Aetna Life Insurance Company Outline of Medicare Supplement Coverage Benefit Plans A, B, C, F, G and N are Offered This chart shows the benefits included in each of the standard Medicare supplement plans. Every company must make Plan "A available. Some plans may not be available in your state. Basic Benefits: 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. Plans K, L and N require insured to pay a portion of Part B coinsurance or copayments. Blood - First three pints of blood each year. Hospice - Part A coinsurance A B C D F l F* G K L M N Basic Basic Basic including Basic including Basic including Basic including including including 100% Part B 100% Part B 100% Part B 100% Part B 100% Part B 100% Part B coinsurance coinsurance * coinsurance coinsurance coinsurance coinsurance Basic including 100% Part B coinsurance Part A Deductible Skilled Nursing Facility Coinsurance Part A Deductible Part B Deductible Foreign Travel Emergency Skilled Nursing Facility Coinsurance Part A Deductible Foreign Travel Emergency Skilled Nursing Facility Coinsurance Part A Deductible Part B Deductible Part B Excess- 100% Foreign Travel Emergency Skilled Nursing Facility Coinsurance Part A Deductible Part B Excess- 100% Foreign Travel Emergency Hospitalization and preventive care paid at 100%; other basic benefits paid at 50% 50% Skilled Nursing Facility Coinsurance 50% Part A Deductible Out-of-pocket limit $4,960; paid at 100% after limit reached Hospitalization and preventive care paid at 100%; other basic benefits paid at 75% 75% Skilled Nursing Facility Coinsurance 75% Part A Deductible Out-of-pocket limit $2,480; paid at 100% after limit reached Skilled Nursing Facility Coinsurance 50% Part A Deductible Foreign Travel Emergency Basic including 100% Part B coinsurance, except up to $20 copayment for office visit, and up to $50 copayment for ER Skilled Nursing Facility Coinsurance Part A Deductible Foreign Travel Emergency GR-11613-03-OOC-TX 18.02.312.1-TX N (12/15)
Aetna Life Insurance Company Outline of Medicare Supplement Coverage Benefit Plans A, B, C, F, G and N are Offered *Plan F also has an option called a high deductible Plan F. This high deductible plan pays the same benefits as Plan F after one has paid a calendar year $2,180 deductible. Benefits from high deductible Plan F will not begin until out-of-pocket expenses exceed $2,180. 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 do not include, the Plan s separate foreign travel emergency deductible.
PREMIUM INFORMATION Questions? We re here to help. Just call us at 1-800-345-6022 (TTY: 711) We, Aetna Life Insurance Company, can only raise your premium if we raise the premium for all policies like yours in this state, when your age changes or to coincide with changes in Medicare. Aetna will send a written notice at least 31 days before the change becomes effective. The monthly premiums shown will apply when payment is made on a quarterly, semi-annual or annual basis or if you elect to have your payments automatically deducted from your checking account (Electronic Funds Transfer program) or credit card account. To obtain quarterly premium, multiply the monthly premium by 3. For semi-annual premium and annual premium, multiply the monthly premium by 6 or 12, respectively. If you elect to pay your premium on a monthly basis by check or money order, add $2 to the monthly premium shown to calculate your monthly premium amount. If you use tobacco and you enroll other than during the Medicare Supplement Open Enrollment and Guaranteed issue rights periods, a tobacco use premium rate will apply. Please refer to the Guaranteed Issue Guidelines notice included in your enrollment materials for details on open enrollment and guaranteed issue rights. Tobacco use premium rates are determined by multiplying the premium shown by a factor of 1.10.
MONTHLY PREMIUMS The rates in the table below apply to the following ZIP CODES: 77000 through 77099; 77200 through 77799 PLAN A PLAN B PLAN C PLAN F PLAN G PLAN N Attained Age Male Female Male Female Male Female Male Female Male Female Male Female 65 $165.91 $153.16 $184.66 $169.58 $207.91 $191.16 $212.99 $195.83 $194.16 $180.66 $123.27 $114.91 66 $172.16 $158.99 $191.58 $175.91 $215.66 $198.33 $220.99 $203.24 $203.49 $189.33 $129.33 $120.56 67 $178.41 $164.66 $198.58 $182.24 $223.41 $205.49 $228.91 $210.49 $212.82 $197.91 $135.37 $126.19 68 $185.58 $171.41 $207.74 $190.74 $234.07 $215.24 $239.82 $220.49 $221.99 $206.58 $141.41 $131.83 69 $192.74 $177.99 $216.82 $198.99 $244.57 $224.91 $250.57 $230.41 $231.32 $215.16 $147.44 $137.45 70 $199.91 $184.58 $225.91 $207.41 $255.07 $234.57 $261.32 $240.24 $240.49 $223.82 $153.44 $143.05 71 $207.08 $191.16 $235.07 $215.74 $265.49 $244.16 $271.99 $250.07 $249.74 $232.41 $159.45 $148.64 72 $214.16 $197.66 $244.16 $224.07 $275.99 $253.74 $282.66 $259.99 $258.99 $240.99 $165.42 $154.21 73 $219.07 $202.24 $251.74 $230.99 $284.99 $262.07 $291.90 $268.41 $269.16 $250.49 $172.19 $160.53 74 $223.91 $206.66 $259.32 $237.99 $293.90 $270.24 $300.99 $276.82 $279.32 $259.91 $178.92 $166.79 75 $228.74 $211.16 $266.91 $244.91 $302.90 $278.49 $310.24 $285.24 $289.41 $269.24 $185.65 $173.06 76 $233.49 $215.57 $274.32 $251.91 $311.82 $286.74 $319.40 $293.65 $299.57 $278.74 $192.36 $179.30 77 $238.32 $220.07 $281.91 $258.74 $320.74 $294.99 $328.49 $301.99 $309.65 $288.16 $199.04 $185.53 78 $241.82 $223.24 $287.07 $263.49 $327.24 $300.82 $335.07 $308.15 $318.15 $296.07 $204.95 $191.04 79 $245.24 $226.41 $292.07 $268.07 $333.57 $306.74 $341.65 $314.07 $326.65 $303.90 $210.79 $196.48 80 $248.49 $229.41 $297.07 $272.66 $339.82 $312.40 $347.90 $319.90 $335.07 $311.82 $216.58 $201.88 81 $251.74 $232.32 $302.07 $277.32 $346.15 $318.24 $354.40 $325.82 $343.49 $319.57 $222.40 $207.31 82 $254.66 $235.16 $306.99 $281.82 $352.40 $323.90 $360.82 $331.74 $351.82 $327.40 $228.21 $212.72 83 $256.74 $236.99 $312.90 $287.32 $360.74 $331.65 $369.40 $339.65 $368.57 $342.90 $240.19 $223.88 84 $258.57 $238.66 $318.82 $292.65 $369.24 $339.40 $377.90 $347.57 $385.15 $358.40 $252.18 $235.07 85 $260.41 $240.41 $324.99 $298.32 $378.07 $347.57 $386.90 $355.74 $399.73 $371.90 $262.84 $245.02 86 $262.07 $241.91 $329.90 $302.82 $385.65 $354.49 $394.65 $362.90 $414.82 $385.98 $273.96 $255.37 87 $263.74 $243.49 $334.82 $307.32 $391.40 $359.90 $400.57 $368.40 $430.40 $400.48 $285.53 $266.17 88 $265.41 $244.99 $339.90 $311.99 $397.23 $365.24 $406.57 $373.82 $446.65 $415.57 $297.60 $277.42 89 $267.16 $246.57 $344.99 $316.74 $403.23 $370.74 $412.73 $379.48 $463.48 $431.23 $310.20 $289.15 90+ $268.82 $248.16 $350.15 $321.40 $409.23 $376.23 $418.90 $385.15 $480.98 $447.48 $323.29 $301.38 Enrolled When Under Age 65 and Disabled Under 65 $931.21 $931.21 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A 65 & Older $931.21 $931.21 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A
MONTHLY PREMIUMS The rates in the table below apply to the following ZIP CODES: 75000 through 75499; 75700 through 75799; 76000 through 76299; 76400 through 76499 PLAN A PLAN B PLAN C PLAN F PLAN G PLAN N Attained Age Male Female Male Female Male Female Male Female Male Female Male Female 65 $157.61 $145.50 $175.43 $161.10 $197.51 $181.60 $202.34 $186.03 $184.45 $171.63 $117.11 $109.16 66 $163.55 $151.04 $182.00 $167.11 $204.88 $188.41 $209.94 $193.08 $193.32 $179.86 $122.86 $114.53 67 $169.49 $156.43 $188.65 $173.13 $212.24 $195.22 $217.46 $199.97 $202.18 $188.01 $128.60 $119.88 68 $176.30 $162.84 $197.35 $181.21 $222.37 $204.48 $227.83 $209.47 $210.89 $196.25 $134.34 $125.23 69 $183.11 $169.09 $205.98 $189.04 $232.34 $213.66 $238.04 $218.89 $219.76 $204.40 $140.07 $130.58 70 $189.91 $175.35 $214.61 $197.04 $242.32 $222.85 $248.26 $228.23 $228.47 $212.63 $145.77 $135.90 71 $196.72 $181.60 $223.32 $204.95 $252.21 $231.95 $258.39 $237.57 $237.25 $220.79 $151.47 $141.21 72 $203.45 $187.78 $231.95 $212.87 $262.19 $241.05 $268.52 $246.99 $246.04 $228.94 $157.15 $146.50 73 $208.12 $192.13 $239.15 $219.44 $270.74 $248.97 $277.31 $254.99 $255.70 $237.97 $163.59 $152.51 74 $212.71 $196.33 $246.36 $226.09 $279.21 $256.73 $285.94 $262.98 $265.36 $246.91 $169.98 $158.45 75 $217.30 $200.60 $253.56 $232.66 $287.76 $264.56 $294.73 $270.98 $274.93 $255.78 $176.36 $164.41 76 $221.82 $204.80 $260.61 $239.31 $296.23 $272.40 $303.43 $278.97 $284.59 $264.80 $182.75 $170.34 77 $226.41 $209.07 $267.81 $245.80 $304.70 $280.24 $312.06 $286.89 $294.17 $273.75 $189.09 $176.25 78 $229.73 $212.08 $272.72 $250.31 $310.88 $285.78 $318.32 $292.75 $302.25 $281.27 $194.70 $181.48 79 $232.98 $215.09 $277.47 $254.67 $316.89 $291.40 $324.57 $298.37 $310.32 $288.71 $200.25 $186.66 80 $236.07 $217.94 $282.22 $259.02 $322.83 $296.78 $330.51 $303.91 $318.32 $296.23 $205.75 $191.79 81 $239.15 $220.71 $286.97 $263.46 $328.85 $302.33 $336.68 $309.53 $326.31 $303.59 $211.28 $196.94 82 $241.92 $223.40 $291.64 $267.73 $334.78 $307.71 $342.78 $315.15 $334.23 $311.03 $216.80 $202.08 83 $243.90 $225.14 $297.26 $272.96 $342.70 $315.07 $350.93 $322.67 $350.14 $325.76 $228.18 $212.69 84 $245.64 $226.72 $302.88 $278.02 $350.77 $322.43 $359.01 $330.19 $365.89 $340.48 $239.57 $223.32 85 $247.39 $228.39 $308.74 $283.41 $359.16 $330.19 $367.56 $337.95 $379.75 $353.31 $249.70 $232.77 86 $248.97 $229.81 $313.41 $287.68 $366.37 $336.76 $374.92 $344.76 $394.08 $366.69 $260.26 $242.60 87 $250.55 $231.32 $318.08 $291.95 $371.83 $341.91 $380.54 $349.98 $408.88 $380.46 $271.25 $252.86 88 $252.14 $232.74 $322.91 $296.39 $377.37 $346.97 $386.24 $355.13 $424.32 $394.79 $282.72 $263.55 89 $253.80 $234.24 $327.74 $300.90 $383.07 $352.20 $392.10 $360.51 $440.31 $409.67 $294.69 $274.69 90+ $255.38 $235.75 $332.65 $305.33 $388.77 $357.42 $397.95 $365.89 $456.93 $425.11 $307.13 $286.31 Enrolled When Under Age 65 and Disabled Under 65 $884.65 $884.65 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A 65 & Older $884.65 $884.65 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A
MONTHLY PREMIUMS The rates in the table below apply to all other ZIP CODES in the state PLAN A PLAN B PLAN C PLAN F PLAN G PLAN N Attained Age Male Female Male Female Male Female Male Female Male Female Male Female 65 $149.32 $137.84 $166.19 $152.62 $187.12 $172.04 $191.69 $176.24 $174.74 $162.59 $110.94 $103.42 66 $154.94 $143.09 $172.42 $158.32 $194.09 $178.49 $198.89 $182.92 $183.14 $170.39 $116.40 $108.51 67 $160.57 $148.19 $178.72 $164.02 $201.07 $184.94 $206.02 $189.44 $191.54 $178.12 $121.83 $113.57 68 $167.02 $154.27 $186.97 $171.67 $210.67 $193.72 $215.84 $198.44 $199.79 $185.92 $127.27 $118.64 69 $173.47 $160.19 $195.14 $179.09 $220.12 $202.42 $225.52 $207.37 $208.19 $193.64 $132.70 $123.70 70 $179.92 $166.12 $203.32 $186.67 $229.57 $211.12 $235.19 $216.22 $216.44 $201.44 $138.09 $128.74 71 $186.37 $172.04 $211.57 $194.17 $238.94 $219.74 $244.79 $225.07 $224.77 $209.17 $143.50 $133.78 72 $192.74 $177.89 $219.74 $201.67 $248.39 $228.37 $254.39 $233.99 $233.09 $216.89 $148.88 $138.79 73 $197.17 $182.02 $226.57 $207.89 $256.49 $235.87 $262.71 $241.57 $242.24 $225.44 $154.98 $144.48 74 $201.52 $185.99 $233.39 $214.19 $264.51 $243.22 $270.89 $249.14 $251.39 $233.92 $161.03 $150.11 75 $205.87 $190.04 $240.22 $220.42 $272.61 $250.64 $279.21 $256.71 $260.46 $242.32 $167.08 $155.76 76 $210.14 $194.02 $246.89 $226.72 $280.64 $258.06 $287.46 $264.29 $269.61 $250.86 $173.13 $161.37 77 $214.49 $198.07 $253.71 $232.87 $288.66 $265.49 $295.64 $271.79 $278.69 $259.34 $179.14 $166.98 78 $217.64 $200.92 $258.36 $237.14 $294.51 $270.74 $301.56 $277.34 $286.34 $266.46 $184.45 $171.93 79 $220.72 $203.77 $262.86 $241.27 $300.21 $276.06 $307.49 $282.66 $293.99 $273.51 $189.71 $176.83 80 $223.64 $206.47 $267.36 $245.39 $305.84 $281.16 $313.11 $287.91 $301.56 $280.64 $194.92 $181.70 81 $226.57 $209.09 $271.86 $249.59 $311.54 $286.41 $318.96 $293.24 $309.14 $287.61 $200.16 $186.58 82 $229.19 $211.64 $276.29 $253.64 $317.16 $291.51 $324.74 $298.56 $316.64 $294.66 $205.39 $191.45 83 $231.07 $213.29 $281.61 $258.59 $324.66 $298.49 $332.46 $305.69 $331.71 $308.61 $216.17 $201.49 84 $232.72 $214.79 $286.94 $263.39 $332.31 $305.46 $340.11 $312.81 $346.64 $322.56 $226.96 $211.57 85 $234.37 $216.37 $292.49 $268.49 $340.26 $312.81 $348.21 $320.16 $359.76 $334.71 $236.55 $220.52 86 $235.87 $217.72 $296.91 $272.54 $347.09 $319.04 $355.19 $326.61 $373.34 $347.39 $246.56 $229.83 87 $237.37 $219.14 $301.34 $276.59 $352.26 $323.91 $360.51 $331.56 $387.36 $360.44 $256.97 $239.55 88 $238.87 $220.49 $305.91 $280.79 $357.51 $328.71 $365.91 $336.44 $401.98 $374.01 $267.84 $249.68 89 $240.44 $221.92 $310.49 $285.06 $362.91 $333.66 $371.46 $341.54 $417.13 $388.11 $279.18 $260.24 90+ $241.94 $223.34 $315.14 $289.26 $368.31 $338.61 $377.01 $346.64 $432.88 $402.73 $290.96 $271.24 Enrolled When Under Age 65 and Disabled Under 65 $838.09 $838.09 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A 65 & Older $838.09 $838.09 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A
DISCLOSURES Questions? We re here to help. Just call us at 1-800-345-6022 (TTY: 711) Use this outline to compare benefits and premiums among policies. READ YOUR POLICY VERY CAREFULLY This is only an outline describing your policy's most important features. The policy is your insurance contract. You must read the policy itself to understand all of the rights and duties of both you and Aetna Life Insurance Company. RIGHT TO RETURN POLICY If you find that you are not satisfied with your policy, you may return it to Aetna Life Insurance Company, PO Box 14770, Lexington, KY 40512. If you send the policy back to us within 30 days after you receive it, we will treat the policy as if it had never been issued and return all of your payments. POLICY REPLACEMENT If you are replacing another health insurance policy, do NOT cancel it until you have actually received your new policy and are sure you want to keep it. NOTICE This policy may not fully cover all of your medical costs. Neither Aetna Life Insurance Company nor its agents are connected with Medicare. This outline of coverage does not give all the details of Medicare coverage. Contact your local Social Security Office or consult Medicare & You for more details. EXCLUSIONS AND LIMITATIONS This policy may not fully cover all of your medical costs. Certain exclusions and limitations apply based upon your Medicare coverage. (continued on next page)
DISCLOSURES Questions? We re here to help. Just call us at 1-800-345-6022 (TTY: 711) In addition, this policy contains a Pre-Existing Conditions Limitation. This policy does not pay benefits for loss which occurs within six months after the effective date of your coverage as a result of a pre-existing condition. A pre-existing condition is a condition for which medical advice was given or treatment was recommended by or received from a physician within 6 months before the effective date of coverage. Please note that pre-existing conditions will be covered after 6 months from the effective date of coverage. This exclusion does not apply to loss which occurs more than six months after the effective date of coverage. If you apply for this policy during the 6 month period beginning with the first of the month in which you are eligible, and as of the date you apply you had a continuous period of Creditable Coverage of at least 6 months the pre-existing conditions limitation will not apply to you. If you apply for this policy during the 6- month period beginning with the first of the month in which you are eligible, and as of the date you apply you had a continuous period of Creditable Coverage of less than 6 months, the pre-existing conditions limitation will be reduced by the aggregate of the period of Creditable Coverage applicable as of your enrollment date. If this policy is issued to replace another Medicare supplement policy as a result of certain situations involving health coverage changes, the pre-existing conditions exclusion will not be applied. Some of these situations include: personal choice; loss of the policyholder's group coverage; termination of a Medicare Advantage program under which you were covered; termination of coverage because you moved out of the plan's service area; the insurance company that provided you Medicare Supplement coverage went out of business, or committed fraud. REFUND OF PREMIUM The policy includes a provision describing the Refund of Premium in certain circumstances. If the insured dies or if the policy is cancelled, Aetna will refund any part of the premiums paid which applies to the period after the date of death of the insured or the date of cancellation. COMPLETE ANSWERS ARE VERY IMPORTANT When you fill out the application for the new policy, be sure to answer truthfully and completely all questions about your medical and health history. The Company may cancel your policy and refuse to pay any claims if you leave out or falsify important medical information. Review the application carefully before you sign it. Be certain that all information has been properly recorded.
PLAN A Medicare (Part A) Hospital Per Benefit Period HOSPITALIZATION* Semi-private room and board, general nursing and miscellaneous services and supplies - Plan A First 60 days All but $1,288 $1,288 (Part A deductible) 61st thru 90th day All but $322 a day $322 a day 91st day and after: While using 60 lifetime reserve days All but $644 a day $644 a day Once lifetime reserve days are used: Additional 365 days 100% of Medicareeligible expenses - Beyond the additional 365 days All costs SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital First 20 days All approved amounts 21st thru 100th day All but $161 a day ** Up to $161 a day 101st day and after All costs *A Benefit Period begins on the first day you receive care as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. **NOTICE When your Medicare Part A hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy s Core Benefits. During this time, the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
PLAN A (continued) Medicare (Part A) Hospital Per Benefit Period Plan A BLOOD First 3 pints 3 pints Additional amounts 100% HOSPICE CARE You must meet Medicare s requirements, including a doctor s certification of terminal illness All but a very limited copayment/ coinsurance for outpatient drugs and inpatient respite care Medicare copayment/ coinsurance PLAN A Medicare (Part B) Medical Per Calendar Year Plan A MEDICAL EXPENSES INPATIENT OR OUTPATIENT HOSPITAL TREATMENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $166 of Medicare-approved amounts* $166 (Part B deductible) Remainder of Medicare-approved amounts Generally 80% Generally 20% Part B excess charges (above Medicareapproved amounts) All costs *Once you have been billed $166 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
PLAN A (continued) Medicare (Part B) Medical Per Calendar Year BLOOD Plan A First 3 pints All costs Next $166 of Medicare-approved amounts* $166 (Part B deductible) Remainder of Medicare-approved amounts 80% 20% CLINICAL LABORATORY SERVICES Tests for diagnostic services 100% PARTS A & B - - Plan A HOME HEALTH CARE Medicare-Approved Medically necessary skilled care services and medical supplies 100% Durable medical equipment: First $166 of Medicare-approved amounts* Remainder of Medicare-approved amounts $166 (Part B deductible) 80% 20% *Once you have been billed $166 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
PLAN B Medicare (Part A) Hospital Per Benefit Period Plan B HOSPITALIZATION* Semi-private room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,288 $1,288 (Part A deductible) 61 st thru 90 th day All but $322 a day $322 a day 91 st day and after: While using 60 lifetime reserve days All but $644 a day $644 a day Once lifetime reserve days are used: - Additional 365 days 100% of Medicareeligible expenses ** - Beyond the additional 365 days All costs SKILLED NURSING FACILITY CARE* You must meet Medicare s requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital First 20 days All approved amounts 21 st thru 100 th day All but $161 a day Up to $161 a day 101 st day and after All costs *A Benefit Period begins on the first day you receive care as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. **NOTICE When your Medicare Part A Hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy s Core Benefits. During this time, the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
PLAN B (continued) Medicare (Part A) Hospital Per Benefit Period Plan B BLOOD First 3 pints 3 pints Additional amounts 100% HOSPICE CARE You must meet Medicare s requirements including a doctor s certification of terminal illness All but very limited copayment/ coinsurance for outpatient drugs and inpatient respite care Medicare copayment/ coinsurance PLAN B Medicare (Part B) Medical Per Calendar Year Plan B MEDICAL EXPENSES INPATIENT OR OUTPATIENT HOSPITAL TREATMENT, such as physician s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $166 of Medicare-approved amounts* $166 (Part B deductible) Remainder of Medicare-approved amounts Generally 80% Generally 20% Part B Excess Charges (above Medicareapproved amounts) All costs *Once you have been billed $166 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
PLAN B (continued) Medicare (Part B) Medical Per Calendar Year Plan B BLOOD First 3 pints All costs Next $166 of Medicare-approved amounts* $166 (Part B deductible) Remainder of Medicare-approved amounts 80% 20% CLINICAL LABORATORY SERVICES Tests for diagnostic services 100% PARTS A & B Plan B HOME HEALTH CARE Medicare-Approved Medically necessary skilled care services and medical supplies Durable medical equipment: - - First $166 of Medicare-approved amounts* Remainder of Medicare-approved amounts 100% $166 (Part B deductible) 80% 20% *Once you have been billed $166 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
PLAN C Medicare (Part A) Hospital Per Benefit Period HOSPITALIZATION* Semi-private room and board, general nursing and miscellaneous services and supplies - First 60 days All but $1,288 $1,288 (Part A deductible) Plan C 61st thru 90th day All but $322 a day $322 a day 91st day and after: While using 60 lifetime reserve days All but $644 a day $644 a day Once lifetime reserve days are used: Additional 365 days 100% of Medicareeligible expenses - Beyond the additional 365 days All costs SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital First 20 days All approved amounts 21st thru 100th day All but $161 a day Up to $161 a day 101st day and after All costs ** *A Benefit Period begins on the first day you receive care as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. **NOTICE When your Medicare Part A Hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy s Core Benefits. During this time, the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
PLAN C (continued) Medicare (Part A) Hospital Per Benefit Period Plan C BLOOD First 3 pints 3 pints Additional amounts 100% HOSPICE CARE You must meet Medicare s requirements including a doctor s certification of terminal illness All but very limited copayment/ coinsurance for outpatient drugs and inpatient respite care Medicare copayment/ coinsurance PLAN C Medicare (Part B) Medical Per Calendar Year MEDICAL EXPENSES INPATIENT OR OUTPATIENT HOSPITAL TREATMENT, such as physician s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $166 of Medicare-approved amounts* $166 (Part B deductible) Plan C Remainder of Medicare-approved amounts Generally 80% Generally 20% Part B Excess Charges (above Medicareapproved amounts) All costs *Once you have been billed $166 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
PLAN C (continued) Medicare (Part B) Medical Per Calendar Year Plan C BLOOD First 3 pints All costs Next $166 of Medicare-approved amounts* $166 (Part B deductible) Remainder of Medicare-approved amounts 80% 20% CLINICAL LABORATORY SERVICES Tests for diagnostic services 100% PARTS A & B Plan C HOME HEALTH CARE Medicare-Approved Medically necessary skilled care services and medical supplies Durable medical equipment: - - First $166 of Medicare-approved amounts* Remainder of Medicare-approved amounts 100% $166 (Part B deductible) 80% 20% FOREIGN TRAVEL NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA OTHER BENEFITS Not Covered by Medicare Plan C First $250 each calendar year $250 Remainder of such charges 80% to a lifetime maximum benefit of $50,000 20% and amounts over the $50,000 lifetime maximum *Once you have been billed $166 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
PLAN F Medicare (Part A) Hospital Per Benefit Period HOSPITALIZATION* Semi-private room and board, general nursing and miscellaneous services and supplies - First 60 days All but $1,288 $1,288 (Part A deductible) Plan F 61st thru 90th day All but $322 a day $322 a day 91st day and after: While using 60 lifetime reserve days All but $644 a day $644 a day Once lifetime reserve days are used: Additional 365 days 100% of Medicareeligible expenses - Beyond the additional 365 days All costs SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital First 20 days All approved amounts 21st thru 100th day All but $161 a day Up to $161 a day 101st day and after All costs ** *A Benefit Period begins on the first day you receive care as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. **NOTICE When your Medicare Part A Hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy s Core Benefits. During this time, the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
PLAN F (continued) Medicare (Part A) Hospital Per Benefit Period BLOOD Plan F First 3 pints 3 pints Additional amounts 100% HOSPICE CARE You must meet Medicare s requirements, including a doctor s certification of terminal illness All but very limited copayment/ coinsurance for outpatient drugs and inpatient respite care Medicare copayment/ coinsurance PLAN F Medicare (Part B) Medical Per Calendar Year MEDICAL EXPENSES Plan F INPATIENT OR OUTPATIENT HOSPITAL TREATMENT, such as physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $166 of Medicare-approved amounts* $166 (Part B deductible) Remainder of Medicare-approved amounts Generally 80% Generally 20% Part B Excess Charges (above Medicareapproved amounts) 100% BLOOD First 3 pints All costs Next $166 of Medicare-approved amounts* $166 (Part B deductible) Remainder of Medicare-approved amounts 80% 20% *Once you have been billed $166 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
PLAN F (continued) Medicare (Part B) Medical Per Calendar Year Plan F CLINICAL LABORATORY SERVICES Tests for diagnostic services 100% PARTS A & B Plan F HOME HEALTH CARE Medicare-Approved Medically necessary skilled care services and medical supplies 100% Durable medical equipment: - - First $166 of Medicare-approved amounts* Remainder of Medicare-approved amounts $166 (Part B deductible) 80% 20% OTHER BENEFITS Not Covered by Medicare FOREIGN TRAVEL NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA Plan F First $250 each calendar year $250 Remainder of such charges 80% to a lifetime maximum benefit of $50,000 20% and amounts over the $50,000 lifetime maximum *Once you have been billed $166 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B deductible will have been met for the calendar year.
PLAN G Medicare (Part A) Hospital Per Benefit Period Plan G HOSPITALIZATION* Semi-private room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,288 $1,288 (Part A deductible) 61st thru 90th day All but $322 a day $322 a day 91st day and after: While using 60 lifetime reserve days All but $644 a day $644 a day Once lifetime reserve days are used: -Additional 365 days 100% of Medicare eligible expenses ** -Beyond the additional 365 days All costs SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital First 20 days All approved amounts 21st thru 100th day All but $161 a day Up to $161 a day 101st day and after All costs BLOOD First 3 pints 3 pints Additional amounts 100% HOSPICE CARE You must meet Medicare s requirements, including a doctor s certification of terminal illness All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care Medicare copayment/ coinsurance *A Benefit Period begins on the first day you receive care as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. ** NOTICE When your Medicare Part A Hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy s Core Benefits. During this time, the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
PLAN G Medicare (Part B) Medical Per Calendar Year Plan G MEDICAL EXPENSES IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENTS, such as physician s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $166 of Medicare-approved amounts* $166 (Part B deductible) Remainder of Medicare-approved amounts Generally 80% Generally 20% Part B Excess Charges (above Medicareapproved amounts) 100% of all costs BLOOD First 3 pints All costs Next $166 of Medicare-approved amounts* $166 (Part B deductible) Remainder of Medicare-approved amounts 80% 20% CLINICAL LABORATORY SERVICES Tests for diagnostic services 100% *Once you have been billed $166 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.
PLAN G (continued) PARTS A & B Plan G HOME HEALTH CARE Medicare Approved -Medically necessary skilled care services and medical supplies -Durable medical equipment: - First $166 of Medicare-approved amounts* - Remainder of Medicare-approved amounts 100% $166 (Part B deductible) 80% 20% OTHER BENEFITS Not Covered by Medicare Plan G FOREIGN TRAVEL NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year $250 Remainder of such charges 80% to a lifetime maximum benefit of $50,000 20% and amounts over the $50,000 lifetime maximum *Once you have been billed $166 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.
PLAN N Medicare (Part A) Hospital Per Benefit Period Plan N HOSPITALIZATION* Semi-private room and board, general nursing and miscellaneous services and supplies First 60 days All but $1,288 $1,288 (Part A deductible) 61st thru 90th day All but $322 a day $322 a day 91st day and after: While using 60 lifetime reserve days All but $644 a day $644 a day Once lifetime reserve days are used: -Additional 365 days 100% of Medicare eligible expenses ** -Beyond the additional 365 days All costs SKILLED NURSING FACILITY CARE* You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare-approved facility within 30 days after leaving the hospital First 20 days All approved amounts 21st thru 100th day All but $161.00 a day Up to $161.00 a day 101st day and after All costs BLOOD First 3 pints 3 pints Additional amounts 100% HOSPICE CARE You must meet Medicare s requirements, All but very limited Medicare copayment/ including a doctor s certification of terminal copayment/coinsurance coinsurance illness for outpatient drugs and inpatient respite care *A Benefit Period begins on the first day you receive care as an inpatient in a hospital and ends after you have been out of the hospital and have not received skilled care in any other facility for 60 days in a row. **NOTICE When your Medicare Part A Hospital benefits are exhausted, the insurer stands in the place of Medicare and will pay whatever amount Medicare would have paid for up to an additional 365 days as provided in the policy s Core Benefits. During this time, the hospital is prohibited from billing you for the balance based on any difference between its billed charges and the amount Medicare would have paid.
PLAN N Medicare (Part B) Medical Per Calendar Year Plan N MEDICAL EXPENSES IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENTS, such as physician s services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment First $166 of Medicare-approved amounts* $166 (Part B deductible) Remainder of Medicare-approved amounts Generally 80% Balance, other than up to $20 per office visit and up to $50 per emergency room visit. The co-payment of up to $50 is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense. Up to $20 per office visit and up to $50 per emergency room visit. The copayment of up to $50 is waived if the insured is admitted to any hospital and the emergency visit is covered as a Medicare Part A expense. Part B Excess Charges (above Medicareapproved amounts) All costs BLOOD First 3 pints All costs Next $166 of Medicare-approved amounts* $166 (Part B deductible) Remainder of Medicare-approved amounts 80% 20% CLINICAL LABORATORY SERVICES Tests for diagnostic services 100% *Once you have been billed $166 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.
PLAN N (continued) PARTS A & B HOME HEALTH CARE Medicare Approved Medically necessary skilled care services and medical supplies Durable medical equipment: - First $166 of Medicare-approved amounts* - Remainder of Medicare-approved amounts Plan N 100% $166 (Part B Deductible) 80% 20% OTHER BENEFITS Not Covered by Medicare Plan N FOREIGN TRAVEL NOT COVERED BY MEDICARE Medically necessary emergency care services beginning during the first 60 days of each trip outside the USA First $250 each calendar year $250 Remainder of such charges 80% to a lifetime maximum benefit of $50,000 20% and amounts over the $50,000 lifetime maximum *Once you have been billed $166 of Medicare-approved amounts for covered services (which are noted with an asterisk), your Part B Deductible will have been met for the calendar year.
Guaranteed Issue Guidelines Questions? We re here to help. Just call us at 1-800-345-6022 (TTY: 711) FOR INDIVIDUALS WHO ARE 65 YEARS OF AGE OR OLDER AT THE TIME OF ENROLLMENT: In some situations, you are eligible for Guaranteed Issue of an Individual Medicare Supplement Plan. If one of the following conditions applies to you, you are eligible for an Aetna Individual Medicare Supplement Plan SM on a guaranteed issue basis ( Eligible Person ) and you will not be required to complete the Statement of Health Questions section of the Application. Open Enrollment - You are eligible for Guaranteed Issue if you are at least age 65 and apply for an Aetna Individual Medicare Supplement Plan insurance policy prior to or during the six-month period beginning with the first day of the month in which you are enrolled for benefits under Medicare Part B. You must submit evidence that you have Medicare Parts A and B with your Application. Other Situations - You are eligible for Guaranteed Issue for an Aetna Individual Medicare Supplement Plan insurance policy if you apply for the policy in the guarantee issue time periods described below, you submit evidence of the date of termination or disenrollment with the Application, and you meet one of the following conditions: 1. You are enrolled in an employee welfare benefit plan that provides health benefits that supplement the benefits under Medicare, and the plan terminates or ceases to provide such supplemental health benefits to you; or you are enrolled under an employee welfare benefit plan that is primary to Medicare and the plan terminates or the plan ceases to provide all health benefits to you because you leave the plan. 2. You are enrolled with a Medicare Advantage organization under a Medicare Advantage Plan (the Plan ) under Medicare Part C or you are 65 years of age or older and are enrolled under a Program of All-Inclusive Care for the Elderly (PACE) under section 1894 of the Social Security Act, and there are circumstances similar to the following that would permit discontinuance of your enrollment in such program if you were enrolled in a Medicare Advantage plan and any of the following apply: The certification of the organization or plan under this part has been terminated; or The organization has terminated or otherwise discontinued providing the Plan in the area in which you reside; or You are no longer eligible to elect the Plan because: (i) of a change in your place of residence or other change in circumstances specified by the Secretary of the Department of Health and Human (the Secretary ), excluding those circumstances where you were disenrolled from the Plan for any of the reasons described in Section 1851 (g)(3)(b) of the federal Social Security Act (e.g., where you have not paid premiums on a timely basis, or you have engaged in disruptive behavior as specified in standards under Section 1856); or (ii) the Plan is terminated for all enrollees residing within a particular residential service area; or GR-11613-03-OOC GI -TX 18.03.700.1-TX E (12/13)
You demonstrate, in accordance with guidelines established by the Secretary, that: (i) the organization offering the Plan substantially violated a material provision of the organization s misrepresented the Plan s provisions in marketing the Plan to you; or You meet such other exceptional conditions as the Secretary may provide. 3. You are enrolled with: An eligible organization under a contract under Section 1876 (Medicare cost); a similar organization operating under demonstration project authority, effective for periods before April 1, 1999; An organization under agreement under section 1833(a)(1 )(A) (health care prepayment plan); or an organization under a Medicare SELECT policy; and Your enrollment ceases under the same circumstances that would permit discontinuance of an individual s election of coverage under Section 2 above. 4. You are enrolled in a Medicare supplement policy and the enrollment ceases because: Of the insolvency of the issuer or bankruptcy of the non-issuer organization; or Of other involuntary termination of coverage or enrollment under the policy; or The issuer of the policy substantially violated a material provision of the policy; or The issuer or an agent or other entity acting on the issuer s behalf, materially misrepresented the policy s provisions in marketing the policy to you. 5. You were enrolled under a Medicare supplement policy and you terminate enrollment and subsequently enroll, for the first time, with: (1) any Medicare Advantage organization under a Medicare Advantage Plan under Medicare Part C; (2) any eligible organization under a contract under Section 1876 (Medicare cost); (3) any similar organization operating under demonstration project authority; (4) any PACE program under Section 1894 of the Social Security Act; (5) any organization under an agreement under Section 1833(a)(1)(A) (health care prepayment plan); or (6) a Medicare SELECT policy, and enrollment under this section is terminated by you during any period within the first 12 months of such subsequent enrollment (during which you are permitted to terminate such subsequent enrollment under Section 1851(e) of the federal Social Security Act). 6. You, upon first becoming enrolled for benefits under Medicare Part A B at age sixty-five or older, enroll in a Medicare Advantage Plan under Medicare Part C, or in a PACE program under Section 1894 of the Social Security Act, and disenroll from the plan by not later than 12 months after the effective date of enrollment. 7. You enroll in a Medicare Part D plan during the initial enrollment period and, at the time of enrollment in Part D were enrolled in a Medicare supplement policy that covers outpatient prescription drugs and you terminate enrollment in the Medicare supplement policy and submit evidence of enrollment in Medicare Part D along with the application for the policy. 8. You have lost eligibility for health benefits under Title XIX of the Social Security Act (Medicaid). GR-11613-03-OOC GI -TX 18.03.700.1-TX E (12/13)
--------------------------------------------------------------------------------------------------------------------------------------- Guaranteed Issue Time Periods In the case of an individual described in situation #1, the guaranteed issue period begins on the later of: (i) the date you receive a notice of termination or cessation of all supplemental health benefits (or, if a notice is not received, notice that a claim has been denied because of such a termination or cessation); or (ii) the date that the applicable coverage terminates or ceases; and ends sixty-three (63) days after the date of the applicable notice; In the case of an individual described in situations #2, #3, #5 or #6 whose enrollment terminated involuntarily, the guaranteed issue period begins on the date that you receive a notice of termination and ends sixty-three (63) days after the date the applicable coverage is terminated; In the case of an individual described in situation #4 (insolvency of the issuer or bankruptcy of the non-issuer organization), the guaranteed issue period begins on the earlier of: (i) the date that you receive a notice of termination, a notice of the issuer s bankruptcy or insolvency, or other such similar notice if any, and (ii) the date that the applicable coverage is terminated, and ends on the date that is sixty-three (63) days after the date the coverage is terminated; In the case of an individual described in situations #2, #4 (issuer or the policy substantially violated a material provision of the policy), #4 (the issuer or an agent or other entity acting on the issuer s behalf, materially misrepresented the policy s provisions in marketing the policy to you), #5 or #6, who disenrolls voluntarily, the guaranteed issue period begins on the date that is sixty (60) days before the effective date of the disenrollment and ends on the date that is sixty-three (63) days after the effective date; In the case of an individual described in situation #7, the guaranteed issue period begins on the date the individual receives notice pursuant to Section 1882(v)(2)(B) of the Social Security Act from the Medicare supplement issuer during the sixty day (60) period immediately preceding the initial enrollment period and ends on the date that is 63 days after the effective date of the individual s coverage under Medicare Part D; and In the case of an individual described in this Guaranteed Issue Guide but not described in the preceding situations, the guaranteed issue period begins on the effective date of disenrollment and ends on the date that is sixty-three (63) days after the effective date. Extended Medigap Access for Interrupted Trial Periods In the case of an individual described in situation #5, whose enrollment with an organization or provider described in item (1) is involuntarily terminated within the first twelve (12) months of enrollment, and who, without an intervening enrollment, enrolls with another such organization or provider, the subsequent enrollment shall be deemed to be an initial enrollment; In the case of an individual described in situation #6, whose enrollment with a plan or in a program described in situation #6 is involuntarily terminated within the first twelve (12) months of enrollment, and who, without an intervening enrollment, enrolls in another such plan or program, the subsequent enrollment shall be deemed to be an initial enrollment; and For the purposes of situations #5 and #6, no enrollment of an individual with an organization or provider described in #5 (1 through 6), or with a plan or in a program described in #6, may be deemed to be an initial enrollment under this paragraph after the two-year period beginning on the date on which you first enrolled with such an organization, provider, plan or program. GR-11613-03-OOC GI -TX 18.03.700.1-TX E (12/13)
Products to which Eligible Persons are Entitled The Aetna Individual Supplement Plan insurance policy to which Eligible Persons are entitled. During Open Enrollment An Eligible Person may enroll in Aetna Individual Medicare Supplement Plan insurance policy A, B, C, F, G or N. During Other Situations Under situations #1, #2, #3, #4 and #8, an Eligible Person may enroll in a Medicare supplement policy which has a benefit package classified as plan A, B, C, F or G. Under situation #5, an Eligible Person may enroll in the same Medicare supplement policy in which you were most recently previously enrolled, if available, or, if not so available, a policy described as plan A, B, C, F or G. Under situation #6, an Eligible Person may enroll in any Medicare supplement policy offered by Aetna Life Insurance Company. Under situation #7, an Eligible Person may enroll in a Medicare supplement policy that has a benefit package classified as Plan A, B or F and that is offered and is available for issuance to new enrollees by the same issuer that issued the individual's Medicare supplement policy with outpatient prescription drug coverage. FOR INDIVIDUALS WHO ARE LESS THAN AGE 65 AT THE TIME OF ENROLLMENT: If the following applies to you, you are eligible for Guaranteed Issue ( Eligible Person ). Enrollment is permitted only during the timeframe mentioned below. Open Enrollment - You are eligible for Guaranteed Issue if you become eligible for Medicare by reason of disability and you apply for an Aetna Individual Medicare Supplement Plan insurance policy prior to or during the six-month period beginning with the first day of the month in which you are enrolled for benefits under Medicare Part B. You must submit evidence that you have Medicare Parts A and B with your Application. The Application must be submitted within a six (6) month period beginning with the first day of the month in which you are enrolled for benefits under Medicare Part B. Other Situations - You are eligible for Guaranteed Issue for an Aetna Individual Medicare Supplement Plan insurance policy if you apply for the policy in the guarantee issue time periods described below, you submit evidence of the date of termination or disenrollment with the Application, and you meet one of the following conditions. If you lost coverage due to one of the events mentioned below, you will have 63 days from the date coverage ends or from the date of notice of termination of coverage to enroll. 1. You are enrolled in an employee welfare benefit plan that provides health benefits that supplement the benefits under Medicare, and the plan terminates or ceases to provide such supplemental health benefits to you; or you are enrolled under an employee welfare benefit plan that is primary to Medicare and the plan terminates or the plan ceases to provide all health benefits to you because you leave the plan. 2. You are enrolled with a Medicare Advantage organization under a Medicare Advantage Plan (the Plan ) under Medicare Part C or you are 65 years of age or older and are enrolled under a Program of All-Inclusive Care for the Elderly (PACE) under section 1894 of the Social Security Act, and there are circumstances similar to the following that would permit discontinuance of your enrollment in such program if you were enrolled in a Medicare Advantage plan and any of the following apply: GR-11613-03-OOC GI -TX 18.03.700.1-TX E (12/13)