SERVICES

MEDICARE BENEFITS

YOUR MEDICARE SUPPLEMENT COVERAGE

In 1989 Medicare Pays Per Calendar year

Effective January 1, 1990, Medicare Will Pay

In 1989 Your coverage Pays

Effective January 1, 1990 Your Coverage Will Pay

9th through 150th day - 100% of cost

Beyond 100 days Nothing/benefit period

Beyond 150 days - Nothing

MEDICARE PART B SERVICES & SUPPLIES

80% of allowable charges (after $75 deductible)

80% of allowable charges (after $75 deductible/ calendar year)

PRESCRIPTION DRUGS

Inpatient prescription drugs 80% of allowable charges for immunosuppressive drugs during the first year following a covered transplant (after $75 deductible/calendar year)

Inpatient prescription drugs. 80% of allowable charges for immunosuppressive drugs during the first year following a covered transplant (after $75 deductible/calendar year)

BLOOD

80% of all costs except Nonreplacement fees (blood Deductible) for first 3 Pints in each benefit Period (after $75 Deductible/calendar year

80% of all costs except Nonreplacement fees (blood Deductible) for first 3 pints (after $75 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 INFORMATION 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]