Omaha Insurance Company A Mutual of Omaha Company … · 2017-09-22 · OUTLINE OF MEDICARE...
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VA OICH AGY 002 Omaha Insurance Company A Mutual of Omaha Company OUTLINE OF MEDICARE SUPPLEMENT COVERAGE – COVER PAGE BENEFIT PLANS A, F, HIGH DEDUCTIBLE F, G AND N 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 insureds to pay a portion of Part B coinsurance or copayments. Blood: First 3 pints of blood each year. Hospice: Part A coinsurance. Plan A Plan B Plan C Plan D Plan F F* Plan G Plan K Plan L Plan M Plan N Basic, including 100% Part B Coinsurance Basic, including 100% Part B Coinsurance Basic, including 100% Part B Coinsurance Basic, including 100% Part B Coinsurance Basic, including 100% Part B Coinsurance* Basic, including 100% Part B Coinsurance 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 Coinsurance, except up to $20 copayment for office visit, and up to $50 copayment 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 Coinsurance 75% Skilled Nursing Facility Coinsurance Skilled Nursing Facility Co- insurance Skilled Nursing Facility Coinsurance Part A Deductible Part A Deductible Part A Deductible Part A Deductible Part A Deductible 50% Part A Deductible 75% Part A Deductible 50% Part A Deductible Part A Deductible Part B Deductible Part B Deductible Part B Excess (100%) Part B Excess (100%) Foreign Travel Emergency Foreign Travel Emergency Foreign Travel Emergency Foreign Travel Emergency Foreign Travel Emergency Foreign Travel Emergency Out-of-pocket limit $4,960; paid at 100% after limit reached Out-of-pocket limit $2,480; paid at 100% after limit reached *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/certificate. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan's separate foreign travel emergency deductible. 1 VA_OIC_AGY_090116
Transcript of Omaha Insurance Company A Mutual of Omaha Company … · 2017-09-22 · OUTLINE OF MEDICARE...
VA OICH AGY 002
Omaha Insurance CompanyA Mutual of Omaha Company
OUTLINE OF MEDICARE SUPPLEMENT COVERAGE – COVER PAGEBENEFIT PLANS A, F, HIGH DEDUCTIBLE F, G AND N
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 beavailable 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 insureds to pay a portion of Part B coinsurance or copayments.Blood: First 3 pints of blood each year.Hospice: Part A coinsurance.Plan A Plan B Plan C Plan D Plan F F* Plan G Plan K Plan L Plan M Plan NBasic,including100% Part BCoinsurance
Basic,including100% Part BCoinsurance
Basic,including100% Part BCoinsurance
Basic,including100% Part BCoinsurance
Basic,including100% Part BCoinsurance*
Basic,including100% Part BCoinsurance
Hospitalization andpreventive care paidat 100%; other basicbenefits paid at 50%
Hospitalization andpreventive care paidat 100%; other basicbenefits paid at 75%
Basic, including100% Part B Co-insurance
Basic, including 100% PartB Coinsurance, except upto $20 copayment for officevisit, and up to $50copayment for ER
SkilledNursingFacility Co-insurance
SkilledNursingFacility Co-insurance
SkilledNursingFacility Co-insurance
SkilledNursingFacility Co-insurance
50% Skilled NursingFacility Coinsurance
75% Skilled NursingFacility Coinsurance
Skilled NursingFacility Co-insurance
Skilled Nursing FacilityCoinsurance
Part ADeductible
Part ADeductible
Part ADeductible
Part ADeductible
Part ADeductible
50% Part ADeductible
75% Part ADeductible
50% Part ADeductible
Part A Deductible
Part BDeductible
Part BDeductiblePart B Excess(100%)
Part B Excess(100%)
ForeignTravelEmergency
ForeignTravelEmergency
ForeignTravelEmergency
ForeignTravelEmergency
Foreign TravelEmergency
Foreign Travel Emergency
Out-of-pocket limit$4,960; paid at 100%after limit reached
Out-of-pocket limit$2,480; paid at 100%after limit reached
*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 $2,180deductible. 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 expensesthat would ordinarily be paid by the policy/certificate. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan's separateforeign travel emergency deductible.
1 VA_OIC_AGY_090116
VA OICH AGY 002
MONTHLY NON-TOBACCO PREMIUMS*ZIP CODES: 201, 22403, 22405-408, 22412, 22427-428, 22430, 22433, 22446, 22463, 22471, 22501, 22508, 22514, 22534-535, 22538, 22542, 22545-546, 22551-
556, 22565, 22567, 22580, 226-229, 23004, 23022, 23024, 23027, 23040, 23055, 23084, 23093, 23117, 23123, 23170, 238-246
FEMALE MALE
Plan A NM20
Plan F NM23
Plan High F NM34
Plan G NM24
Plan N NM35
Attained
Age
Plan A NM20
Plan F NM23
Plan High F NM34
Plan G NM24
Plan N NM35
87.15 126.30 35.09 96.10 76.76 65 100.17 145.18 40.33 110.45 88.2287.15 126.30 35.09 96.10 76.76 66 100.17 145.18 40.33 110.45 88.2287.15 126.30 35.09 96.10 76.76 67 100.17 145.18 40.33 110.45 88.2288.41 128.13 35.60 97.48 77.86 68 101.63 147.28 40.92 112.06 89.5089.99 130.42 36.23 99.23 79.25 69 103.43 149.90 41.64 114.04 91.0992.19 133.61 37.12 101.64 81.19 70 105.96 153.57 42.67 116.84 93.3395.02 137.71 38.26 104.77 83.69 71 109.22 158.29 43.97 120.44 96.1997.85 141.81 39.39 107.89 86.18 72 112.47 163.01 45.28 124.02 99.06100.97 146.33 40.65 111.33 88.92 73 116.06 168.19 46.72 127.96 102.21104.08 150.84 41.90 114.76 91.66 74 119.63 173.39 48.17 131.91 105.36107.20 155.35 43.16 118.20 94.41 75 123.22 178.57 49.61 135.86 108.52110.66 160.38 44.55 122.01 97.45 76 127.20 184.35 51.21 140.25 112.03114.12 165.39 45.94 125.83 100.50 77 131.17 190.10 52.81 144.63 115.52117.89 170.86 47.46 130.00 103.83 78 135.52 196.39 54.56 149.41 119.34121.67 176.33 48.98 134.15 107.15 79 139.85 202.68 56.30 154.20 123.16125.45 181.81 50.50 138.32 110.48 80 144.19 208.97 58.05 158.98 126.99129.22 187.28 52.02 142.48 113.81 81 148.53 215.26 59.80 163.77 130.81133.00 192.74 53.55 146.65 117.13 82 152.87 221.55 61.55 168.56 134.63136.76 198.22 55.06 150.81 120.45 83 157.21 227.84 63.29 173.35 138.45140.55 203.70 56.58 154.97 123.78 84 161.55 234.13 65.04 178.13 142.27143.36 207.76 57.72 158.07 126.25 85 164.78 238.82 66.34 181.69 145.12145.51 210.89 58.59 160.45 128.15 86 167.25 242.40 67.34 184.41 147.30147.70 214.05 59.46 162.85 130.07 87 169.76 246.03 68.35 187.18 149.51149.90 217.26 60.35 165.29 132.02 88 172.31 249.72 69.37 189.99 151.75152.16 220.52 61.26 167.77 134.00 89 174.89 253.47 70.41 192.84 154.03154.44 223.82 62.18 170.29 136.02 90 177.52 257.27 71.47 195.73 156.33156.75 227.18 63.11 172.84 138.05 91 180.18 261.13 72.54 198.68 158.68159.11 230.59 64.06 175.44 140.12 92 182.88 265.04 73.63 201.65 161.06161.49 234.04 65.02 178.07 142.23 93 185.62 269.01 74.73 204.67 163.48163.91 237.56 66.00 180.74 144.36 94 188.40 273.06 75.86 207.75 165.94166.37 241.12 66.98 183.45 146.53 95 191.23 277.14 76.99 210.85 168.42168.87 244.74 67.99 186.20 148.72 96 194.10 281.31 78.15 214.03 170.95171.40 248.41 69.01 188.99 150.95 97 197.02 285.53 79.32 217.23 173.50173.97 252.14 70.05 191.83 153.22 98 199.97 289.81 80.51 220.49 176.11176.59 255.92 71.09 194.71 155.51 99+ 202.97 294.16 81.71 223.80 178.75
*See PREMIUM INFORMATION regarding Risk Class and Household Premium Discount rating.
To obtain annual, semiannual, and quarterly premiums, multiply the above-quoted premiums by 12, 6, and 3, respectively.
2 VA_OIC_AGY_090116
VA OICH AGY 002
MONTHLY TOBACCO PREMIUMS*ZIP CODES: 201, 22403, 22405-408, 22412, 22427-428, 22430, 22433, 22446, 22463, 22471, 22501, 22508, 22514, 22534-535, 22538, 22542, 22545-546, 22551-
556, 22565, 22567, 22580, 226-229, 23004, 23022, 23024, 23027, 23040, 23055, 23084, 23093, 23117, 23123, 23170, 238-246
FEMALE MALE
Plan A NM20
Plan F NM23
Plan High F NM34
Plan G NM24
Plan N NM35
Attained
Age
Plan A NM20
Plan F NM23
Plan High F NM34
Plan G NM24
Plan N NM35
94.21 136.54 37.93 103.89 82.98 65 108.29 156.95 43.60 119.41 95.3894.21 136.54 37.93 103.89 82.98 66 108.29 156.95 43.60 119.41 95.3894.21 136.54 37.93 103.89 82.98 67 108.29 156.95 43.60 119.41 95.3895.58 138.52 38.48 105.39 84.18 68 109.87 159.22 44.23 121.14 96.7697.28 140.99 39.17 107.27 85.67 69 111.82 162.05 45.02 123.29 98.4799.66 144.44 40.13 109.88 87.77 70 114.55 166.02 46.12 126.32 100.89102.73 148.88 41.36 113.27 90.47 71 118.08 171.12 47.54 130.20 103.99105.78 153.31 42.59 116.64 93.17 72 121.59 176.22 48.95 134.08 107.09109.15 158.20 43.95 120.36 96.13 73 125.47 181.83 50.51 138.33 110.50112.52 163.07 45.30 124.07 99.10 74 129.33 187.45 52.07 142.61 113.91115.89 167.95 46.66 127.78 102.06 75 133.21 193.05 53.63 146.87 117.31119.63 173.38 48.16 131.91 105.35 76 137.51 199.29 55.37 151.62 121.11123.37 178.80 49.67 136.03 108.65 77 141.81 205.51 57.09 156.35 124.89127.45 184.72 51.31 140.54 112.25 78 146.51 212.32 58.98 161.53 129.02131.53 190.63 52.95 145.03 115.84 79 151.19 219.12 60.87 166.70 133.15135.62 196.55 54.60 149.54 119.44 80 155.88 225.91 62.76 171.87 137.29139.69 202.46 56.24 154.03 123.03 81 160.58 232.72 64.65 177.05 141.41143.78 208.37 57.89 158.54 126.63 82 165.27 239.51 66.54 182.23 145.55147.85 214.29 59.53 163.04 130.22 83 169.96 246.32 68.42 187.40 149.68151.95 220.21 61.17 167.54 133.82 84 174.65 253.11 70.31 192.57 153.81154.98 224.60 62.40 170.88 136.49 85 178.14 258.18 71.72 196.43 156.88157.30 227.98 63.34 173.45 138.54 86 180.81 262.05 72.80 199.36 159.24159.67 231.40 64.28 176.05 140.62 87 183.53 265.98 73.89 202.36 161.63162.06 234.88 65.25 178.69 142.73 88 186.28 269.97 75.00 205.39 164.05164.49 238.39 66.23 181.38 144.87 89 189.07 274.02 76.12 208.47 166.52166.96 241.97 67.22 184.10 147.04 90 191.91 278.13 77.26 211.60 169.01169.46 245.60 68.23 186.85 149.25 91 194.79 282.30 78.42 214.79 171.54172.01 249.28 69.25 189.66 151.48 92 197.71 286.53 79.60 218.00 174.12174.58 253.02 70.29 192.51 153.76 93 200.68 290.82 80.79 221.27 176.73177.20 256.82 71.35 195.39 156.07 94 203.68 295.20 82.01 224.59 179.39179.86 260.67 72.41 198.32 158.41 95 206.74 299.62 83.23 227.95 182.07182.57 264.58 73.50 201.29 160.78 96 209.84 304.12 84.48 231.38 184.81185.29 268.55 74.60 204.31 163.19 97 212.99 308.68 85.75 234.84 187.57188.07 272.58 75.73 207.38 165.64 98 216.18 313.31 87.04 238.37 190.39190.90 276.67 76.85 210.49 168.12 99+ 219.43 318.01 88.34 241.94 193.24
*See PREMIUM INFORMATION regarding Risk Class and Household Premium Discount rating.
To obtain annual, semiannual, and quarterly premiums, multiply the above-quoted premiums by 12, 6, and 3, respectively.
3 VA_OIC_AGY_090116
VA OICH AGY 002
MONTHLY NON-TOBACCO PREMIUMS*ZIP CODES: 220-223, 22401-402, 22404, 22432, 22435-438, 22442-443, 22448, 22451, 22454, 22456, 22460, 22469, 22472-473, 22476, 22480-482, 22485,
22488, 22503-504, 22507, 22509, 22511, 22513, 22517, 22520, 22523-524, 22526, 22528-530, 22539, 22544, 22547-548, 22558, 22560, 22570, 22572, 22576-579,
22581, 23001-003, 23005, 23009, 23011, 23014-015, 23018, 23021, 23023, 23025, 23030-23032
FEMALE MALE
Plan A NM20
Plan F NM23
Plan High F NM34
Plan G NM24
Plan N NM35
Attained
Age
Plan A NM20
Plan F NM23
Plan High F NM34
Plan G NM24
Plan N NM35
108.94 157.88 43.86 120.12 95.95 65 125.21 181.47 50.41 138.07 110.28108.94 157.88 43.86 120.12 95.95 66 125.21 181.47 50.41 138.07 110.28108.94 157.88 43.86 120.12 95.95 67 125.21 181.47 50.41 138.07 110.28110.52 160.17 44.49 121.85 97.33 68 127.03 184.10 51.15 140.07 111.88112.48 163.02 45.29 124.03 99.06 69 129.29 187.37 52.05 142.56 113.86115.23 167.01 46.40 127.05 101.49 70 132.45 191.96 53.33 146.05 116.66118.78 172.14 47.82 130.97 104.61 71 136.53 197.86 54.97 150.54 120.23122.31 177.27 49.24 134.87 107.72 72 140.59 203.76 56.60 155.03 123.82126.21 182.91 50.82 139.17 111.15 73 145.08 210.24 58.40 159.95 127.77130.10 188.55 52.38 143.45 114.58 74 149.54 216.74 60.21 164.89 131.71134.00 194.19 53.94 147.74 118.01 75 154.02 223.22 62.01 169.82 135.64138.33 200.47 55.69 152.52 121.81 76 159.00 230.43 64.02 175.31 140.03142.65 206.74 57.43 157.29 125.63 77 163.97 237.62 66.01 180.78 144.40147.37 213.58 59.33 162.49 129.79 78 169.40 245.49 68.20 186.77 149.18152.09 220.42 61.23 167.69 133.94 79 174.82 253.35 70.38 192.75 153.96156.81 227.27 63.13 172.90 138.10 80 180.24 261.21 72.56 198.73 158.74161.52 234.10 65.03 178.10 142.26 81 185.67 269.08 74.75 204.72 163.51166.25 240.93 66.93 183.31 146.42 82 191.09 276.93 76.93 210.70 168.29170.96 247.77 68.83 188.51 150.57 83 196.52 284.80 79.11 216.68 173.06175.69 254.62 70.73 193.72 154.73 84 201.94 292.66 81.30 222.66 177.84179.19 259.70 72.15 197.59 157.82 85 205.97 298.52 82.93 227.12 181.40181.88 263.61 73.23 200.56 160.18 86 209.06 303.00 84.18 230.51 184.12184.62 267.56 74.32 203.56 162.59 87 212.20 307.54 85.43 233.98 186.88187.38 271.58 75.44 206.61 165.03 88 215.39 312.15 86.72 237.49 189.68190.19 275.64 76.57 209.72 167.50 89 218.61 316.84 88.01 241.05 192.54193.05 279.78 77.72 212.86 170.02 90 221.90 321.58 89.33 244.67 195.42195.94 283.97 78.89 216.05 172.57 91 225.22 326.41 90.68 248.35 198.35198.89 288.23 80.07 219.29 175.15 92 228.60 331.30 92.04 252.06 201.33201.86 292.56 81.27 222.59 177.79 93 232.03 336.26 93.41 255.84 204.35204.89 296.94 82.49 225.92 180.45 94 235.51 341.32 94.82 259.68 207.42207.96 301.40 83.73 229.31 183.16 95 239.04 346.43 96.24 263.57 210.52211.09 305.92 84.99 232.75 185.90 96 242.63 351.64 97.68 267.54 213.69214.25 310.51 86.26 236.24 188.69 97 246.27 356.91 99.15 271.53 216.88217.46 315.17 87.56 239.78 191.52 98 249.96 362.27 100.64 275.61 220.14220.73 319.89 88.86 243.38 194.39 99+ 253.72 367.70 102.14 279.75 223.44
*See PREMIUM INFORMATION regarding Risk Class and Household Premium Discount rating.
To obtain annual, semiannual, and quarterly premiums, multiply the above-quoted premiums by 12, 6, and 3, respectively.
4 VA_OIC_AGY_090116
VA OICH AGY 002
MONTHLY TOBACCO PREMIUMS*ZIP CODES: 220-223, 22401-402, 22404, 22432, 22435-438, 22442-443, 22448, 22451, 22454, 22456, 22460, 22469, 22472-473, 22476, 22480-482, 22485,
22488, 22503-504, 22507, 22509, 22511, 22513, 22517, 22520, 22523-524, 22526, 22528-530, 22539, 22544, 22547-548, 22558, 22560, 22570, 22572, 22576-579,
22581, 23001-003, 23005, 23009, 23011, 23014-015, 23018, 23021, 23023, 23025, 23030-23032
FEMALE MALE
Plan A NM20
Plan F NM23
Plan High F NM34
Plan G NM24
Plan N NM35
Attained
Age
Plan A NM20
Plan F NM23
Plan High F NM34
Plan G NM24
Plan N NM35
117.77 170.68 47.41 129.86 103.73 65 135.36 196.19 54.50 149.26 119.22117.77 170.68 47.41 129.86 103.73 66 135.36 196.19 54.50 149.26 119.22117.77 170.68 47.41 129.86 103.73 67 135.36 196.19 54.50 149.26 119.22119.48 173.15 48.10 131.73 105.22 68 137.33 199.03 55.29 151.43 120.95121.60 176.24 48.96 134.09 107.09 69 139.77 202.56 56.27 154.11 123.09124.58 180.55 50.16 137.35 109.72 70 143.19 207.53 57.66 157.90 126.11128.41 186.10 51.70 141.58 113.09 71 147.59 213.90 59.42 162.75 129.98132.23 191.64 53.24 145.80 116.46 72 151.99 220.28 61.19 167.59 133.86136.44 197.74 54.94 150.45 120.16 73 156.84 227.29 63.14 172.92 138.13140.65 203.84 56.63 155.08 123.87 74 161.66 234.31 65.09 178.26 142.38144.87 209.93 58.32 159.72 127.58 75 166.51 241.32 67.04 183.59 146.64149.54 216.72 60.21 164.88 131.69 76 171.89 249.12 69.21 189.52 151.39154.22 223.50 62.08 170.04 135.81 77 177.26 256.89 71.37 195.44 156.11159.32 230.89 64.14 175.67 140.31 78 183.13 265.40 73.73 201.91 161.27164.42 238.29 66.19 181.29 144.80 79 188.99 273.90 76.08 208.38 166.44169.52 245.69 68.25 186.92 149.29 80 194.85 282.39 78.45 214.84 171.61174.62 253.08 70.30 192.54 153.79 81 200.72 290.90 80.81 221.31 176.77179.72 260.47 72.36 198.17 158.29 82 206.58 299.39 83.17 227.78 181.93184.82 267.86 74.41 203.80 162.78 83 212.45 307.90 85.53 234.25 187.09189.93 275.26 76.47 209.42 167.27 84 218.31 316.39 87.89 240.71 192.26193.72 280.76 78.00 213.61 170.61 85 222.67 322.73 89.65 245.53 196.10196.63 284.98 79.17 216.82 173.17 86 226.01 327.56 91.00 249.20 199.05199.59 289.26 80.35 220.07 175.77 87 229.41 332.48 92.36 252.95 202.04202.57 293.60 81.56 223.36 178.41 88 232.85 337.46 93.75 256.74 205.06205.62 297.99 82.78 226.72 181.08 89 236.33 342.52 95.15 260.59 208.15208.70 302.46 84.02 230.12 183.80 90 239.89 347.66 96.58 264.50 211.26211.83 306.99 85.29 233.56 186.56 91 243.48 352.88 98.03 268.48 214.43215.02 311.60 86.56 237.07 189.35 92 247.14 358.16 99.50 272.50 217.65218.23 316.28 87.86 240.64 192.20 93 250.84 363.53 100.99 276.58 220.92221.50 321.02 89.18 244.24 195.08 94 254.60 368.99 102.51 280.74 224.24224.83 325.84 90.52 247.90 198.01 95 258.43 374.52 104.04 284.94 227.59228.21 330.73 91.88 251.62 200.97 96 262.30 380.15 105.60 289.23 231.01231.62 335.69 93.25 255.39 203.99 97 266.24 385.85 107.19 293.55 234.46235.09 340.72 94.66 259.22 207.05 98 270.22 391.64 108.80 297.96 237.99238.63 345.83 96.07 263.12 210.15 99+ 274.29 397.51 110.42 302.43 241.55
*See PREMIUM INFORMATION regarding Risk Class and Household Premium Discount rating.
To obtain annual, semiannual, and quarterly premiums, multiply the above-quoted premiums by 12, 6, and 3, respectively.
5 VA_OIC_AGY_090116
VA OICH AGY 002
MONTHLY NON-TOBACCO PREMIUMS*ZIP CODES: 23035, 23038-039, 23043, 23045, 23047, 23050, 23056, 23058-072, 23075-076, 23079-081, 23083, 23085-086, 23089-092, 23101-103, 23105-116,
23119-120, 23124-131, 23138-141, 23146-150, 23153-156, 23160-163, 23168-169, 23173, 23175-178, 23180-181, 23183-188, 23190, 23192, 232 - 237
FEMALE MALE
Plan A NM20
Plan F NM23
Plan High F NM34
Plan G NM24
Plan N NM35
Attained
Age
Plan A NM20
Plan F NM23
Plan High F NM34
Plan G NM24
Plan N NM35
108.94 157.88 43.86 120.12 95.95 65 125.21 181.47 50.41 138.07 110.28108.94 157.88 43.86 120.12 95.95 66 125.21 181.47 50.41 138.07 110.28108.94 157.88 43.86 120.12 95.95 67 125.21 181.47 50.41 138.07 110.28110.52 160.17 44.49 121.85 97.33 68 127.03 184.10 51.15 140.07 111.88112.48 163.02 45.29 124.03 99.06 69 129.29 187.37 52.05 142.56 113.86115.23 167.01 46.40 127.05 101.49 70 132.45 191.96 53.33 146.05 116.66118.78 172.14 47.82 130.97 104.61 71 136.53 197.86 54.97 150.54 120.23122.31 177.27 49.24 134.87 107.72 72 140.59 203.76 56.60 155.03 123.82126.21 182.91 50.82 139.17 111.15 73 145.08 210.24 58.40 159.95 127.77130.10 188.55 52.38 143.45 114.58 74 149.54 216.74 60.21 164.89 131.71134.00 194.19 53.94 147.74 118.01 75 154.02 223.22 62.01 169.82 135.64138.33 200.47 55.69 152.52 121.81 76 159.00 230.43 64.02 175.31 140.03142.65 206.74 57.43 157.29 125.63 77 163.97 237.62 66.01 180.78 144.40147.37 213.58 59.33 162.49 129.79 78 169.40 245.49 68.20 186.77 149.18152.09 220.42 61.23 167.69 133.94 79 174.82 253.35 70.38 192.75 153.96156.81 227.27 63.13 172.90 138.10 80 180.24 261.21 72.56 198.73 158.74161.52 234.10 65.03 178.10 142.26 81 185.67 269.08 74.75 204.72 163.51166.25 240.93 66.93 183.31 146.42 82 191.09 276.93 76.93 210.70 168.29170.96 247.77 68.83 188.51 150.57 83 196.52 284.80 79.11 216.68 173.06175.69 254.62 70.73 193.72 154.73 84 201.94 292.66 81.30 222.66 177.84179.19 259.70 72.15 197.59 157.82 85 205.97 298.52 82.93 227.12 181.40181.88 263.61 73.23 200.56 160.18 86 209.06 303.00 84.18 230.51 184.12184.62 267.56 74.32 203.56 162.59 87 212.20 307.54 85.43 233.98 186.88187.38 271.58 75.44 206.61 165.03 88 215.39 312.15 86.72 237.49 189.68190.19 275.64 76.57 209.72 167.50 89 218.61 316.84 88.01 241.05 192.54193.05 279.78 77.72 212.86 170.02 90 221.90 321.58 89.33 244.67 195.42195.94 283.97 78.89 216.05 172.57 91 225.22 326.41 90.68 248.35 198.35198.89 288.23 80.07 219.29 175.15 92 228.60 331.30 92.04 252.06 201.33201.86 292.56 81.27 222.59 177.79 93 232.03 336.26 93.41 255.84 204.35204.89 296.94 82.49 225.92 180.45 94 235.51 341.32 94.82 259.68 207.42207.96 301.40 83.73 229.31 183.16 95 239.04 346.43 96.24 263.57 210.52211.09 305.92 84.99 232.75 185.90 96 242.63 351.64 97.68 267.54 213.69214.25 310.51 86.26 236.24 188.69 97 246.27 356.91 99.15 271.53 216.88217.46 315.17 87.56 239.78 191.52 98 249.96 362.27 100.64 275.61 220.14220.73 319.89 88.86 243.38 194.39 99+ 253.72 367.70 102.14 279.75 223.44
*See PREMIUM INFORMATION regarding Risk Class and Household Premium Discount rating.
To obtain annual, semiannual, and quarterly premiums, multiply the above-quoted premiums by 12, 6, and 3, respectively.
6 VA_OIC_AGY_090116
VA OICH AGY 002
MONTHLY TOBACCO PREMIUMS*ZIP CODES: 23035, 23038-039, 23043, 23045, 23047, 23050, 23056, 23058-072, 23075-076, 23079-081, 23083, 23085-086, 23089-092, 23101-103, 23105-116,
23119-120, 23124-131, 23138-141, 23146-150, 23153-156, 23160-163, 23168-169, 23173, 23175-178, 23180-181, 23183-188, 23190, 23192, 232 - 237
FEMALE MALE
Plan A NM20
Plan F NM23
Plan High F NM34
Plan G NM24
Plan N NM35
Attained
Age
Plan A NM20
Plan F NM23
Plan High F NM34
Plan G NM24
Plan N NM35
117.77 170.68 47.41 129.86 103.73 65 135.36 196.19 54.50 149.26 119.22117.77 170.68 47.41 129.86 103.73 66 135.36 196.19 54.50 149.26 119.22117.77 170.68 47.41 129.86 103.73 67 135.36 196.19 54.50 149.26 119.22119.48 173.15 48.10 131.73 105.22 68 137.33 199.03 55.29 151.43 120.95121.60 176.24 48.96 134.09 107.09 69 139.77 202.56 56.27 154.11 123.09124.58 180.55 50.16 137.35 109.72 70 143.19 207.53 57.66 157.90 126.11128.41 186.10 51.70 141.58 113.09 71 147.59 213.90 59.42 162.75 129.98132.23 191.64 53.24 145.80 116.46 72 151.99 220.28 61.19 167.59 133.86136.44 197.74 54.94 150.45 120.16 73 156.84 227.29 63.14 172.92 138.13140.65 203.84 56.63 155.08 123.87 74 161.66 234.31 65.09 178.26 142.38144.87 209.93 58.32 159.72 127.58 75 166.51 241.32 67.04 183.59 146.64149.54 216.72 60.21 164.88 131.69 76 171.89 249.12 69.21 189.52 151.39154.22 223.50 62.08 170.04 135.81 77 177.26 256.89 71.37 195.44 156.11159.32 230.89 64.14 175.67 140.31 78 183.13 265.40 73.73 201.91 161.27164.42 238.29 66.19 181.29 144.80 79 188.99 273.90 76.08 208.38 166.44169.52 245.69 68.25 186.92 149.29 80 194.85 282.39 78.45 214.84 171.61174.62 253.08 70.30 192.54 153.79 81 200.72 290.90 80.81 221.31 176.77179.72 260.47 72.36 198.17 158.29 82 206.58 299.39 83.17 227.78 181.93184.82 267.86 74.41 203.80 162.78 83 212.45 307.90 85.53 234.25 187.09189.93 275.26 76.47 209.42 167.27 84 218.31 316.39 87.89 240.71 192.26193.72 280.76 78.00 213.61 170.61 85 222.67 322.73 89.65 245.53 196.10196.63 284.98 79.17 216.82 173.17 86 226.01 327.56 91.00 249.20 199.05199.59 289.26 80.35 220.07 175.77 87 229.41 332.48 92.36 252.95 202.04202.57 293.60 81.56 223.36 178.41 88 232.85 337.46 93.75 256.74 205.06205.62 297.99 82.78 226.72 181.08 89 236.33 342.52 95.15 260.59 208.15208.70 302.46 84.02 230.12 183.80 90 239.89 347.66 96.58 264.50 211.26211.83 306.99 85.29 233.56 186.56 91 243.48 352.88 98.03 268.48 214.43215.02 311.60 86.56 237.07 189.35 92 247.14 358.16 99.50 272.50 217.65218.23 316.28 87.86 240.64 192.20 93 250.84 363.53 100.99 276.58 220.92221.50 321.02 89.18 244.24 195.08 94 254.60 368.99 102.51 280.74 224.24224.83 325.84 90.52 247.90 198.01 95 258.43 374.52 104.04 284.94 227.59228.21 330.73 91.88 251.62 200.97 96 262.30 380.15 105.60 289.23 231.01231.62 335.69 93.25 255.39 203.99 97 266.24 385.85 107.19 293.55 234.46235.09 340.72 94.66 259.22 207.05 98 270.22 391.64 108.80 297.96 237.99238.63 345.83 96.07 263.12 210.15 99+ 274.29 397.51 110.42 302.43 241.55
*See PREMIUM INFORMATION regarding Risk Class and Household Premium Discount rating.
To obtain annual, semiannual, and quarterly premiums, multiply the above-quoted premiums by 12, 6, and 3, respectively.
7 VA_OIC_AGY_090116
VA OIC AGY 002
Premium Information We, Omaha Insurance Company, can only raise your premium if we raise the premium for all policies like yours in the same geographic area of the state where you live. Your premium may change each year as you age. This change will only be made on the first renewal date that coincides with or follows each anniversary of the policy date. Schedules of rates may vary depending upon the policy date.
NOTE: While the cost of this policy at your present age may be lower than the cost of Medicare Supplement coverage that is based on issue age or community rated, it is important to compare the potential cost of these policies over the life of the coverage. Premiums for other Medicare Supplement policies that are issue age or community rated do not increase due to changes in your age.
Disclosures Use this outline to compare benefits and premiums among policies.
Risk Class Rating If, according to our underwriting standards, you are overweight or underweight for your height, you will be considered to be a greater insurable risk. In such a case, your premium will be priced either as Class I – 10% or Class II – 20% higher than the rates illustrated, based on your Body Mass Index (BMI) reading. Risk class rating will not be applicable when you apply for coverage during an open enrollment or guaranteed issue period.
Household Premium Discount You are eligible for a household premium discount if: (a) you reside with your spouse of any age, (b) you reside with your domestic partner of any age, or (c) for the past year you have resided with at least one, but not more than three, other adults who are age 60 or older. The discounted premium will be priced 12% lower than the rates illustrated. The policy’s household premium discount will be removed if the other adult or spouse no longer resides with you (other than in the case of his or her death).
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 your insurance company.
Right to Return Policy If you find that you are not satisfied with your policy, you may return it to Mutual of Omaha Plaza, Omaha, NE 68175. 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 The policy may not fully cover all of your medical costs. Neither we 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.
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.
Exclusions Exclusions apply to your coverage. Please be sure to review the exclusions in your policy. This policy does not cover Part A benefits for benefit periods that begin while this policy is not in force, and other exclusions apply.
8 VA_OIC_AGY_090116
VA OICH AGY 002
PLAN AMEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD
*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not receivedskilled care in any other facility for 60 days in a row.
Services Medicare Pays Plan A Pays You PayHOSPITALIZATION* - Semiprivate room and board, general nursing, and miscellaneous services and supplies
All but $1,288 $0 $1,288 (Part A deductible)All but $322 a day $322 a day $0
All but $644 a day $644 a day $0
$0 100% of Medicare-eligible expenses $0**
First 60 days61st through 90th day91st day and after(while using 60 lifetime reserve days): Once lifetime reserve days are used (Additional 365 days):Beyond the additional 365 days $0 $0 All costsSKILLED 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 $0 $021st through 100th day All but $161.00 a day $0 Up to $161.00 a day101st day and after $0 $0 All costsBLOODFirst 3 pints $0 3 pints $0Additional amounts 100% $0 $0HOSPICE CARE - You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.
All but very limited copayment/coinsurancefor outpatient drugs and inpatient respitecare
Medicare copayment/ coinsurance $0
** NOTICE: When your Medicare Part A hospital benefits are exhausted, we stand in the place of Medicare and will pay whatever amount Medicare would have paidup to an additional 365 days as provided in the policy’s/certificate’s “Core Benefits”. During this time the hospital is prohibited from billing you for the balance basedon any difference between its billed charges and the amount Medicare would have paid.
9 VA_OIC_AGY_090116
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PLAN AMEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR
*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 metfor the calendar year.
Services Medicare Pays Plan A Pays You PayMEDICAL EXPENSES - IN OR OUT OF THE HOSPITAL AND 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 equipmentFirst $166 of Medicare-approved amounts * $0 $0 $166 (Part B deductible)Remainder of Medicare-approved amounts Generally 80% Generally 20% $0Part B Excess Charges (above Medicare-approved amounts)
$0 $0 All costsBLOODFirst 3 pints $0 All costs $0Next $166 of Medicare-approved amounts * $0 $0 $166 (Part B deductible)Remainder of Medicare-approved amounts 80% 20% $0CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES
100% $0 $0
PARTS A AND B
HOME HEALTH CARE – MEDICARE-APPROVED SERVICESMedically necessary skilled care services andmedical supplies 100% $0 $0DURABLE MEDICAL EQUIPMENTFirst $166 of Medicare-approved amounts $0 $0 $166 (Part B deductible)Remainder of Medicare-approved amounts 80% 20% $0
10 VA_OIC_AGY_090116
VA OICH AGY 002
PLANS F AND HIGH DEDUCTIBLE FMEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD
*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not receivedskilled care in any other facility for 60 days in a row.
Services Medicare Pays Plan F Pays You Pay
Plan High Deductible FPays
(After you pay $2,180deductible***)
You Pay (Inaddition to
$2,180deductible***)
HOSPITALIZATION* - Semiprivate room and board, general nursing, and miscellaneous services and suppliesFirst 60 days All but $1,288 $1,288 (Part A
deductible)$0 $1,288 (Part A
deductible)$0
61st through 90th day All but $322 a day $322 a day $0 $322 a day $091st day and after(while using 60 lifetime reserve days): All but $644 a day $644 a day $0 $644 a day $0Once lifetime reserve days are used(Additional 365 days): $0
100% of Medicare-eligible expenses $0**
100% of Medicare-eligible expenses
$0**
Beyond the additional 365 days $0 $0 All costs $0 All costsSKILLED 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 $0 $0 $0 $021st through 100th day All but $161.00 a day Up to $161 a day $0 Up to $161 a day $0101st day and after $0 $0 All costs $0 All costsBLOODFirst 3 pints $0 3 pints $0 3 pints $0Additional amounts 100% $0 $0 $0 $0HOSPICE CARE - You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.
All but very limited copayment/coinsurance for outpatient drugsand inpatient respite care
Medicarecopayment/coinsurance
$0 Medicare copayment/coinsurance
$0
** NOTICE: When your Medicare Part A hospital benefits are exhausted, we stand in the place of Medicare and will pay whatever amount Medicare would have paidup to an additional 365 days as provided in the policy’s/certificate’s “Core Benefits”. During this time the hospital is prohibited from billing you for the balance basedon any difference between its billed charges and the amount Medicare would have paid.*** High deductible plan F 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 beginuntil out-of-pocket expenses exceed $2,180. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the policy/certificate. Theseexpenses include the Medicare deductibles for Part A and Part B, but do not include the plan's separate foreign travel emergency deductible.
11 VA_OIC_AGY_090116
VA OICH AGY 002
PLANS F AND HIGH DEDUCTIBLE FMEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR
*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 metfor the calendar year.
Services Medicare Pays Plan F Pays You Pay
Plan High Deductible FPays
(After you pay $2,180deductible***)
You Pay (Inaddition to $2,180
deductible***)MEDICAL EXPENSES - IN OR OUT OF THE HOSPITAL AND 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 equipmentFirst $166 of Medicare-approved amounts * $0 $166 (Part B deductible) $0 $166 (Part B deductible) $0Remainder of Medicare-approved amounts Generally 80% Generally 20% $0 Generally 20% $0Part B Excess Charges (above Medicare-approved amounts)
$0 100% $0 100% $0BLOODFirst 3 pints $0 All costs $0 All costs $0Next $166 of Medicare-approved amounts * $0 $166 (Part B deductible) $0 $166 (Part B deductible) $0Remainder of Medicare-approved amounts 80% 20% $0 20% $0CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES
100% $0 $0 $0 $0
PARTS A AND B
HOME HEALTH CARE – MEDICARE-APPROVED SERVICESMedically necessary skilled care services andmedical supplies 100% $0 $0 $0 $0DURABLE MEDICAL EQUIPMENTFirst $166 of Medicare-approved amounts $0 $166 (Part B deductible) $0 $166 (Part B deductible) $0Remainder of Medicare-approved amounts 80% 20% $0 20% $0*** High deductible plan F 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/ certificate. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan's separate foreign travel emergency deductible.
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VA OICH AGY 002
PLANS F AND HIGH DEDUCTIBLE FMEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR
OTHER BENEFITS – NOT COVERED BY MEDICARE
Services Medicare Pays Plan F Pays You Pay
Plan High Deductible FPays
(After you pay $2,180deductible***)
You Pay (In addition to$2,180 deductible***)
FOREIGN TRAVEL – NOT COVERED BY MEDICAREMedically necessary emergency care services beginning during the first 60 days of each trip outside the USAFirst $250 each calendar year $0 $0 $250 $0 $250Remainder of charges $0 80% to a lifetime maximum
benefit of $50,00020% and amountsover the $50,000lifetime maximumbenefit
80% to a lifetimemaximum benefit of$50,000
20% and amounts over the$50,000 lifetime maximumbenefit
*** High deductible plan F 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/certificate. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan's separate foreign travel emergency deductible.
13 VA_OIC_AGY_090116
VA OICH AGY 002
PLANS G AND NMEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD
*A benefit period begins on the first day you receive service as an inpatient in a hospital and ends after you have been out of the hospital and have not receivedskilled care in any other facility for 60 days in a row.
Services Medicare Pays Plan G Pays You Pay Plan N Pays You PayHOSPITALIZATION* - Semiprivate room and board, general nursing, and miscellaneous services and suppliesFirst 60 days All but $1,288 $1,288 (Part A
deductible)$0 $1,288 (Part A
deductible)$0
61st through 90th day All but $322 a day $322 a day $0 $322 a day $091st day and after(while using 60 lifetime reserve days): All but $644 a day $644 a day $0 $644 a day $0Once lifetime reserve days are used(Additional 365 days): $0
100% of Medicare-eligible expenses $0**
100% of Medicare-eligible expenses $0**
Beyond the additional 365 days $0 $0 All costs $0 All costsSKILLED 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 $0 $0 $0 $021st through 100th day All but $161.00 a day Up to $161 a day $0 Up to $161 a day $0101st day and after $0 $0 All costs $0 All costsBLOODFirst 3 pints $0 3 pints $0 3 pints $0Additional amounts 100% $0 $0 $0 $0HOSPICE CARE - You must meet Medicare’s requirements, including a doctor’s certification of terminal illness.
All but very limitedcopayment/ coinsurance foroutpatient drugs and inpatientrespite care
Medicare copayment/coinsurance
$0 Medicare copayment/coinsurance
$0
** NOTICE: When your Medicare Part A hospital benefits are exhausted, we stand in the place of Medicare and will pay whatever amount Medicare would have paidup to an additional 365 days as provided in the policy’s/certificate’s “Core Benefits”. During this time the hospital is prohibited from billing you for the balance basedon any difference between its billed charges and the amount Medicare would have paid.
14 VA_OIC_AGY_090116
VA OICH AGY 002
PLANS G AND NMEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR
*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 metfor the calendar year.
Services Medicare Pays Plan G Pays You Pay Plan N Pays You PayMEDICAL EXPENSES - IN OR OUT OF THE HOSPITAL AND 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 equipmentFirst $166 of Medicare-approvedamounts *
$0 $0 $166 (Part Bdeductible)
$0 $166 (Part B deductible)
Remainder of Medicare-approvedamounts
Generally 80% Generally 20% $0 Balance, other than up to $20per office visit and up to $50per emergency room visit.The copayment of up to $50is waived if the insured isadmitted to any hospital andthe emergency visit iscovered as a Medicare Part Aexpense.
Up to $20 per office visit andup to $50 per emergencyroom visit. The copaymentof up to $50 is waived if theinsured is admitted to anyhospital and the emergencyvisit is covered as aMedicare Part A expense.
Part B Excess Charges (above Medicare-approved amounts)$0 100% $0 $0 All costs
BLOODFirst 3 pints $0 All costs $0 All costs $0Next $166 of Medicare-approvedamounts *
$0 $0 $166 (Part Bdeductible)
$0 $166 (Part B deductible)
Remainder of Medicare-approvedamounts
80% 20% $0 20% $0
CLINICAL LABORATORY SERVICES - TESTS FOR DIAGNOSTIC SERVICES
100% $0 $0 $0 $0
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VA OICH AGY 002
PLANS G AND NMEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR
PARTS A AND B
Services Medicare Pays Plan G Pays You Pay Plan N Pays You PayHOME HEALTH CARE – MEDICARE-APPROVED SERVICESMedically necessary skilled careservices and medical supplies 100% $0 $0 $0 $0DURABLE MEDICAL EQUIPMENTFirst $166 of Medicare-approvedamounts
$0 $0 $166 (Part Bdeductible)
$0 $166 (Part B deductible)
Remainder of Medicare-approvedamounts
80% 20% $0 20% $0
OTHER BENEFITS – NOT COVERED BY MEDICARE
Services Medicare Pays Plan G Pays You Pay Plan N Pays You PayFOREIGN TRAVEL – NOT COVERED BY MEDICAREMedically necessary emergency care services beginning during the first 60 days of each trip outside the USAFirst $250 each calendar year $0 $0 $250 $0 $250Remainder of charges $0 80% to a lifetime
maximum benefit of$50,000
20% and amountsover the $50,000lifetime maximumbenefit
80% to a lifetimemaximum benefit of$50,000
20% and amounts over the$50,000 lifetime maximumbenefit
16 VA_OIC_AGY_090116
