 85.86 78 79.87 87.86 72.61 79.87 78 67.86 74.65 61.69 67.86
79 102.33 112.55 93.02 102.33 79 88.98 97.87 80.89 88.98 79 82.77 91.04 75.25 82.77 79 70.32 77.35 63.93 70.32
80 108.05 118.86 98.23 108.05 80 93.96 103.36 85.42 93.96 80 87.40 96.15 79.46 87.40 80 74.26 81.69 67.51 74.26
81 114.07 125.47 103.68 114.07 81 99.19 109.10 90.16 99.19 81 92.27 101.49 83.87 92.27 81 78.39 86.23 71.26 78.39
82 120.37 132.41 109.43 120.37 82 104.67 115.14 95.16 104.67 82 97.37 107.11 88.52 97.37 82 82.73 91.00 75.21 82.73
83 126.97 139.67 115.43 126.97 83 110.41 121.45 100.37 110.41 83 102.71 112.98 93.37 102.71 83 87.26 95.99 79.33 87.26
84 132.58 145.84 120.53 132.58 84 115.29 126.82 104.81 115.29 84 107.25 117.97 97.50 107.25 84 91.12 100.23 82.84 91.12
85 138.39 152.24 125.80 138.39 85 120.34 132.38 109.39 120.34 85 111.94 123.14 101.76 111.94 85 95.11 104.62 86.46 95.11 86 144.38 158.83 131.26 144.38 86 125.55 138.11 114.14 125.55 86 116.79 128.47 106.18 116.79 86 99.23 109.15 90.21 99.23 87 150.59 165.65 136.88 150.59 87 130.95 144.04 119.03 130.95 87 121.81 133.99 110.73 121.81 87 103.49 113.84 94.08 103.49 88 157.01 172.71 142.73 157.01 88 136.53 150.18 124.11 136.53 88 127.00 139.70 115.45 127.00 88 107.90 118.69 98.09 107.90 89 163.59 179.95 148.72 163.59 89 142.25 156.48 129.32 142.25 89 132.33 145.56 120.30 132.33 89 112.43 123.67 102.21 112.43 90+ 170.41 187.44 154.91 170.41 90+ 148.18 162.99 134.70 148.18 90+ 137.84 151.62 125.30 137.84 90+ 117.11 128.82 106.46 117.11
< 65 (open enrollee)
65.26 59.33
< 65 (open enrollee)
56.75 51.59
< 65 (open enrollee)
52.79 47.99
< 65 (open enrollee)
44.85 40.77
STANDARD PLAN FX FORM NUMBER: MS.FX.PAL.PA
Area 1 Area 2 Area 3 Area 4