23 CAR pt. 103, Appendix A. Medicare Supplement Insurance Modification Notification Letter

SERVICES MEDICARE BENEFITS YOUR MEDICARE SUPPLEMENT COVERAGE In 1989 In 1989 Medicare Pays Effective January 1, Your coverage Effective January 1, 1990 Per Calendar year 1990, Medicare Will Pay Pays Your Coverage Will Pay 9th through 150th day - Beyond 100 days 100% of cost Nothing/benefit period Beyond 150 days - Nothing ` MEDICARE PART B 80% of allowable charges 80% of allowable charges SERVICES & (after $75 deductible) (after $75 deductible/ SUPPLIES calendar year) PRESCRIPTION Inpatient prescription drugs Inpatient prescription drugs. DRUGS 80% of allowable charges for 80% of allowable charges for immunosuppressive drugs immunosuppressive drugs during the first year during the first year following a covered following a covered transplant (after $75 transplant (after $75 deductible/calendar year) deductible/calendar year) BLOOD 80% of all costs except 80% of all costs except Nonreplacement fees (blood Nonreplacement fees (blood Deductible) for first 3 Deductible) for first 3 Pints in each benefit pints (after $75 Period (after $75 deductible/calendar year) Deductible/calendar year [Any other policy benefits not mentioned in this chart should be added to the chart in the order prescribed by the outline of coverage, if there are corresponding Medicare benefits, they should be shown.] [Describe any coverage provisions changing due to Medicare modifications.] [Include information about when premium adjustments that may be necessary due to changes in Medicare benefits will be effective.] THIS CHART SUMMARIZING THE CHANGES IN YOUR MEDICARE BENEFITS AND IN YOUR MEDICARE SUPPLEMENT PROVIDED BY [COMPANY] ONLY BRIEFLY DESCRIBES SUCH BENEFITS. FOR INFORMAITON ON YOUR MEDICARE BENEFITS CONTACT YOUR SOCIAL SECURITY OFFICE OR THE HEALTH CARE FINANCING ADMINISTRATION. FOR INFORMATION ON YOUR MEDICARE SUPPLEMENT [policy] CONTACT: [COMPANY OR FOR AN INDIVIDUAL POLICY - NAME OF AGENT] [ADDRESS/PHONE NUMBER] 2