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Columbia Mutual Medicare Supplement Plan Information
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Columbia Mutual Medicare Supplement Rates Rates effective 08/2011 Plan A MTC 20 Plan F MTC 24 Plan G MTC 25 Male / 65yr / Non-tobacco / zip codes 970-972 $95.95 $134.62 $110.06 Female / 65yr / Non-tobacco / zip codes 970-972 $83.48 $117.12 $95.75 Male / 65yr / Tobacco / zip codes 970-972 $110.29 $154.73 $126.51 Female / 65yr / Tobacco / zip codes 970-972 $95.95 $134.62 $110.06 Male / 65yr / Non-tobacco / zip codes 973-979 $92.26 $129.44 $105.83 Female / 65yr / Non-tobacco / zip codes 973-979 $80.27 $112.61 $92.07 Male / 65yr / Tobacco / zip codes 973-979 $106.05 $148.78 $121.64 Female / 65yr / Tobacco / zip codes 973-979 $92.26 $129.44 $105.83 Benefits Plan A Plan F Plan G Medicare Part A Coinsurance and Hospital Benefits Medicare Part A Deductible   Medicare Part B Coinsurance or Co-payment Medicare Part B Deductible     Medicare Part B Excess Charges   Blood (First Three Pints) Hospice Care Coinsurance or Co-payment Skilled Nursing Coinsurance   Foreign Travel Emergency (Up to Plan Limits)3   Medicare Preventive Care Part B Coinsurance

1. Medigap Plan F offers a high deductible option. You must pay for Medicare-covered costs up to the high-deductible amount ($2,070 in 2012) before your Medigap policy pays anything
2. 100% part B coinsurance except up to $20 copayment for office visits and up to $50 copayment for ER.
3. You must also pay a separate deductible for foreign travel emergency ($250 per year).
4. After you meet your out-of-pocket yearly limit and your yearly Part B deductible ($140 in 2012) the plan pays 100% of covered services for the rest of the calendar year (This applies only to plans K & L)
5. Modified Plan F offers an individual assistance program, as well as coverage for preventive dental care (available in some states)

• 2012 Out of Pocket Limit for Plan K is $4,660.
• 2012 Out of Pocket Limit for Plan L is $2,330.