Form Title: 18 pt - Member Login - United Commercial …access.uct.org/agentdownloadformspdf/Microsoft Word Docs... · Web viewOutline of Medicare Supplement Coverage – Cover Page:

Home Office:1801 Watermark Drive, Suite 100, P.O. Box 159019, Columbus, OH 43215(614) 487-9680 • Toll-free: (800) 848-0123 • Fax: (614) 487-9675

Outline of Medicare Supplement Coverage – Cover Page: 1 of 2Benefit Plans A, B, C, D, F and G

See Outlines of Coverage sections for details about ALL plans.

Basic Benefits for Plans A-J: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.Blood: First three pints of blood each year.

A B C D E F F* G H I J J*Basic Benefits Basic Benefits Basic Benefits Basic Benefits Basic Benefits Basic Benefits Basic Benefits Basic Benefits Basic Benefits Basic Benefits

Skilled NursingFacility Coinsurance

Skilled Nursing Facility Coinsurance







Part A Deductible

Part A Deductible

Part A Deductible

Part A Deductible

Part A Deductible

Part A Deductible

Part A Deductible

Part A Deductible

Part A Deductible

Part B Deductible

Part B Deductible

Part B Deductible

Part B Excess (100%)

Part B Excess (80%)



Foreign Travel Emergency








At-Home Recovery

At-Home Recovery

At-Home Recovery

At-Home Recovery

Preventive Care NOT covered by Medicare

Preventive Care NOT covered by Medicare

* Plans F and J also have an option called a high deductible Plan F and a high deductible Plan J. These high deductible plans pay the same or offer the same benefits as Plans F and J after one has paid a calendar year $2,000 deductible. Benefits from high deductible Plans F and J will not begin until out-of-pocket expenses are $2,000. 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 does not include, in Plan J, the plan’s separate prescription drug deductible or, in Plans F and J, the plan’s separate foreign emergency deductible.

MSA OC 10 IN Effective 1-1-10 Page 1

These charts show the benefits included in each Medicare supplement plans.Every company must make available Plan “A”. Some plans may not be available in your state.


Outline of Medicare Supplement Coverage – Cover Page 2Basic Benefits for Plans K and L include similar services as plans A-J, but cost-sharing for the basic benefits is at different levels.

J K** L**

Basic Benefits

100% of Part A Hospitalization Coinsurance plus coverage for 365 Days after Medicare Benefits End

50% Hospice cost-sharing

50% of Medicare-eligible expenses for the first three pints of blood

50% Part B Coinsurance, except 100% Coinsurance for Part B Preventive Services

100% of Part A Hospitalization Coinsurance plus coverage for 365 Days after Medicare Benefits End

75% Hospice cost-sharing

75% of Medicare-eligible expenses for the first three pints of blood

75% Part B Coinsurance, except 100% Coinsurance for Part B Preventive Services

Skilled Nursing Coinsurance 50% Skilled Nursing Facility Coinsurance 75% Skilled Nursing Facility CoinsurancePart A Deductible 50% Part A Deductible 75% Part A DeductiblePart B DeductiblePart B Excess (100%)Foreign Travel EmergencyAt-Home RecoveryPreventative Care NOT covered by Medicare

$4,620 Out of Pocket Annual Limit *** $2,310 Out of Policy Annual Limit ***

** Plans K and L provide for different cost-sharing for items and services than Plans A-J. Once you reach the annual limit, the plans pays 100% of the Medicare copayments, coinsurances, and deductibles for the rest of the calendar year. The out-of-pocket annual limit does NOT include charges from your provider that exceed Medicare-approved amounts, called “Excess Charges.” You will be responsible for paying excess charges.

*** The out-of-pocket annual limit will increase each year for inflation.

See Outlines of Coverage for details and exceptions.

MSA OC 10 IN Effective 1-1-10 Page 2


Annual Non-Smoker Premium RatesFor Use In Indiana Zip Codes

46400-46499

Attained Age Plan A Plan B Plan C Plan D Plan F Plan GFemale Male Female Male Female Male Female Male Female Male Female Male

65 $1,213.73 $1,395.81 $1,566.31 $1,801.25 $1,878.35 $2,160.10 $1,719.21 $1,977.10 $1,929.83 $2,219.29 $1,563.16 $1,797.6366 $1,273.03 $1,463.99 $1,645.89 $1,892.78 $1,967.26 $2,262.37 $1,809.70 $2,081.16 $2,020.32 $2,323.36 $1,636.44 $1,881.9267 $1,330.75 $1,530.36 $1,725.44 $1,984.28 $2,054.64 $2,362.84 $1,898.62 $2,183.43 $2,110.81 $2,427.42 $1,709.74 $1,966.2168 $1,390.03 $1,598.54 $1,805.02 $2,075.78 $2,142.00 $2,463.31 $1,987.55 $2,285.69 $2,201.28 $2,531.50 $1,783.03 $2,050.5069 $1,447.76 $1,664.93 $1,884.58 $2,167.28 $2,230.93 $2,565.59 $2,076.49 $2,387.97 $2,291.76 $2,635.52 $1,856.34 $2,134.7770 $1,503.93 $1,729.51 $1,962.59 $2,256.98 $2,316.73 $2,664.24 $2,165.42 $2,490.23 $2,380.69 $2,737.80 $1,928.36 $2,217.6171 $1,558.52 $1,792.30 $2,039.05 $2,344.91 $2,402.54 $2,762.93 $2,251.20 $2,588.88 $2,469.61 $2,840.05 $2,000.39 $2,300.4572 $1,611.56 $1,853.30 $2,113.92 $2,431.01 $2,486.78 $2,859.82 $2,337.02 $2,687.57 $2,555.42 $2,938.76 $2,069.89 $2,380.3873 $1,661.49 $1,910.72 $2,187.26 $2,515.34 $2,569.47 $2,954.90 $2,419.71 $2,782.66 $2,639.69 $3,035.64 $2,138.13 $2,458.8774 $1,709.86 $1,966.32 $2,257.45 $2,596.07 $2,649.03 $3,046.38 $2,499.26 $2,874.14 $2,722.35 $3,130.71 $2,205.12 $2,535.8775 $1,755.11 $2,018.37 $2,324.54 $2,673.23 $2,725.48 $3,134.31 $2,575.72 $2,962.08 $2,800.38 $3,220.44 $2,268.30 $2,608.5476 $1,798.77 $2,068.59 $2,388.49 $2,746.77 $2,798.80 $3,218.63 $2,649.03 $3,046.38 $2,875.25 $3,306.54 $2,328.95 $2,678.2877 $1,837.78 $2,113.45 $2,447.78 $2,814.95 $2,867.45 $3,297.56 $2,717.70 $3,125.35 $2,947.01 $3,389.06 $2,387.09 $2,745.1578 $1,872.11 $2,152.92 $2,503.96 $2,879.55 $2,932.96 $3,372.93 $2,781.64 $3,198.89 $3,012.54 $3,464.42 $2,440.17 $2,806.1979 $1,903.31 $2,188.81 $2,555.42 $2,938.76 $2,992.26 $3,441.12 $2,840.94 $3,267.09 $3,074.95 $3,536.18 $2,490.71 $2,864.3180 $1,931.38 $2,221.09 $2,600.66 $2,990.77 $3,048.43 $3,505.68 $2,895.53 $3,329.87 $3,131.13 $3,600.80 $2,536.19 $2,916.6381 $1,953.23 $2,246.22 $2,642.79 $3,039.22 $3,098.34 $3,563.11 $2,943.91 $3,385.50 $3,182.59 $3,659.99 $2,577.90 $2,964.5882 $1,976.64 $2,273.14 $2,683.36 $3,085.88 $3,146.73 $3,618.75 $2,992.26 $3,441.12 $3,232.51 $3,717.40 $2,618.32 $3,011.0883 $2,000.04 $2,300.03 $2,722.35 $3,130.71 $3,195.06 $3,674.32 $3,039.06 $3,494.91 $3,282.43 $3,774.81 $2,658.77 $3,057.5984 $2,021.87 $2,325.17 $2,761.35 $3,175.56 $3,241.88 $3,728.16 $3,084.30 $3,546.95 $3,330.81 $3,830.43 $2,697.97 $3,102.6685 $2,045.29 $2,352.09 $2,800.38 $3,220.44 $3,287.12 $3,780.19 $3,128.00 $3,597.20 $3,377.61 $3,884.24 $2,735.85 $3,146.2386 $2,068.68 $2,378.98 $2,836.24 $3,261.69 $3,332.37 $3,832.23 $3,166.98 $3,642.04 $3,424.41 $3,938.08 $2,773.78 $3,189.8487 $2,092.07 $2,405.90 $2,873.68 $3,304.75 $3,376.05 $3,882.46 $3,202.87 $3,683.31 $3,468.09 $3,988.29 $2,809.14 $3,230.5488 $2,113.92 $2,431.01 $2,908.01 $3,344.22 $3,416.61 $3,929.11 $3,237.19 $3,722.77 $3,511.79 $4,038.55 $2,844.53 $3,271.2189 $2,137.30 $2,457.91 $2,940.77 $3,381.88 $3,457.17 $3,975.74 $3,271.52 $3,762.26 $3,552.35 $4,085.20 $2,877.40 $3,309.0090 $2,160.72 $2,484.82 $2,973.55 $3,419.58 $3,496.18 $4,020.59 $3,302.73 $3,798.13 $3,591.34 $4,130.05 $2,908.97 $3,345.3291 $2,182.56 $2,509.96 $3,004.75 $3,455.45 $3,532.04 $4,061.86 $3,332.37 $3,832.23 $3,628.77 $4,173.09 $2,939.32 $3,380.2092 $2,205.97 $2,536.86 $3,034.38 $3,489.53 $3,566.38 $4,101.34 $3,358.89 $3,862.72 $3,664.66 $4,214.36 $2,968.38 $3,413.6493 $2,229.36 $2,563.77 $3,062.46 $3,521.85 $3,600.69 $4,140.78 $3,385.41 $3,893.22 $3,698.99 $4,253.84 $2,996.17 $3,445.6094 $2,251.20 $2,588.88 $3,088.99 $3,552.34 $3,630.34 $4,174.90 $3,408.79 $3,920.11 $3,730.19 $4,289.72 $3,021.46 $3,474.6895 $2,274.60 $2,615.79 $3,115.52 $3,582.86 $3,659.98 $4,208.97 $3,430.64 $3,945.25 $3,759.84 $4,323.81 $3,045.46 $3,502.2896 $2,296.47 $2,640.93 $3,140.47 $3,611.56 $3,689.62 $4,243.07 $3,450.93 $3,968.58 $3,791.04 $4,359.70 $3,070.75 $3,531.3597 $2,319.85 $2,667.84 $3,166.98 $3,642.04 $3,719.28 $4,277.16 $3,472.77 $3,993.71 $3,820.67 $4,393.78 $3,094.73 $3,558.9598 $2,343.27 $2,694.76 $3,193.53 $3,672.56 $3,748.90 $4,311.24 $3,494.62 $4,018.81 $3,851.87 $4,429.65 $3,120.01 $3,588.0399 $2,366.67 $2,721.68 $3,218.47 $3,701.24 $3,780.11 $4,347.12 $3,518.02 $4,045.72 $3,883.08 $4,465.53 $3,145.28 $3,617.09

MODAL FACTORS Semi Annual – 0.51500 Quarterly – 0.26250 Direct Monthly – 0.10000 Monthly EFT – 0.08333

MSA OC 10 IN For new business issued 11/1/2009 or later Page 3



46000-46399, 47100-47199, 47800-47899


65 $1,092.36 $1,256.23 $1,409.68 $1,621.13 $1,690.52 $1,944.09 $1,547.29 $1,779.39 $1,736.85 $1,997.36 $1,406.84 $1,617.8766 $1,145.73 $1,317.59 $1,481.30 $1,703.50 $1,770.53 $2,036.13 $1,628.73 $1,873.04 $1,818.29 $2,091.02 $1,472.80 $1,693.7367 $1,197.68 $1,377.32 $1,552.90 $1,785.85 $1,849.18 $2,126.56 $1,708.76 $1,965.09 $1,899.73 $2,184.68 $1,538.77 $1,769.5968 $1,251.03 $1,438.69 $1,624.52 $1,868.20 $1,927.80 $2,216.98 $1,788.80 $2,057.12 $1,981.15 $2,278.35 $1,604.73 $1,845.4569 $1,302.98 $1,498.44 $1,696.12 $1,950.55 $2,007.84 $2,309.03 $1,868.84 $2,149.17 $2,062.58 $2,371.97 $1,670.71 $1,921.2970 $1,353.54 $1,556.56 $1,766.33 $2,031.28 $2,085.06 $2,397.82 $1,948.88 $2,241.21 $2,142.62 $2,464.02 $1,735.52 $1,995.8571 $1,402.67 $1,613.07 $1,835.15 $2,110.42 $2,162.29 $2,486.64 $2,026.08 $2,329.99 $2,222.65 $2,556.05 $1,800.35 $2,070.4172 $1,450.40 $1,667.97 $1,902.53 $2,187.91 $2,238.10 $2,573.84 $2,103.32 $2,418.81 $2,299.88 $2,644.88 $1,862.90 $2,142.3473 $1,495.34 $1,719.65 $1,968.53 $2,263.81 $2,312.52 $2,659.41 $2,177.74 $2,504.39 $2,375.72 $2,732.08 $1,924.32 $2,212.9874 $1,538.87 $1,769.69 $2,031.71 $2,336.46 $2,384.13 $2,741.74 $2,249.33 $2,586.73 $2,450.12 $2,817.64 $1,984.61 $2,282.2875 $1,579.60 $1,816.53 $2,092.09 $2,405.91 $2,452.93 $2,820.88 $2,318.15 $2,665.87 $2,520.34 $2,898.40 $2,041.47 $2,347.6976 $1,618.89 $1,861.73 $2,149.64 $2,472.09 $2,518.92 $2,896.77 $2,384.13 $2,741.74 $2,587.73 $2,975.89 $2,096.06 $2,410.4577 $1,654.00 $1,902.11 $2,203.00 $2,533.46 $2,580.71 $2,967.80 $2,445.93 $2,812.82 $2,652.31 $3,050.15 $2,148.38 $2,470.6478 $1,684.90 $1,937.63 $2,253.56 $2,591.60 $2,639.66 $3,035.64 $2,503.48 $2,879.00 $2,711.29 $3,117.98 $2,196.15 $2,525.5779 $1,712.98 $1,969.93 $2,299.88 $2,644.88 $2,693.03 $3,097.01 $2,556.85 $2,940.38 $2,767.46 $3,182.56 $2,241.64 $2,577.8880 $1,738.24 $1,998.98 $2,340.59 $2,691.69 $2,743.59 $3,155.11 $2,605.98 $2,996.88 $2,818.02 $3,240.72 $2,282.57 $2,624.9781 $1,757.91 $2,021.60 $2,378.51 $2,735.30 $2,788.51 $3,206.80 $2,649.52 $3,046.95 $2,864.33 $3,293.99 $2,320.11 $2,668.1282 $1,778.98 $2,045.83 $2,415.02 $2,777.29 $2,832.06 $3,256.88 $2,693.03 $3,097.01 $2,909.26 $3,345.66 $2,356.49 $2,709.9783 $1,800.04 $2,070.03 $2,450.12 $2,817.64 $2,875.55 $3,306.89 $2,735.15 $3,145.42 $2,954.19 $3,397.33 $2,392.89 $2,751.8384 $1,819.68 $2,092.65 $2,485.22 $2,858.00 $2,917.69 $3,355.34 $2,775.87 $3,192.26 $2,997.73 $3,447.39 $2,428.17 $2,792.3985 $1,840.76 $2,116.88 $2,520.34 $2,898.40 $2,958.41 $3,402.17 $2,815.20 $3,237.48 $3,039.85 $3,495.82 $2,462.27 $2,831.6186 $1,861.81 $2,141.08 $2,552.62 $2,935.52 $2,999.13 $3,449.01 $2,850.28 $3,277.84 $3,081.97 $3,544.27 $2,496.40 $2,870.8687 $1,882.86 $2,165.31 $2,586.31 $2,974.28 $3,038.45 $3,494.21 $2,882.58 $3,314.98 $3,121.28 $3,589.46 $2,528.23 $2,907.4988 $1,902.53 $2,187.91 $2,617.21 $3,009.80 $3,074.95 $3,536.20 $2,913.47 $3,350.49 $3,160.61 $3,634.70 $2,560.08 $2,944.0989 $1,923.57 $2,212.12 $2,646.69 $3,043.69 $3,111.45 $3,578.17 $2,944.37 $3,386.03 $3,197.12 $3,676.68 $2,589.66 $2,978.1090 $1,944.65 $2,236.34 $2,676.20 $3,077.62 $3,146.56 $3,618.53 $2,972.46 $3,418.32 $3,232.21 $3,717.05 $2,618.07 $3,010.7991 $1,964.30 $2,258.96 $2,704.28 $3,109.91 $3,178.84 $3,655.67 $2,999.13 $3,449.01 $3,265.89 $3,755.78 $2,645.39 $3,042.1892 $1,985.37 $2,283.17 $2,730.94 $3,140.58 $3,209.74 $3,691.21 $3,023.00 $3,476.45 $3,298.19 $3,792.92 $2,671.54 $3,072.2893 $2,006.42 $2,307.39 $2,756.21 $3,169.67 $3,240.62 $3,726.70 $3,046.87 $3,503.90 $3,329.09 $3,828.46 $2,696.55 $3,101.0494 $2,026.08 $2,329.99 $2,780.09 $3,197.11 $3,267.31 $3,757.41 $3,067.91 $3,528.10 $3,357.17 $3,860.75 $2,719.31 $3,127.2195 $2,047.14 $2,354.21 $2,803.97 $3,224.57 $3,293.98 $3,788.07 $3,087.58 $3,550.73 $3,383.86 $3,891.43 $2,740.91 $3,152.0596 $2,066.82 $2,376.84 $2,826.42 $3,250.40 $3,320.66 $3,818.76 $3,105.84 $3,571.72 $3,411.94 $3,923.73 $2,763.68 $3,178.2297 $2,087.87 $2,401.06 $2,850.28 $3,277.84 $3,347.35 $3,849.44 $3,125.49 $3,594.34 $3,438.60 $3,954.40 $2,785.26 $3,203.0698 $2,108.94 $2,425.28 $2,874.18 $3,305.30 $3,374.01 $3,880.12 $3,145.16 $3,616.93 $3,466.68 $3,986.69 $2,808.01 $3,229.2399 $2,130.00 $2,449.51 $2,896.62 $3,331.12 $3,402.10 $3,912.41 $3,166.22 $3,641.15 $3,494.77 $4,018.98 $2,830.75 $3,255.38





All Other Zip Codes


65 $970.98 $1,116.65 $1,253.05 $1,441.00 $1,502.68 $1,728.08 $1,375.37 $1,581.68 $1,543.86 $1,775.43 $1,250.53 $1,438.1066 $1,018.42 $1,171.19 $1,316.71 $1,514.22 $1,573.81 $1,809.90 $1,447.76 $1,664.93 $1,616.26 $1,858.69 $1,309.15 $1,505.5467 $1,064.60 $1,224.29 $1,380.35 $1,587.42 $1,643.71 $1,890.27 $1,518.90 $1,746.74 $1,688.65 $1,941.94 $1,367.79 $1,572.9768 $1,112.02 $1,278.83 $1,444.02 $1,660.62 $1,713.60 $1,970.65 $1,590.04 $1,828.55 $1,761.02 $2,025.20 $1,426.42 $1,640.4069 $1,158.21 $1,331.94 $1,507.66 $1,733.82 $1,784.74 $2,052.47 $1,661.19 $1,910.38 $1,833.41 $2,108.42 $1,485.07 $1,707.8270 $1,203.14 $1,383.61 $1,570.07 $1,805.58 $1,853.38 $2,131.39 $1,732.34 $1,992.18 $1,904.55 $2,190.24 $1,542.69 $1,774.0971 $1,246.82 $1,433.84 $1,631.24 $1,875.93 $1,922.03 $2,210.34 $1,800.96 $2,071.10 $1,975.69 $2,272.04 $1,600.31 $1,840.3672 $1,289.25 $1,482.64 $1,691.14 $1,944.81 $1,989.42 $2,287.86 $1,869.62 $2,150.06 $2,044.34 $2,351.01 $1,655.91 $1,904.3073 $1,329.19 $1,528.58 $1,749.81 $2,012.27 $2,055.58 $2,363.92 $1,935.77 $2,226.13 $2,111.75 $2,428.51 $1,710.50 $1,967.1074 $1,367.89 $1,573.06 $1,805.96 $2,076.86 $2,119.22 $2,437.10 $1,999.41 $2,299.31 $2,177.88 $2,504.57 $1,764.10 $2,028.7075 $1,404.09 $1,614.70 $1,859.63 $2,138.58 $2,180.38 $2,507.45 $2,060.58 $2,369.66 $2,240.30 $2,576.35 $1,814.64 $2,086.8376 $1,439.02 $1,654.87 $1,910.79 $2,197.42 $2,239.04 $2,574.90 $2,119.22 $2,437.10 $2,300.20 $2,645.23 $1,863.16 $2,142.6277 $1,470.22 $1,690.76 $1,958.22 $2,251.96 $2,293.96 $2,638.05 $2,174.16 $2,500.28 $2,357.61 $2,711.25 $1,909.67 $2,196.1278 $1,497.69 $1,722.34 $2,003.17 $2,303.64 $2,346.37 $2,698.34 $2,225.31 $2,559.11 $2,410.03 $2,771.54 $1,952.14 $2,244.9579 $1,522.65 $1,751.05 $2,044.34 $2,351.01 $2,393.81 $2,752.90 $2,272.75 $2,613.67 $2,459.96 $2,828.94 $1,992.57 $2,291.4580 $1,545.10 $1,776.87 $2,080.53 $2,392.62 $2,438.74 $2,804.54 $2,316.42 $2,663.90 $2,504.90 $2,880.64 $2,028.95 $2,333.3081 $1,562.58 $1,796.98 $2,114.23 $2,431.38 $2,478.67 $2,850.49 $2,355.13 $2,708.40 $2,546.07 $2,927.99 $2,062.32 $2,371.6682 $1,581.31 $1,818.51 $2,146.69 $2,468.70 $2,517.38 $2,895.00 $2,393.81 $2,752.90 $2,586.01 $2,973.92 $2,094.66 $2,408.8683 $1,600.03 $1,840.02 $2,177.88 $2,504.57 $2,556.05 $2,939.46 $2,431.25 $2,795.93 $2,625.94 $3,019.85 $2,127.02 $2,446.0784 $1,617.50 $1,860.14 $2,209.08 $2,540.45 $2,593.50 $2,982.53 $2,467.44 $2,837.56 $2,664.65 $3,064.34 $2,158.38 $2,482.1385 $1,636.23 $1,881.67 $2,240.30 $2,576.35 $2,629.70 $3,024.15 $2,502.40 $2,877.76 $2,702.09 $3,107.39 $2,188.68 $2,516.9886 $1,654.94 $1,903.18 $2,268.99 $2,609.35 $2,665.90 $3,065.78 $2,533.58 $2,913.63 $2,739.53 $3,150.46 $2,219.02 $2,551.8787 $1,673.66 $1,924.72 $2,298.94 $2,643.80 $2,700.84 $3,105.97 $2,562.30 $2,946.65 $2,774.47 $3,190.63 $2,247.31 $2,584.4388 $1,691.14 $1,944.81 $2,326.41 $2,675.38 $2,733.29 $3,143.29 $2,589.75 $2,978.22 $2,809.43 $3,230.84 $2,275.62 $2,616.9789 $1,709.84 $1,966.33 $2,352.62 $2,705.50 $2,765.74 $3,180.59 $2,617.22 $3,009.81 $2,841.88 $3,268.16 $2,301.92 $2,647.2090 $1,728.58 $1,987.86 $2,378.84 $2,735.66 $2,796.94 $3,216.47 $2,642.18 $3,038.50 $2,873.07 $3,304.04 $2,327.18 $2,676.2691 $1,746.05 $2,007.97 $2,403.80 $2,764.36 $2,825.63 $3,249.49 $2,665.90 $3,065.78 $2,903.02 $3,338.47 $2,351.46 $2,704.1692 $1,764.78 $2,029.49 $2,427.50 $2,791.62 $2,853.10 $3,281.07 $2,687.11 $3,090.18 $2,931.73 $3,371.49 $2,374.70 $2,730.9193 $1,783.49 $2,051.02 $2,449.97 $2,817.48 $2,880.55 $3,312.62 $2,708.33 $3,114.58 $2,959.19 $3,403.07 $2,396.94 $2,756.4894 $1,800.96 $2,071.10 $2,471.19 $2,841.87 $2,904.27 $3,339.92 $2,727.03 $3,136.09 $2,984.15 $3,431.78 $2,417.17 $2,779.7495 $1,819.68 $2,092.63 $2,492.42 $2,866.29 $2,927.98 $3,367.18 $2,744.51 $3,156.20 $3,007.87 $3,459.05 $2,436.37 $2,801.8296 $1,837.18 $2,112.74 $2,512.38 $2,889.25 $2,951.70 $3,394.46 $2,760.74 $3,174.86 $3,032.83 $3,487.76 $2,456.60 $2,825.0897 $1,855.88 $2,134.27 $2,533.58 $2,913.63 $2,975.42 $3,421.73 $2,778.22 $3,194.97 $3,056.54 $3,515.02 $2,475.78 $2,847.1698 $1,874.62 $2,155.81 $2,554.82 $2,938.05 $2,999.12 $3,448.99 $2,795.70 $3,215.05 $3,081.50 $3,543.72 $2,496.01 $2,870.4299 $1,893.34 $2,177.34 $2,574.78 $2,960.99 $3,024.09 $3,477.70 $2,814.42 $3,236.58 $3,106.46 $3,572.42 $2,516.22 $2,893.67




Annual Smoker Premium RatesFor Use In All Indiana Zip Codes

46400-46499


65 $1,424.34 $1,638.00 $1,837.78 $2,113.45 $2,205.97 $2,536.86 $2,020.32 $2,323.36 $2,266.80 $2,606.84 $1,836.12 $2,111.5366 $1,494.56 $1,718.75 $1,932.94 $2,222.90 $2,308.94 $2,655.29 $2,124.83 $2,443.56 $2,372.91 $2,728.86 $1,922.06 $2,210.3767 $1,563.21 $1,797.69 $2,026.55 $2,330.54 $2,413.48 $2,775.49 $2,229.36 $2,563.77 $2,478.98 $2,850.83 $2,007.98 $2,309.1968 $1,631.84 $1,876.63 $2,120.16 $2,438.17 $2,516.43 $2,893.90 $2,333.89 $2,683.98 $2,585.08 $2,972.84 $2,093.90 $2,407.9969 $1,700.49 $1,955.56 $2,212.21 $2,544.05 $2,619.39 $3,012.29 $2,438.42 $2,804.20 $2,691.14 $3,094.81 $2,179.84 $2,506.8170 $1,766.03 $2,030.94 $2,304.24 $2,649.89 $2,720.79 $3,128.92 $2,542.96 $2,924.40 $2,795.69 $3,215.06 $2,264.50 $2,604.1771 $1,829.97 $2,104.46 $2,394.73 $2,753.96 $2,822.21 $3,245.55 $2,644.35 $3,041.01 $2,900.21 $3,335.24 $2,349.16 $2,701.5472 $1,892.38 $2,176.24 $2,482.11 $2,854.43 $2,920.51 $3,358.60 $2,744.20 $3,155.84 $3,001.63 $3,451.87 $2,431.31 $2,796.0173 $1,951.69 $2,244.44 $2,567.91 $2,953.11 $3,017.21 $3,469.80 $2,840.94 $3,267.09 $3,099.89 $3,564.87 $2,510.91 $2,887.5574 $2,009.38 $2,310.80 $2,650.59 $3,048.18 $3,110.83 $3,577.48 $2,934.52 $3,374.72 $3,196.63 $3,676.13 $2,589.28 $2,977.6875 $2,062.44 $2,371.81 $2,730.16 $3,139.69 $3,201.31 $3,681.50 $3,025.01 $3,478.78 $3,288.67 $3,781.97 $2,663.81 $3,063.3976 $2,112.36 $2,429.22 $2,805.03 $3,225.80 $3,287.12 $3,780.19 $3,110.83 $3,577.48 $3,376.05 $3,882.46 $2,734.58 $3,144.7877 $2,157.61 $2,481.23 $2,875.25 $3,306.54 $3,368.24 $3,873.47 $3,191.95 $3,670.75 $3,460.29 $3,979.35 $2,802.82 $3,223.2478 $2,198.16 $2,527.89 $2,940.77 $3,381.88 $3,443.13 $3,959.62 $3,266.82 $3,756.84 $3,538.30 $4,069.03 $2,866.01 $3,295.9279 $2,235.60 $2,570.95 $3,000.06 $3,450.05 $3,514.88 $4,042.13 $3,337.05 $3,837.60 $3,611.62 $4,153.37 $2,925.41 $3,364.2280 $2,268.36 $2,608.62 $3,054.65 $3,512.86 $3,578.86 $4,115.69 $3,401.01 $3,911.18 $3,677.16 $4,228.72 $2,978.49 $3,425.2581 $2,294.90 $2,639.14 $3,103.02 $3,568.48 $3,638.14 $4,183.87 $3,457.17 $3,975.74 $3,738.00 $4,298.69 $3,027.75 $3,481.9482 $2,321.40 $2,669.62 $3,151.39 $3,624.11 $3,695.86 $4,250.24 $3,513.34 $4,040.35 $3,797.28 $4,366.87 $3,075.78 $3,537.1583 $2,347.94 $2,700.14 $3,198.19 $3,677.92 $3,752.04 $4,314.84 $3,567.94 $4,103.15 $3,854.99 $4,433.24 $3,122.54 $3,590.9484 $2,376.02 $2,732.41 $3,243.43 $3,729.95 $3,806.65 $4,377.64 $3,620.99 $4,164.15 $3,911.18 $4,497.86 $3,168.03 $3,643.2485 $2,402.54 $2,762.93 $3,288.67 $3,781.97 $3,861.23 $4,440.42 $3,674.03 $4,225.14 $3,967.32 $4,562.42 $3,213.54 $3,695.5786 $2,429.06 $2,793.42 $3,332.37 $3,832.23 $3,912.72 $4,499.63 $3,717.72 $4,275.37 $4,020.38 $4,623.44 $3,256.49 $3,744.9687 $2,455.57 $2,823.92 $3,374.48 $3,880.66 $3,964.22 $4,558.84 $3,761.39 $4,325.61 $4,073.42 $4,684.44 $3,299.46 $3,794.3988 $2,483.66 $2,856.22 $3,415.03 $3,927.29 $4,012.57 $4,614.46 $3,801.95 $4,372.25 $4,123.33 $4,741.83 $3,339.90 $3,840.8789 $2,510.18 $2,886.72 $3,454.05 $3,972.16 $4,059.36 $4,668.28 $3,840.97 $4,417.10 $4,171.70 $4,797.46 $3,379.08 $3,885.9490 $2,536.72 $2,917.22 $3,493.04 $4,017.01 $4,104.61 $4,720.30 $3,878.39 $4,460.15 $4,218.50 $4,851.26 $3,416.98 $3,929.5391 $2,563.22 $2,947.72 $3,528.93 $4,058.27 $4,148.29 $4,770.55 $3,912.72 $4,499.63 $4,262.20 $4,901.53 $3,452.37 $3,970.2292 $2,591.32 $2,980.02 $3,563.24 $4,097.75 $4,188.84 $4,817.18 $3,945.48 $4,537.31 $4,304.32 $4,949.96 $3,486.48 $4,009.4593 $2,617.84 $3,010.51 $3,597.59 $4,137.21 $4,227.86 $4,862.04 $3,975.11 $4,571.38 $4,343.31 $4,994.81 $3,518.08 $4,045.7994 $2,644.35 $3,041.01 $3,628.77 $4,173.09 $4,263.75 $4,903.30 $4,003.20 $4,603.69 $4,380.76 $5,037.87 $3,548.40 $4,080.6895 $2,670.90 $3,071.53 $3,658.42 $4,207.18 $4,298.08 $4,942.81 $4,028.17 $4,632.39 $4,416.63 $5,079.12 $3,577.48 $4,114.0796 $2,697.39 $3,102.00 $3,688.06 $4,241.27 $4,332.40 $4,982.26 $4,053.12 $4,661.10 $4,450.95 $5,118.61 $3,605.27 $4,146.0697 $2,723.93 $3,132.53 $3,719.28 $4,277.16 $4,368.26 $5,023.50 $4,079.66 $4,691.62 $4,486.84 $5,159.88 $3,634.34 $4,179.5098 $2,752.00 $3,164.81 $3,748.90 $4,311.24 $4,402.58 $5,062.99 $4,104.61 $4,720.30 $4,524.29 $5,202.92 $3,664.66 $4,214.3699 $2,780.09 $3,197.10 $3,780.11 $4,347.12 $4,438.47 $5,104.24 $4,131.14 $4,750.81 $4,560.16 $5,244.18 $3,693.72 $4,247.79




Annual Smoker Premium RatesFor Use In All Indiana Zip Codes

46000-46399, 47100-47199, 47800-47899


65 $1,281.91 $1,474.20 $1,654.00 $1,902.11 $1,985.37 $2,283.17 $1,818.29 $2,091.02 $2,040.12 $2,346.16 $1,652.51 $1,900.3866 $1,345.10 $1,546.88 $1,739.65 $2,000.61 $2,078.05 $2,389.76 $1,912.35 $2,199.20 $2,135.62 $2,455.97 $1,729.85 $1,989.3367 $1,406.89 $1,617.92 $1,823.90 $2,097.49 $2,172.13 $2,497.94 $2,006.42 $2,307.39 $2,231.08 $2,565.75 $1,807.18 $2,078.2768 $1,468.66 $1,688.97 $1,908.14 $2,194.35 $2,264.79 $2,604.51 $2,100.50 $2,415.58 $2,326.57 $2,675.56 $1,884.51 $2,167.1969 $1,530.44 $1,760.00 $1,990.99 $2,289.65 $2,357.45 $2,711.06 $2,194.58 $2,523.78 $2,422.03 $2,785.33 $1,961.86 $2,256.1370 $1,589.43 $1,827.85 $2,073.82 $2,384.90 $2,448.71 $2,816.03 $2,288.66 $2,631.96 $2,516.12 $2,893.55 $2,038.05 $2,343.7571 $1,646.97 $1,894.01 $2,155.26 $2,478.56 $2,539.99 $2,921.00 $2,379.92 $2,736.91 $2,610.19 $3,001.72 $2,114.24 $2,431.3972 $1,703.14 $1,958.62 $2,233.90 $2,568.99 $2,628.46 $3,022.74 $2,469.78 $2,840.26 $2,701.47 $3,106.68 $2,188.18 $2,516.4173 $1,756.52 $2,020.00 $2,311.12 $2,657.80 $2,715.49 $3,122.82 $2,556.85 $2,940.38 $2,789.90 $3,208.38 $2,259.82 $2,598.8074 $1,808.44 $2,079.72 $2,385.53 $2,743.36 $2,799.75 $3,219.73 $2,641.07 $3,037.25 $2,876.97 $3,308.52 $2,330.35 $2,679.9175 $1,856.20 $2,134.63 $2,457.14 $2,825.72 $2,881.18 $3,313.35 $2,722.51 $3,130.90 $2,959.80 $3,403.77 $2,397.43 $2,757.0576 $1,901.12 $2,186.30 $2,524.53 $2,903.22 $2,958.41 $3,402.17 $2,799.75 $3,219.73 $3,038.45 $3,494.21 $2,461.12 $2,830.3077 $1,941.85 $2,233.11 $2,587.73 $2,975.89 $3,031.42 $3,486.12 $2,872.76 $3,303.68 $3,114.26 $3,581.42 $2,522.54 $2,900.9278 $1,978.34 $2,275.10 $2,646.69 $3,043.69 $3,098.82 $3,563.66 $2,940.14 $3,381.16 $3,184.47 $3,662.13 $2,579.41 $2,966.3379 $2,012.04 $2,313.86 $2,700.05 $3,105.05 $3,163.39 $3,637.92 $3,003.35 $3,453.84 $3,250.46 $3,738.03 $2,632.87 $3,027.8080 $2,041.52 $2,347.76 $2,749.19 $3,161.57 $3,220.97 $3,704.12 $3,060.91 $3,520.06 $3,309.44 $3,805.85 $2,680.64 $3,082.7381 $2,065.41 $2,375.23 $2,792.72 $3,211.63 $3,274.33 $3,765.48 $3,111.45 $3,578.17 $3,364.20 $3,868.82 $2,724.98 $3,133.7582 $2,089.26 $2,402.66 $2,836.25 $3,261.70 $3,326.27 $3,825.22 $3,162.01 $3,636.32 $3,417.55 $3,930.18 $2,768.20 $3,183.4483 $2,113.15 $2,430.13 $2,878.37 $3,310.13 $3,376.84 $3,883.36 $3,211.15 $3,692.84 $3,469.49 $3,989.92 $2,810.29 $3,231.8584 $2,138.42 $2,459.17 $2,919.09 $3,356.96 $3,425.99 $3,939.88 $3,258.89 $3,747.74 $3,520.06 $4,048.07 $2,851.23 $3,278.9285 $2,162.29 $2,486.64 $2,959.80 $3,403.77 $3,475.11 $3,996.38 $3,306.63 $3,802.63 $3,570.59 $4,106.18 $2,892.19 $3,326.0186 $2,186.15 $2,514.08 $2,999.13 $3,449.01 $3,521.45 $4,049.67 $3,345.95 $3,847.83 $3,618.34 $4,161.10 $2,930.84 $3,370.4687 $2,210.01 $2,541.53 $3,037.03 $3,492.59 $3,567.80 $4,102.96 $3,385.25 $3,893.05 $3,666.08 $4,216.00 $2,969.51 $3,414.9588 $2,235.29 $2,570.60 $3,073.53 $3,534.56 $3,611.31 $4,153.01 $3,421.76 $3,935.03 $3,711.00 $4,267.65 $3,005.91 $3,456.7889 $2,259.16 $2,598.05 $3,108.65 $3,574.94 $3,653.42 $4,201.45 $3,456.87 $3,975.39 $3,754.53 $4,317.71 $3,041.17 $3,497.3590 $2,283.05 $2,625.50 $3,143.74 $3,615.31 $3,694.15 $4,248.27 $3,490.55 $4,014.14 $3,796.65 $4,366.13 $3,075.28 $3,536.5891 $2,306.90 $2,652.95 $3,176.04 $3,652.44 $3,733.46 $4,293.50 $3,521.45 $4,049.67 $3,835.98 $4,411.38 $3,107.13 $3,573.2092 $2,332.19 $2,682.02 $3,206.92 $3,687.98 $3,769.96 $4,335.46 $3,550.93 $4,083.58 $3,873.89 $4,454.96 $3,137.83 $3,608.5193 $2,356.06 $2,709.46 $3,237.83 $3,723.49 $3,805.07 $4,375.84 $3,577.60 $4,114.24 $3,908.98 $4,495.33 $3,166.27 $3,641.2194 $2,379.92 $2,736.91 $3,265.89 $3,755.78 $3,837.38 $4,412.97 $3,602.88 $4,143.32 $3,942.68 $4,534.08 $3,193.56 $3,672.6195 $2,403.81 $2,764.38 $3,292.58 $3,786.46 $3,868.27 $4,448.53 $3,625.35 $4,169.15 $3,974.97 $4,571.21 $3,219.73 $3,702.6696 $2,427.65 $2,791.80 $3,319.25 $3,817.14 $3,899.16 $4,484.03 $3,647.81 $4,194.99 $4,005.86 $4,606.75 $3,244.74 $3,731.4597 $2,451.54 $2,819.28 $3,347.35 $3,849.44 $3,931.43 $4,521.15 $3,671.69 $4,222.46 $4,038.16 $4,643.89 $3,270.91 $3,761.5598 $2,476.80 $2,848.33 $3,374.01 $3,880.12 $3,962.32 $4,556.69 $3,694.15 $4,248.27 $4,071.86 $4,682.63 $3,298.19 $3,792.9299 $2,502.08 $2,877.39 $3,402.10 $3,912.41 $3,994.62 $4,593.82 $3,718.03 $4,275.73 $4,104.14 $4,719.76 $3,324.35 $3,823.01




Annual Smoker Premium RatesFor Use In Indiana Zip Codes

All Other Zip Codes


65 $1,139.47 $1,310.40 $1,470.22 $1,690.76 $1,764.78 $2,029.49 $1,616.26 $1,858.69 $1,813.44 $2,085.47 $1,468.90 $1,689.2266 $1,195.65 $1,375.00 $1,546.35 $1,778.32 $1,847.15 $2,124.23 $1,699.86 $1,954.85 $1,898.33 $2,183.09 $1,537.65 $1,768.3067 $1,250.57 $1,438.15 $1,621.24 $1,864.43 $1,930.78 $2,220.39 $1,783.49 $2,051.02 $1,983.18 $2,280.66 $1,606.38 $1,847.3568 $1,305.47 $1,501.30 $1,696.13 $1,950.54 $2,013.14 $2,315.12 $1,867.11 $2,147.18 $2,068.06 $2,378.27 $1,675.12 $1,926.3969 $1,360.39 $1,564.45 $1,769.77 $2,035.24 $2,095.51 $2,409.83 $1,950.74 $2,243.36 $2,152.91 $2,475.85 $1,743.87 $2,005.4570 $1,412.82 $1,624.75 $1,843.39 $2,119.91 $2,176.63 $2,503.14 $2,034.37 $2,339.52 $2,236.55 $2,572.05 $1,811.60 $2,083.3471 $1,463.98 $1,683.57 $1,915.78 $2,203.17 $2,257.77 $2,596.44 $2,115.48 $2,432.81 $2,320.17 $2,668.19 $1,879.33 $2,161.2372 $1,513.90 $1,740.99 $1,985.69 $2,283.54 $2,336.41 $2,686.88 $2,195.36 $2,524.67 $2,401.30 $2,761.50 $1,945.05 $2,236.8173 $1,561.35 $1,795.55 $2,054.33 $2,362.49 $2,413.77 $2,775.84 $2,272.75 $2,613.67 $2,479.91 $2,851.90 $2,008.73 $2,310.0474 $1,607.50 $1,848.64 $2,120.47 $2,438.54 $2,488.66 $2,861.98 $2,347.62 $2,699.78 $2,557.30 $2,940.90 $2,071.42 $2,382.1475 $1,649.95 $1,897.45 $2,184.13 $2,511.75 $2,561.05 $2,945.20 $2,420.01 $2,783.02 $2,630.94 $3,025.58 $2,131.05 $2,450.7176 $1,689.89 $1,943.38 $2,244.02 $2,580.64 $2,629.70 $3,024.15 $2,488.66 $2,861.98 $2,700.84 $3,105.97 $2,187.66 $2,515.8277 $1,726.09 $1,984.98 $2,300.20 $2,645.23 $2,694.59 $3,098.78 $2,553.56 $2,936.60 $2,768.23 $3,183.48 $2,242.26 $2,578.5978 $1,758.53 $2,022.31 $2,352.62 $2,705.50 $2,754.50 $3,167.70 $2,613.46 $3,005.47 $2,830.64 $3,255.22 $2,292.81 $2,636.7479 $1,788.48 $2,056.76 $2,400.05 $2,760.04 $2,811.90 $3,233.70 $2,669.64 $3,070.08 $2,889.30 $3,322.70 $2,340.33 $2,691.3880 $1,814.69 $2,086.90 $2,443.72 $2,810.29 $2,863.09 $3,292.55 $2,720.81 $3,128.94 $2,941.73 $3,382.98 $2,382.79 $2,740.2081 $1,835.92 $2,111.31 $2,482.42 $2,854.78 $2,910.51 $3,347.10 $2,765.74 $3,180.59 $2,990.40 $3,438.95 $2,422.20 $2,785.5582 $1,857.12 $2,135.70 $2,521.11 $2,899.29 $2,956.69 $3,400.19 $2,810.67 $3,232.28 $3,037.82 $3,493.50 $2,460.62 $2,829.7283 $1,878.35 $2,160.11 $2,558.55 $2,942.34 $3,001.63 $3,451.87 $2,854.35 $3,282.52 $3,083.99 $3,546.59 $2,498.03 $2,872.7584 $1,900.82 $2,185.93 $2,594.74 $2,983.96 $3,045.32 $3,502.11 $2,896.79 $3,331.32 $3,128.94 $3,598.29 $2,534.42 $2,914.5985 $1,922.03 $2,210.34 $2,630.94 $3,025.58 $3,088.98 $3,552.34 $2,939.22 $3,380.11 $3,173.86 $3,649.94 $2,570.83 $2,956.4686 $1,943.25 $2,234.74 $2,665.90 $3,065.78 $3,130.18 $3,599.70 $2,974.18 $3,420.30 $3,216.30 $3,698.75 $2,605.19 $2,995.9787 $1,964.46 $2,259.14 $2,699.58 $3,104.53 $3,171.38 $3,647.07 $3,009.11 $3,460.49 $3,258.74 $3,747.55 $2,639.57 $3,035.5188 $1,986.93 $2,284.98 $2,732.02 $3,141.83 $3,210.06 $3,691.57 $3,041.56 $3,497.80 $3,298.66 $3,793.46 $2,671.92 $3,072.7089 $2,008.14 $2,309.38 $2,763.24 $3,177.73 $3,247.49 $3,734.62 $3,072.78 $3,533.68 $3,337.36 $3,837.97 $2,703.26 $3,108.7590 $2,029.38 $2,333.78 $2,794.43 $3,213.61 $3,283.69 $3,776.24 $3,102.71 $3,568.12 $3,374.80 $3,881.01 $2,733.58 $3,143.6291 $2,050.58 $2,358.18 $2,823.14 $3,246.62 $3,318.63 $3,816.44 $3,130.18 $3,599.70 $3,409.76 $3,921.22 $2,761.90 $3,176.1892 $2,073.06 $2,384.02 $2,850.59 $3,278.20 $3,351.07 $3,853.74 $3,156.38 $3,629.85 $3,443.46 $3,959.97 $2,789.18 $3,207.5693 $2,094.27 $2,408.41 $2,878.07 $3,309.77 $3,382.29 $3,889.63 $3,180.09 $3,657.10 $3,474.65 $3,995.85 $2,814.46 $3,236.6394 $2,115.48 $2,432.81 $2,903.02 $3,338.47 $3,411.00 $3,922.64 $3,202.56 $3,682.95 $3,504.61 $4,030.30 $2,838.72 $3,264.5495 $2,136.72 $2,457.22 $2,926.74 $3,365.74 $3,438.46 $3,954.25 $3,222.54 $3,705.91 $3,533.30 $4,063.30 $2,861.98 $3,291.2696 $2,157.91 $2,481.60 $2,950.45 $3,393.02 $3,465.92 $3,985.81 $3,242.50 $3,728.88 $3,560.76 $4,094.89 $2,884.22 $3,316.8597 $2,179.14 $2,506.02 $2,975.42 $3,421.73 $3,494.61 $4,018.80 $3,263.73 $3,753.30 $3,589.47 $4,127.90 $2,907.47 $3,343.6098 $2,201.60 $2,531.85 $2,999.12 $3,448.99 $3,522.06 $4,050.39 $3,283.69 $3,776.24 $3,619.43 $4,162.34 $2,931.73 $3,371.4999 $2,224.07 $2,557.68 $3,024.09 $3,477.70 $3,550.78 $4,083.39 $3,304.91 $3,800.65 $3,648.13 $4,195.34 $2,954.98 $3,398.23




Semi-Annual Non-Smoker Premium RatesFor Use In Indiana Zip Codes

46400-46499


65 $625.07 $718.84 $806.65 $927.64 $967.35 $1,112.45 $885.39 $1,018.21 $993.86 $1,142.93 $805.03 $925.7866 $655.61 $753.95 $847.63 $974.78 $1,013.14 $1,165.12 $932.00 $1,071.80 $1,040.46 $1,196.53 $842.77 $969.1967 $685.34 $788.14 $888.60 $1,021.90 $1,058.14 $1,216.86 $977.79 $1,124.47 $1,087.07 $1,250.12 $880.52 $1,012.6068 $715.87 $823.25 $929.59 $1,069.03 $1,103.13 $1,268.60 $1,023.59 $1,177.13 $1,133.66 $1,303.72 $918.26 $1,056.0169 $745.60 $857.44 $970.56 $1,116.15 $1,148.93 $1,321.28 $1,069.39 $1,229.80 $1,180.26 $1,357.29 $956.02 $1,099.4170 $774.52 $890.70 $1,010.73 $1,162.34 $1,193.12 $1,372.08 $1,115.19 $1,282.47 $1,226.06 $1,409.97 $993.11 $1,142.0771 $802.64 $923.03 $1,050.11 $1,207.63 $1,237.31 $1,422.91 $1,159.37 $1,333.27 $1,271.85 $1,462.63 $1,030.20 $1,184.7372 $829.95 $954.45 $1,088.67 $1,251.97 $1,280.69 $1,472.81 $1,203.57 $1,384.10 $1,316.04 $1,513.46 $1,065.99 $1,225.9073 $855.67 $984.02 $1,126.44 $1,295.40 $1,323.28 $1,521.77 $1,246.15 $1,433.07 $1,359.44 $1,563.35 $1,101.14 $1,266.3274 $880.58 $1,012.65 $1,162.59 $1,336.98 $1,364.25 $1,568.89 $1,287.12 $1,480.18 $1,402.01 $1,612.32 $1,135.64 $1,305.9775 $903.88 $1,039.46 $1,197.14 $1,376.71 $1,403.62 $1,614.17 $1,326.50 $1,525.47 $1,442.20 $1,658.53 $1,168.17 $1,343.4076 $926.37 $1,065.32 $1,230.07 $1,414.59 $1,441.38 $1,657.59 $1,364.25 $1,568.89 $1,480.75 $1,702.87 $1,199.41 $1,379.3177 $946.46 $1,088.43 $1,260.61 $1,449.70 $1,476.74 $1,698.24 $1,399.62 $1,609.56 $1,517.71 $1,745.37 $1,229.35 $1,413.7578 $964.14 $1,108.75 $1,289.54 $1,482.97 $1,510.47 $1,737.06 $1,432.54 $1,647.43 $1,551.46 $1,784.18 $1,256.69 $1,445.1979 $980.20 $1,127.24 $1,316.04 $1,513.46 $1,541.01 $1,772.18 $1,463.08 $1,682.55 $1,583.60 $1,821.13 $1,282.72 $1,475.1280 $994.66 $1,143.86 $1,339.34 $1,540.25 $1,569.94 $1,805.43 $1,491.20 $1,714.88 $1,612.53 $1,854.41 $1,306.14 $1,502.0681 $1,005.91 $1,156.80 $1,361.04 $1,565.20 $1,595.65 $1,835.00 $1,516.11 $1,743.53 $1,639.03 $1,884.89 $1,327.62 $1,526.7682 $1,017.97 $1,170.67 $1,381.93 $1,589.23 $1,620.57 $1,863.66 $1,541.01 $1,772.18 $1,664.74 $1,914.46 $1,348.43 $1,550.7183 $1,030.02 $1,184.52 $1,402.01 $1,612.32 $1,645.46 $1,892.27 $1,565.12 $1,799.88 $1,690.45 $1,944.03 $1,369.27 $1,574.6684 $1,041.26 $1,197.46 $1,422.10 $1,635.41 $1,669.57 $1,920.00 $1,588.41 $1,826.68 $1,715.37 $1,972.67 $1,389.45 $1,597.8785 $1,053.32 $1,211.33 $1,442.20 $1,658.53 $1,692.87 $1,946.80 $1,610.92 $1,852.56 $1,739.47 $2,000.38 $1,408.96 $1,620.3186 $1,065.37 $1,225.17 $1,460.66 $1,679.77 $1,716.17 $1,973.60 $1,630.99 $1,875.65 $1,763.57 $2,028.11 $1,428.50 $1,642.7787 $1,077.42 $1,239.04 $1,479.95 $1,701.95 $1,738.67 $1,999.47 $1,649.48 $1,896.90 $1,786.07 $2,053.97 $1,446.71 $1,663.7388 $1,088.67 $1,251.97 $1,497.63 $1,722.27 $1,759.55 $2,023.49 $1,667.15 $1,917.23 $1,808.57 $2,079.85 $1,464.93 $1,684.6789 $1,100.71 $1,265.82 $1,514.50 $1,741.67 $1,780.44 $2,047.51 $1,684.83 $1,937.56 $1,829.46 $2,103.88 $1,481.86 $1,704.1490 $1,112.77 $1,279.68 $1,531.38 $1,761.08 $1,800.53 $2,070.60 $1,700.91 $1,956.04 $1,849.54 $2,126.98 $1,498.12 $1,722.8491 $1,124.02 $1,292.63 $1,547.45 $1,779.56 $1,819.00 $2,091.86 $1,716.17 $1,973.60 $1,868.82 $2,149.14 $1,513.75 $1,740.8092 $1,136.07 $1,306.48 $1,562.71 $1,797.11 $1,836.69 $2,112.19 $1,729.83 $1,989.30 $1,887.30 $2,170.40 $1,528.72 $1,758.0293 $1,148.12 $1,320.34 $1,577.17 $1,813.75 $1,854.36 $2,132.50 $1,743.49 $2,005.01 $1,904.98 $2,190.73 $1,543.03 $1,774.4894 $1,159.37 $1,333.27 $1,590.83 $1,829.46 $1,869.63 $2,150.07 $1,755.53 $2,018.86 $1,921.05 $2,209.21 $1,556.05 $1,789.4695 $1,171.42 $1,347.13 $1,604.49 $1,845.17 $1,884.89 $2,167.62 $1,766.78 $2,031.80 $1,936.32 $2,226.76 $1,568.41 $1,803.6796 $1,182.68 $1,360.08 $1,617.34 $1,859.95 $1,900.15 $2,185.18 $1,777.23 $2,043.82 $1,952.39 $2,245.25 $1,581.44 $1,818.6597 $1,194.72 $1,373.94 $1,630.99 $1,875.65 $1,915.43 $2,202.74 $1,788.48 $2,056.76 $1,967.65 $2,262.80 $1,593.79 $1,832.8698 $1,206.78 $1,387.80 $1,644.67 $1,891.37 $1,930.68 $2,220.29 $1,799.73 $2,069.69 $1,983.71 $2,281.27 $1,606.81 $1,847.8499 $1,218.84 $1,401.67 $1,657.51 $1,906.14 $1,946.76 $2,238.77 $1,811.78 $2,083.55 $1,999.79 $2,299.75 $1,619.82 $1,862.80





46000-46399, 47100-47199, 47800-47899


65 $562.56 $646.96 $725.98 $834.88 $870.62 $1,001.21 $796.85 $916.39 $894.48 $1,028.64 $724.52 $833.2066 $590.05 $678.56 $762.87 $877.30 $911.83 $1,048.61 $838.80 $964.62 $936.42 $1,076.88 $758.49 $872.2767 $616.80 $709.32 $799.74 $919.71 $952.33 $1,095.18 $880.01 $1,012.02 $978.36 $1,125.11 $792.46 $911.3468 $644.28 $740.92 $836.63 $962.12 $992.82 $1,141.74 $921.23 $1,059.42 $1,020.29 $1,173.35 $826.43 $950.4169 $671.04 $771.70 $873.50 $1,004.53 $1,034.04 $1,189.15 $962.45 $1,106.82 $1,062.23 $1,221.56 $860.41 $989.4770 $697.07 $801.63 $909.66 $1,046.11 $1,073.80 $1,234.88 $1,003.67 $1,154.22 $1,103.45 $1,268.97 $893.79 $1,027.8671 $722.37 $830.73 $945.10 $1,086.87 $1,113.58 $1,280.62 $1,043.43 $1,199.95 $1,144.66 $1,316.36 $927.18 $1,066.2672 $746.96 $859.00 $979.80 $1,126.77 $1,152.62 $1,325.53 $1,083.21 $1,245.69 $1,184.44 $1,362.12 $959.39 $1,103.3173 $770.10 $885.62 $1,013.80 $1,165.86 $1,190.95 $1,369.60 $1,121.54 $1,289.76 $1,223.50 $1,407.02 $991.02 $1,139.6974 $792.52 $911.39 $1,046.33 $1,203.28 $1,227.83 $1,412.00 $1,158.41 $1,332.16 $1,261.81 $1,451.08 $1,022.07 $1,175.3875 $813.49 $935.51 $1,077.42 $1,239.04 $1,263.26 $1,452.75 $1,193.85 $1,372.92 $1,297.98 $1,492.67 $1,051.36 $1,209.0676 $833.73 $958.79 $1,107.07 $1,273.13 $1,297.24 $1,491.84 $1,227.83 $1,412.00 $1,332.68 $1,532.58 $1,079.47 $1,241.3877 $851.81 $979.58 $1,134.55 $1,304.73 $1,329.06 $1,528.42 $1,259.65 $1,448.60 $1,365.94 $1,570.83 $1,106.42 $1,272.3878 $867.72 $997.88 $1,160.59 $1,334.67 $1,359.43 $1,563.35 $1,289.29 $1,482.69 $1,396.31 $1,605.76 $1,131.02 $1,300.6779 $882.18 $1,014.51 $1,184.44 $1,362.12 $1,386.91 $1,594.96 $1,316.78 $1,514.30 $1,425.24 $1,639.02 $1,154.44 $1,327.6180 $895.19 $1,029.48 $1,205.41 $1,386.22 $1,412.95 $1,624.88 $1,342.08 $1,543.39 $1,451.28 $1,668.97 $1,175.52 $1,351.8681 $905.32 $1,041.12 $1,224.93 $1,408.68 $1,436.08 $1,651.50 $1,364.50 $1,569.18 $1,475.13 $1,696.41 $1,194.86 $1,374.0882 $916.17 $1,053.60 $1,243.74 $1,430.31 $1,458.51 $1,677.29 $1,386.91 $1,594.96 $1,498.27 $1,723.01 $1,213.59 $1,395.6483 $927.02 $1,066.06 $1,261.81 $1,451.08 $1,480.91 $1,703.05 $1,408.60 $1,619.89 $1,521.41 $1,749.62 $1,232.34 $1,417.1984 $937.14 $1,077.72 $1,279.89 $1,471.87 $1,502.61 $1,728.00 $1,429.57 $1,644.01 $1,543.83 $1,775.40 $1,250.51 $1,438.0885 $947.99 $1,090.19 $1,297.98 $1,492.67 $1,523.58 $1,752.12 $1,449.83 $1,667.30 $1,565.52 $1,800.35 $1,268.07 $1,458.2886 $958.83 $1,102.66 $1,314.60 $1,511.79 $1,544.55 $1,776.24 $1,467.90 $1,688.09 $1,587.21 $1,825.30 $1,285.65 $1,478.4987 $969.67 $1,115.13 $1,331.95 $1,531.75 $1,564.80 $1,799.52 $1,484.53 $1,707.21 $1,607.46 $1,848.57 $1,302.04 $1,497.3688 $979.80 $1,126.77 $1,347.86 $1,550.05 $1,583.60 $1,821.14 $1,500.44 $1,725.50 $1,627.71 $1,871.87 $1,318.44 $1,516.2189 $990.64 $1,139.24 $1,363.05 $1,567.50 $1,602.40 $1,842.76 $1,516.35 $1,743.81 $1,646.51 $1,893.49 $1,333.67 $1,533.7290 $1,001.49 $1,151.71 $1,378.24 $1,584.98 $1,620.48 $1,863.54 $1,530.82 $1,760.43 $1,664.59 $1,914.28 $1,348.31 $1,550.5691 $1,011.62 $1,163.37 $1,392.70 $1,601.60 $1,637.10 $1,882.67 $1,544.55 $1,776.24 $1,681.93 $1,934.23 $1,362.37 $1,566.7292 $1,022.47 $1,175.83 $1,406.44 $1,617.40 $1,653.02 $1,900.97 $1,556.85 $1,790.37 $1,698.57 $1,953.36 $1,375.84 $1,582.2293 $1,033.31 $1,188.31 $1,419.45 $1,632.38 $1,668.92 $1,919.25 $1,569.14 $1,804.51 $1,714.48 $1,971.65 $1,388.72 $1,597.0494 $1,043.43 $1,199.95 $1,431.75 $1,646.51 $1,682.66 $1,935.07 $1,579.97 $1,816.97 $1,728.94 $1,988.29 $1,400.45 $1,610.5195 $1,054.28 $1,212.42 $1,444.04 $1,660.66 $1,696.40 $1,950.86 $1,590.10 $1,828.62 $1,742.69 $2,004.09 $1,411.57 $1,623.3196 $1,064.41 $1,224.07 $1,455.61 $1,673.96 $1,710.14 $1,966.66 $1,599.51 $1,839.44 $1,757.15 $2,020.72 $1,423.29 $1,636.7897 $1,075.25 $1,236.54 $1,467.90 $1,688.09 $1,723.89 $1,982.46 $1,609.63 $1,851.08 $1,770.88 $2,036.52 $1,434.41 $1,649.5798 $1,086.11 $1,249.02 $1,480.20 $1,702.23 $1,737.62 $1,998.26 $1,619.76 $1,862.72 $1,785.34 $2,053.14 $1,446.12 $1,663.0599 $1,096.95 $1,261.50 $1,491.76 $1,715.52 $1,752.08 $2,014.89 $1,630.60 $1,875.19 $1,799.81 $2,069.77 $1,457.84 $1,676.52





All Other Zip Codes


65 $500.06 $575.07 $645.32 $742.12 $773.88 $889.96 $708.31 $814.57 $795.09 $914.35 $644.02 $740.6266 $524.49 $603.16 $678.11 $779.83 $810.51 $932.10 $745.60 $857.44 $832.37 $957.22 $674.21 $775.3567 $548.27 $630.51 $710.88 $817.52 $846.51 $973.49 $782.23 $899.57 $869.65 $1,000.10 $704.41 $810.0868 $572.69 $658.60 $743.67 $855.22 $882.50 $1,014.88 $818.87 $941.70 $906.93 $1,042.98 $734.61 $844.8169 $596.48 $685.95 $776.45 $892.92 $919.14 $1,057.02 $855.51 $983.84 $944.21 $1,085.83 $764.81 $879.5370 $619.62 $712.56 $808.59 $929.88 $954.49 $1,097.67 $892.15 $1,025.97 $980.84 $1,127.97 $794.48 $913.6671 $642.11 $738.43 $840.09 $966.10 $989.85 $1,138.33 $927.49 $1,066.62 $1,017.48 $1,170.10 $824.16 $947.7972 $663.96 $763.56 $870.94 $1,001.58 $1,024.55 $1,178.25 $962.85 $1,107.28 $1,052.83 $1,210.77 $852.79 $980.7273 $684.53 $787.22 $901.15 $1,036.32 $1,058.62 $1,217.42 $996.92 $1,146.46 $1,087.55 $1,250.68 $880.91 $1,013.0574 $704.46 $810.12 $930.07 $1,069.58 $1,091.40 $1,255.11 $1,029.70 $1,184.15 $1,121.61 $1,289.85 $908.51 $1,044.7875 $723.11 $831.57 $957.71 $1,101.37 $1,122.90 $1,291.34 $1,061.20 $1,220.38 $1,153.76 $1,326.82 $934.54 $1,074.7276 $741.09 $852.26 $984.06 $1,131.67 $1,153.11 $1,326.08 $1,091.40 $1,255.11 $1,184.60 $1,362.29 $959.53 $1,103.4577 $757.17 $870.74 $1,008.49 $1,159.76 $1,181.39 $1,358.59 $1,119.69 $1,287.64 $1,214.17 $1,396.29 $983.48 $1,131.0078 $771.31 $887.00 $1,031.63 $1,186.37 $1,208.38 $1,389.65 $1,146.04 $1,317.94 $1,241.17 $1,427.34 $1,005.35 $1,156.1579 $784.16 $901.79 $1,052.83 $1,210.77 $1,232.81 $1,417.74 $1,170.47 $1,346.04 $1,266.88 $1,456.91 $1,026.17 $1,180.1080 $795.73 $915.09 $1,071.47 $1,232.20 $1,255.95 $1,444.34 $1,192.96 $1,371.91 $1,290.03 $1,483.53 $1,044.91 $1,201.6581 $804.73 $925.44 $1,088.83 $1,252.16 $1,276.52 $1,468.00 $1,212.89 $1,394.83 $1,311.23 $1,507.92 $1,062.09 $1,221.4182 $814.38 $936.53 $1,105.54 $1,271.38 $1,296.45 $1,490.93 $1,232.81 $1,417.74 $1,331.79 $1,531.57 $1,078.75 $1,240.5683 $824.02 $947.61 $1,121.61 $1,289.85 $1,316.36 $1,513.82 $1,252.09 $1,439.90 $1,352.36 $1,555.22 $1,095.41 $1,259.7384 $833.01 $957.97 $1,137.68 $1,308.33 $1,335.65 $1,536.00 $1,270.73 $1,461.34 $1,372.29 $1,578.14 $1,111.56 $1,278.3085 $842.66 $969.06 $1,153.76 $1,326.82 $1,354.29 $1,557.44 $1,288.74 $1,482.05 $1,391.58 $1,600.31 $1,127.17 $1,296.2586 $852.30 $980.14 $1,168.53 $1,343.82 $1,372.94 $1,578.88 $1,304.80 $1,500.52 $1,410.86 $1,622.49 $1,142.80 $1,314.2187 $861.93 $991.23 $1,183.96 $1,361.56 $1,390.93 $1,599.57 $1,319.58 $1,517.52 $1,428.85 $1,643.18 $1,157.37 $1,330.9888 $870.94 $1,001.58 $1,198.10 $1,377.82 $1,407.64 $1,618.79 $1,333.72 $1,533.78 $1,446.86 $1,663.88 $1,171.95 $1,347.7489 $880.57 $1,012.66 $1,211.60 $1,393.33 $1,424.35 $1,638.00 $1,347.87 $1,550.05 $1,463.57 $1,683.10 $1,185.49 $1,363.3190 $890.22 $1,023.75 $1,225.10 $1,408.87 $1,440.43 $1,656.48 $1,360.72 $1,564.83 $1,479.63 $1,701.58 $1,198.50 $1,378.2791 $899.21 $1,034.10 $1,237.96 $1,423.65 $1,455.20 $1,673.49 $1,372.94 $1,578.88 $1,495.05 $1,719.31 $1,211.00 $1,392.6492 $908.86 $1,045.19 $1,250.16 $1,437.69 $1,469.35 $1,689.75 $1,383.86 $1,591.44 $1,509.84 $1,736.32 $1,222.97 $1,406.4293 $918.50 $1,056.27 $1,261.73 $1,451.00 $1,483.48 $1,706.00 $1,394.79 $1,604.01 $1,523.98 $1,752.58 $1,234.42 $1,419.5994 $927.49 $1,066.62 $1,272.66 $1,463.56 $1,495.70 $1,720.06 $1,404.42 $1,615.09 $1,536.84 $1,767.36 $1,244.84 $1,431.5795 $937.14 $1,077.71 $1,283.59 $1,476.14 $1,507.91 $1,734.10 $1,413.42 $1,625.44 $1,549.05 $1,781.41 $1,254.73 $1,442.9496 $946.15 $1,088.06 $1,293.87 $1,487.96 $1,520.12 $1,748.14 $1,421.78 $1,635.05 $1,561.91 $1,796.20 $1,265.15 $1,454.9297 $955.78 $1,099.15 $1,304.80 $1,500.52 $1,532.34 $1,762.19 $1,430.78 $1,645.41 $1,574.12 $1,810.24 $1,275.03 $1,466.2998 $965.43 $1,110.24 $1,315.73 $1,513.09 $1,544.55 $1,776.23 $1,439.78 $1,655.75 $1,586.97 $1,825.02 $1,285.44 $1,478.2799 $975.07 $1,121.33 $1,326.01 $1,524.91 $1,557.41 $1,791.01 $1,449.42 $1,666.84 $1,599.83 $1,839.80 $1,295.86 $1,490.24




Semi-Annual Smoker Premium RatesFor Use In All Indiana Zip Codes

46400-46499


65 $733.54 $843.57 $946.46 $1,088.43 $1,136.07 $1,306.48 $1,040.46 $1,196.53 $1,167.40 $1,342.52 $945.60 $1,087.4466 $769.70 $885.16 $995.46 $1,144.79 $1,189.10 $1,367.47 $1,094.29 $1,258.43 $1,222.05 $1,405.36 $989.86 $1,138.3467 $805.05 $925.81 $1,043.67 $1,200.23 $1,242.94 $1,429.38 $1,148.12 $1,320.34 $1,276.67 $1,468.18 $1,034.11 $1,189.2368 $840.40 $966.46 $1,091.88 $1,255.66 $1,295.96 $1,490.36 $1,201.95 $1,382.25 $1,331.32 $1,531.01 $1,078.36 $1,240.1169 $875.75 $1,007.11 $1,139.29 $1,310.19 $1,348.99 $1,551.33 $1,255.79 $1,444.16 $1,385.94 $1,593.83 $1,122.62 $1,291.0170 $909.51 $1,045.93 $1,186.68 $1,364.69 $1,401.21 $1,611.39 $1,309.62 $1,506.07 $1,439.78 $1,655.76 $1,166.22 $1,341.1571 $942.43 $1,083.80 $1,233.29 $1,418.29 $1,453.44 $1,671.46 $1,361.84 $1,566.12 $1,493.61 $1,717.65 $1,209.82 $1,391.2972 $974.58 $1,120.76 $1,278.29 $1,470.03 $1,504.06 $1,729.68 $1,413.26 $1,625.26 $1,545.84 $1,777.71 $1,252.12 $1,439.9573 $1,005.12 $1,155.89 $1,322.47 $1,520.85 $1,553.86 $1,786.95 $1,463.08 $1,682.55 $1,596.44 $1,835.91 $1,293.12 $1,487.0974 $1,034.83 $1,190.06 $1,365.05 $1,569.81 $1,602.08 $1,842.40 $1,511.28 $1,737.98 $1,646.26 $1,893.21 $1,333.48 $1,533.5175 $1,062.16 $1,221.48 $1,406.03 $1,616.94 $1,648.67 $1,895.97 $1,557.88 $1,791.57 $1,693.67 $1,947.71 $1,371.86 $1,577.6576 $1,087.87 $1,251.05 $1,444.59 $1,661.29 $1,692.87 $1,946.80 $1,602.08 $1,842.40 $1,738.67 $1,999.47 $1,408.31 $1,619.5677 $1,111.17 $1,277.83 $1,480.75 $1,702.87 $1,734.64 $1,994.84 $1,643.85 $1,890.44 $1,782.05 $2,049.37 $1,443.45 $1,659.9778 $1,132.05 $1,301.86 $1,514.50 $1,741.67 $1,773.21 $2,039.20 $1,682.41 $1,934.77 $1,822.22 $2,095.55 $1,476.00 $1,697.4079 $1,151.33 $1,324.04 $1,545.03 $1,776.78 $1,810.16 $2,081.70 $1,718.58 $1,976.36 $1,859.98 $2,138.99 $1,506.59 $1,732.5780 $1,168.21 $1,343.44 $1,573.14 $1,809.12 $1,843.11 $2,119.58 $1,751.52 $2,014.26 $1,893.74 $2,177.79 $1,533.92 $1,764.0081 $1,181.87 $1,359.16 $1,598.06 $1,837.77 $1,873.64 $2,154.69 $1,780.44 $2,047.51 $1,925.07 $2,213.83 $1,559.29 $1,793.2082 $1,195.52 $1,374.85 $1,622.97 $1,866.42 $1,903.37 $2,188.87 $1,809.37 $2,080.78 $1,955.60 $2,248.94 $1,584.03 $1,821.6383 $1,209.19 $1,390.57 $1,647.07 $1,894.13 $1,932.30 $2,222.14 $1,837.49 $2,113.12 $1,985.32 $2,283.12 $1,608.11 $1,849.3384 $1,223.65 $1,407.19 $1,670.37 $1,920.92 $1,960.42 $2,254.48 $1,864.81 $2,144.54 $2,014.26 $2,316.40 $1,631.54 $1,876.2785 $1,237.31 $1,422.91 $1,693.67 $1,947.71 $1,988.53 $2,286.82 $1,892.13 $2,175.95 $2,043.17 $2,349.65 $1,654.97 $1,903.2286 $1,250.97 $1,438.61 $1,716.17 $1,973.60 $2,015.05 $2,317.31 $1,914.63 $2,201.82 $2,070.50 $2,381.07 $1,677.09 $1,928.6587 $1,264.62 $1,454.32 $1,737.86 $1,998.54 $2,041.57 $2,347.80 $1,937.12 $2,227.69 $2,097.81 $2,412.49 $1,699.22 $1,954.1188 $1,279.08 $1,470.95 $1,758.74 $2,022.55 $2,066.47 $2,376.45 $1,958.00 $2,251.71 $2,123.51 $2,442.04 $1,720.05 $1,978.0589 $1,292.74 $1,486.66 $1,778.84 $2,045.66 $2,090.57 $2,404.16 $1,978.10 $2,274.81 $2,148.43 $2,470.69 $1,740.23 $2,001.2690 $1,306.41 $1,502.37 $1,798.92 $2,068.76 $2,113.87 $2,430.95 $1,997.37 $2,296.98 $2,172.53 $2,498.40 $1,759.74 $2,023.7191 $1,320.06 $1,518.08 $1,817.40 $2,090.01 $2,136.37 $2,456.83 $2,015.05 $2,317.31 $2,195.03 $2,524.29 $1,777.97 $2,044.6692 $1,334.53 $1,534.71 $1,835.07 $2,110.34 $2,157.25 $2,480.85 $2,031.92 $2,336.71 $2,216.72 $2,549.23 $1,795.54 $2,064.8793 $1,348.19 $1,550.41 $1,852.76 $2,130.66 $2,177.35 $2,503.95 $2,047.18 $2,354.26 $2,236.80 $2,572.33 $1,811.81 $2,083.5894 $1,361.84 $1,566.12 $1,868.82 $2,149.14 $2,195.83 $2,525.20 $2,061.65 $2,370.90 $2,256.09 $2,594.50 $1,827.43 $2,101.5595 $1,375.51 $1,581.84 $1,884.09 $2,166.70 $2,213.51 $2,545.55 $2,074.51 $2,385.68 $2,274.56 $2,615.75 $1,842.40 $2,118.7596 $1,389.16 $1,597.53 $1,899.35 $2,184.25 $2,231.19 $2,565.86 $2,087.36 $2,400.47 $2,292.24 $2,636.08 $1,856.71 $2,135.2297 $1,402.82 $1,613.25 $1,915.43 $2,202.74 $2,249.65 $2,587.10 $2,101.02 $2,416.18 $2,310.72 $2,657.34 $1,871.69 $2,152.4498 $1,417.28 $1,629.88 $1,930.68 $2,220.29 $2,267.33 $2,607.44 $2,113.87 $2,430.95 $2,330.01 $2,679.50 $1,887.30 $2,170.4099 $1,431.75 $1,646.51 $1,946.76 $2,238.77 $2,285.81 $2,628.68 $2,127.54 $2,446.67 $2,348.48 $2,700.75 $1,902.27 $2,187.61




Semi-Annual Smoker Premium RatesFor Use In All Indiana Zip Codes

46000-46399, 47100-47199, 47800-47899


65 $660.18 $759.21 $851.81 $979.58 $1,022.47 $1,175.83 $936.42 $1,076.88 $1,050.66 $1,208.27 $851.04 $978.6966 $692.73 $796.64 $895.92 $1,030.31 $1,070.19 $1,230.73 $984.86 $1,132.59 $1,099.84 $1,264.83 $890.87 $1,024.5167 $724.55 $833.23 $939.31 $1,080.21 $1,118.65 $1,286.44 $1,033.31 $1,188.31 $1,149.01 $1,321.36 $930.70 $1,070.3168 $756.36 $869.82 $982.69 $1,130.09 $1,166.37 $1,341.32 $1,081.76 $1,244.02 $1,198.18 $1,377.91 $970.52 $1,116.1069 $788.18 $906.40 $1,025.36 $1,179.17 $1,214.09 $1,396.20 $1,130.21 $1,299.75 $1,247.34 $1,434.44 $1,010.36 $1,161.9170 $818.55 $941.34 $1,068.02 $1,228.22 $1,261.09 $1,450.25 $1,178.66 $1,355.46 $1,295.80 $1,490.18 $1,049.60 $1,207.0371 $848.19 $975.42 $1,109.96 $1,276.46 $1,308.09 $1,504.31 $1,225.66 $1,409.51 $1,344.25 $1,545.88 $1,088.84 $1,252.1672 $877.12 $1,008.69 $1,150.46 $1,323.03 $1,353.66 $1,556.71 $1,271.94 $1,462.73 $1,391.26 $1,599.94 $1,126.91 $1,295.9573 $904.61 $1,040.30 $1,190.23 $1,368.77 $1,398.48 $1,608.25 $1,316.78 $1,514.30 $1,436.80 $1,652.32 $1,163.81 $1,338.3874 $931.35 $1,071.06 $1,228.55 $1,412.83 $1,441.87 $1,658.16 $1,360.15 $1,564.18 $1,481.64 $1,703.89 $1,200.13 $1,380.1575 $955.94 $1,099.33 $1,265.43 $1,455.25 $1,483.81 $1,706.38 $1,402.09 $1,612.41 $1,524.30 $1,752.94 $1,234.68 $1,419.8876 $979.08 $1,125.94 $1,300.13 $1,495.16 $1,523.58 $1,752.12 $1,441.87 $1,658.16 $1,564.80 $1,799.52 $1,267.48 $1,457.6177 $1,000.05 $1,150.05 $1,332.68 $1,532.58 $1,561.18 $1,795.35 $1,479.47 $1,701.39 $1,603.84 $1,844.43 $1,299.11 $1,493.9778 $1,018.85 $1,171.68 $1,363.05 $1,567.50 $1,595.89 $1,835.28 $1,514.17 $1,741.30 $1,640.00 $1,886.00 $1,328.40 $1,527.6679 $1,036.20 $1,191.64 $1,390.53 $1,599.10 $1,629.15 $1,873.53 $1,546.72 $1,778.73 $1,673.99 $1,925.09 $1,355.93 $1,559.3280 $1,051.38 $1,209.10 $1,415.83 $1,628.21 $1,658.80 $1,907.62 $1,576.37 $1,812.83 $1,704.36 $1,960.01 $1,380.53 $1,587.6081 $1,063.69 $1,223.24 $1,438.25 $1,653.99 $1,686.28 $1,939.22 $1,602.40 $1,842.76 $1,732.56 $1,992.44 $1,403.36 $1,613.8882 $1,075.97 $1,237.37 $1,460.67 $1,679.77 $1,713.03 $1,969.99 $1,628.43 $1,872.70 $1,760.04 $2,024.04 $1,425.62 $1,639.4783 $1,088.27 $1,251.51 $1,482.36 $1,704.72 $1,739.07 $1,999.93 $1,653.74 $1,901.81 $1,786.79 $2,054.81 $1,447.30 $1,664.4084 $1,101.29 $1,266.47 $1,503.33 $1,728.83 $1,764.38 $2,029.04 $1,678.33 $1,930.08 $1,812.83 $2,084.76 $1,468.38 $1,688.6485 $1,113.58 $1,280.62 $1,524.30 $1,752.94 $1,789.68 $2,058.13 $1,702.91 $1,958.35 $1,838.85 $2,114.68 $1,489.48 $1,712.9086 $1,125.87 $1,294.75 $1,544.55 $1,776.24 $1,813.55 $2,085.58 $1,723.16 $1,981.63 $1,863.45 $2,142.96 $1,509.38 $1,735.7987 $1,138.16 $1,308.89 $1,564.07 $1,798.69 $1,837.42 $2,113.02 $1,743.40 $2,004.92 $1,888.03 $2,171.24 $1,529.30 $1,758.7088 $1,151.18 $1,323.86 $1,582.87 $1,820.30 $1,859.83 $2,138.80 $1,762.20 $2,026.54 $1,911.16 $2,197.84 $1,548.04 $1,780.2489 $1,163.47 $1,337.99 $1,600.95 $1,841.10 $1,881.51 $2,163.75 $1,780.29 $2,047.33 $1,933.58 $2,223.62 $1,566.20 $1,801.1390 $1,175.77 $1,352.13 $1,619.02 $1,861.88 $1,902.49 $2,187.86 $1,797.63 $2,067.28 $1,955.27 $2,248.56 $1,583.77 $1,821.3491 $1,188.05 $1,366.27 $1,635.66 $1,881.01 $1,922.73 $2,211.15 $1,813.55 $2,085.58 $1,975.53 $2,271.86 $1,600.17 $1,840.2092 $1,201.08 $1,381.24 $1,651.56 $1,899.31 $1,941.53 $2,232.76 $1,828.73 $2,103.04 $1,995.05 $2,294.31 $1,615.98 $1,858.3893 $1,213.37 $1,395.37 $1,667.48 $1,917.60 $1,959.61 $2,253.56 $1,842.46 $2,118.83 $2,013.12 $2,315.09 $1,630.63 $1,875.2294 $1,225.66 $1,409.51 $1,681.93 $1,934.23 $1,976.25 $2,272.68 $1,855.48 $2,133.81 $2,030.48 $2,335.05 $1,644.68 $1,891.4095 $1,237.96 $1,423.65 $1,695.68 $1,950.03 $1,992.16 $2,290.99 $1,867.06 $2,147.11 $2,047.11 $2,354.17 $1,658.16 $1,906.8796 $1,250.24 $1,437.78 $1,709.42 $1,965.83 $2,008.07 $2,309.28 $1,878.62 $2,160.42 $2,063.02 $2,372.48 $1,671.04 $1,921.7097 $1,262.54 $1,451.93 $1,723.89 $1,982.46 $2,024.69 $2,328.39 $1,890.92 $2,174.57 $2,079.65 $2,391.60 $1,684.52 $1,937.2098 $1,275.55 $1,466.89 $1,737.62 $1,998.26 $2,040.60 $2,346.70 $1,902.49 $2,187.86 $2,097.01 $2,411.55 $1,698.57 $1,953.3699 $1,288.57 $1,481.86 $1,752.08 $2,014.89 $2,057.23 $2,365.82 $1,914.78 $2,202.00 $2,113.63 $2,430.68 $1,712.04 $1,968.85




Semi-Annual Smoker Premium RatesFor Use In Indiana Zip Codes

All Other Zip Codes


65 $586.83 $674.86 $757.17 $870.74 $908.86 $1,045.19 $832.37 $957.22 $933.92 $1,074.02 $756.48 $869.9566 $615.76 $708.13 $796.37 $915.83 $951.28 $1,093.98 $875.43 $1,006.75 $977.64 $1,124.29 $791.89 $910.6767 $644.04 $740.65 $834.94 $960.18 $994.35 $1,143.50 $918.50 $1,056.27 $1,021.34 $1,174.54 $827.29 $951.3968 $672.32 $773.17 $873.51 $1,004.53 $1,036.77 $1,192.29 $961.56 $1,105.80 $1,065.05 $1,224.81 $862.69 $992.0969 $700.60 $805.69 $911.43 $1,048.15 $1,079.19 $1,241.06 $1,004.63 $1,155.33 $1,108.75 $1,275.06 $898.09 $1,032.8170 $727.60 $836.75 $949.35 $1,091.75 $1,120.97 $1,289.12 $1,047.70 $1,204.85 $1,151.82 $1,324.60 $932.97 $1,072.9271 $753.95 $867.04 $986.63 $1,134.63 $1,162.75 $1,337.17 $1,089.47 $1,252.90 $1,194.89 $1,374.12 $967.85 $1,113.0372 $779.66 $896.61 $1,022.63 $1,176.03 $1,203.25 $1,383.74 $1,130.61 $1,300.21 $1,236.67 $1,422.17 $1,001.70 $1,151.9673 $804.10 $924.71 $1,057.98 $1,216.68 $1,243.09 $1,429.56 $1,170.47 $1,346.04 $1,277.15 $1,468.73 $1,034.49 $1,189.6774 $827.86 $952.05 $1,092.04 $1,255.85 $1,281.66 $1,473.92 $1,209.02 $1,390.38 $1,317.01 $1,514.57 $1,066.78 $1,226.8075 $849.73 $977.19 $1,124.83 $1,293.55 $1,318.94 $1,516.78 $1,246.30 $1,433.26 $1,354.93 $1,558.17 $1,097.49 $1,262.1276 $870.29 $1,000.84 $1,155.67 $1,329.03 $1,354.29 $1,557.44 $1,281.66 $1,473.92 $1,390.93 $1,599.57 $1,126.65 $1,295.6577 $888.94 $1,022.27 $1,184.60 $1,362.29 $1,387.71 $1,595.87 $1,315.08 $1,512.35 $1,425.64 $1,639.49 $1,154.76 $1,327.9778 $905.64 $1,041.49 $1,211.60 $1,393.33 $1,418.57 $1,631.36 $1,345.93 $1,547.82 $1,457.78 $1,676.44 $1,180.80 $1,357.9279 $921.07 $1,059.23 $1,236.02 $1,421.42 $1,448.13 $1,665.36 $1,374.86 $1,581.09 $1,487.99 $1,711.19 $1,205.27 $1,386.0680 $934.56 $1,074.75 $1,258.52 $1,447.30 $1,474.49 $1,695.66 $1,401.22 $1,611.41 $1,514.99 $1,742.23 $1,227.14 $1,411.2081 $945.50 $1,087.33 $1,278.44 $1,470.21 $1,498.91 $1,723.75 $1,424.35 $1,638.00 $1,540.06 $1,771.06 $1,247.43 $1,434.5682 $956.42 $1,099.88 $1,298.37 $1,493.13 $1,522.69 $1,751.10 $1,447.50 $1,664.62 $1,564.48 $1,799.15 $1,267.22 $1,457.3183 $967.35 $1,112.46 $1,317.65 $1,515.30 $1,545.84 $1,777.71 $1,469.99 $1,690.50 $1,588.26 $1,826.49 $1,286.49 $1,479.4784 $978.92 $1,125.75 $1,336.29 $1,536.74 $1,568.34 $1,803.59 $1,491.85 $1,715.63 $1,611.41 $1,853.12 $1,305.23 $1,501.0185 $989.85 $1,138.33 $1,354.93 $1,558.17 $1,590.83 $1,829.45 $1,513.70 $1,740.76 $1,634.54 $1,879.72 $1,323.98 $1,522.5786 $1,000.77 $1,150.89 $1,372.94 $1,578.88 $1,612.04 $1,853.85 $1,531.70 $1,761.45 $1,656.40 $1,904.86 $1,341.67 $1,542.9287 $1,011.69 $1,163.46 $1,390.29 $1,598.83 $1,633.26 $1,878.24 $1,549.69 $1,782.15 $1,678.25 $1,929.99 $1,359.38 $1,563.2988 $1,023.27 $1,176.76 $1,406.99 $1,618.04 $1,653.18 $1,901.16 $1,566.40 $1,801.37 $1,698.81 $1,953.63 $1,376.04 $1,582.4489 $1,034.19 $1,189.33 $1,423.07 $1,636.53 $1,672.46 $1,923.33 $1,582.48 $1,819.85 $1,718.74 $1,976.55 $1,392.18 $1,601.0190 $1,045.13 $1,201.89 $1,439.13 $1,655.01 $1,691.10 $1,944.76 $1,597.90 $1,837.58 $1,738.02 $1,998.72 $1,407.80 $1,618.9791 $1,056.05 $1,214.46 $1,453.92 $1,672.01 $1,709.10 $1,965.47 $1,612.04 $1,853.85 $1,756.03 $2,019.43 $1,422.38 $1,635.7392 $1,067.62 $1,227.77 $1,468.05 $1,688.27 $1,725.80 $1,984.68 $1,625.54 $1,869.37 $1,773.38 $2,039.38 $1,436.43 $1,651.8993 $1,078.55 $1,240.33 $1,482.21 $1,704.53 $1,741.88 $2,003.16 $1,637.75 $1,883.41 $1,789.44 $2,057.86 $1,449.45 $1,666.8794 $1,089.47 $1,252.90 $1,495.05 $1,719.31 $1,756.67 $2,020.16 $1,649.32 $1,896.72 $1,804.87 $2,075.60 $1,461.94 $1,681.2495 $1,100.41 $1,265.47 $1,507.27 $1,733.36 $1,770.81 $2,036.44 $1,659.61 $1,908.54 $1,819.65 $2,092.60 $1,473.92 $1,695.0096 $1,111.32 $1,278.02 $1,519.48 $1,747.40 $1,784.95 $2,052.69 $1,669.89 $1,920.37 $1,833.79 $2,108.87 $1,485.37 $1,708.1897 $1,122.26 $1,290.60 $1,532.34 $1,762.19 $1,799.72 $2,069.68 $1,680.82 $1,932.95 $1,848.58 $2,125.87 $1,497.35 $1,721.9598 $1,133.82 $1,303.90 $1,544.55 $1,776.23 $1,813.86 $2,085.95 $1,691.10 $1,944.76 $1,864.01 $2,143.60 $1,509.84 $1,736.3299 $1,145.40 $1,317.21 $1,557.41 $1,791.01 $1,828.65 $2,102.95 $1,702.03 $1,957.33 $1,878.79 $2,160.60 $1,521.81 $1,750.09




Quarterly Non-Smoker Premium RatesFor Use In Indiana Zip Codes

46400-46499


65 $318.60 $366.40 $411.16 $472.83 $493.07 $567.03 $451.29 $518.99 $506.58 $582.56 $410.33 $471.8866 $334.17 $384.30 $432.05 $496.85 $516.41 $593.87 $475.05 $546.30 $530.33 $609.88 $429.57 $494.0067 $349.32 $401.72 $452.93 $520.87 $539.34 $620.25 $498.39 $573.15 $554.09 $637.20 $448.81 $516.1368 $364.88 $419.62 $473.82 $544.89 $562.28 $646.62 $521.73 $599.99 $577.84 $664.52 $468.05 $538.2669 $380.04 $437.04 $494.70 $568.91 $585.62 $673.47 $545.08 $626.84 $601.59 $691.82 $487.29 $560.3870 $394.78 $454.00 $515.18 $592.46 $608.14 $699.36 $568.42 $653.69 $624.93 $718.67 $506.19 $582.1271 $409.11 $470.48 $535.25 $615.54 $630.67 $725.27 $590.94 $679.58 $648.27 $745.51 $525.10 $603.8772 $423.03 $486.49 $554.90 $638.14 $652.78 $750.70 $613.47 $705.49 $670.80 $771.42 $543.35 $624.8573 $436.14 $501.56 $574.16 $660.28 $674.49 $775.66 $635.17 $730.45 $692.92 $796.86 $561.26 $645.4574 $448.84 $516.16 $592.58 $681.47 $695.37 $799.67 $656.06 $754.46 $714.62 $821.81 $578.84 $665.6775 $460.72 $529.82 $610.19 $701.72 $715.44 $822.76 $676.13 $777.55 $735.10 $845.37 $595.43 $684.7476 $472.18 $543.00 $626.98 $721.03 $734.69 $844.89 $695.37 $799.67 $754.75 $867.97 $611.35 $703.0577 $482.42 $554.78 $642.54 $738.92 $752.71 $865.61 $713.40 $820.40 $773.59 $889.63 $626.61 $720.6078 $491.43 $565.14 $657.29 $755.88 $769.90 $885.39 $730.18 $839.71 $790.79 $909.41 $640.54 $736.6279 $499.62 $574.56 $670.80 $771.42 $785.47 $903.29 $745.75 $857.61 $807.17 $928.25 $653.81 $751.8880 $506.99 $583.04 $682.67 $785.08 $800.21 $920.24 $760.08 $874.09 $821.92 $945.21 $665.75 $765.6281 $512.72 $589.63 $693.73 $797.80 $813.31 $935.32 $772.78 $888.69 $835.43 $960.75 $676.70 $778.2082 $518.87 $596.70 $704.38 $810.04 $826.02 $949.92 $785.47 $903.29 $848.53 $975.82 $687.31 $790.4183 $525.01 $603.76 $714.62 $821.81 $838.70 $964.51 $797.75 $917.41 $861.64 $990.89 $697.93 $802.6284 $530.74 $610.36 $724.85 $833.58 $850.99 $978.64 $809.63 $931.07 $874.34 $1,005.49 $708.22 $814.4585 $536.89 $617.42 $735.10 $845.37 $862.87 $992.30 $821.10 $944.27 $886.62 $1,019.61 $718.16 $825.8986 $543.03 $624.48 $744.51 $856.19 $874.75 $1,005.96 $831.33 $956.04 $898.91 $1,033.75 $728.12 $837.3387 $549.17 $631.55 $754.34 $867.50 $886.21 $1,019.15 $840.75 $966.87 $910.37 $1,046.93 $737.40 $848.0288 $554.90 $638.14 $763.35 $877.86 $896.86 $1,031.39 $849.76 $977.23 $921.84 $1,060.12 $746.69 $858.6989 $561.04 $645.20 $771.95 $887.74 $907.51 $1,043.63 $858.77 $987.59 $932.49 $1,072.37 $755.32 $868.6190 $567.19 $652.27 $780.56 $897.64 $917.75 $1,055.40 $866.97 $997.01 $942.73 $1,084.14 $763.60 $878.1591 $572.92 $658.86 $788.75 $907.06 $927.16 $1,066.24 $874.75 $1,005.96 $952.55 $1,095.44 $771.57 $887.3092 $579.07 $665.93 $796.52 $916.00 $936.17 $1,076.60 $881.71 $1,013.96 $961.97 $1,106.27 $779.20 $896.0893 $585.21 $672.99 $803.90 $924.49 $945.18 $1,086.95 $888.67 $1,021.97 $970.98 $1,116.63 $786.49 $904.4794 $590.94 $679.58 $810.86 $932.49 $952.96 $1,095.91 $894.81 $1,029.03 $979.17 $1,126.05 $793.13 $912.1095 $597.08 $686.64 $817.82 $940.50 $960.74 $1,104.85 $900.54 $1,035.63 $986.96 $1,135.00 $799.43 $919.3596 $602.82 $693.24 $824.37 $948.03 $968.53 $1,113.81 $905.87 $1,041.75 $995.15 $1,144.42 $806.07 $926.9897 $608.96 $700.31 $831.33 $956.04 $976.31 $1,122.75 $911.60 $1,048.35 $1,002.93 $1,153.37 $812.37 $934.2298 $615.11 $707.37 $838.30 $964.05 $984.09 $1,131.70 $917.34 $1,054.94 $1,011.12 $1,162.78 $819.00 $941.8699 $621.25 $714.44 $844.85 $971.58 $992.28 $1,141.12 $923.48 $1,062.00 $1,019.31 $1,172.20 $825.64 $949.49





46000-46399, 47100-47199, 47800-47899


65 $286.74 $329.76 $370.04 $425.55 $443.76 $510.32 $406.16 $467.09 $455.92 $524.31 $369.30 $424.6966 $300.75 $345.87 $388.84 $447.17 $464.77 $534.48 $427.54 $491.67 $477.30 $548.89 $386.61 $444.6067 $314.39 $361.55 $407.64 $468.79 $485.41 $558.22 $448.55 $515.84 $498.68 $573.48 $403.93 $464.5268 $328.39 $377.66 $426.44 $490.40 $506.05 $581.96 $469.56 $539.99 $520.05 $598.07 $421.24 $484.4369 $342.03 $393.34 $445.23 $512.02 $527.06 $606.12 $490.57 $564.16 $541.43 $622.64 $438.56 $504.3470 $355.30 $408.60 $463.66 $533.21 $547.33 $629.43 $511.58 $588.32 $562.44 $646.81 $455.58 $523.9171 $368.20 $423.43 $481.73 $553.98 $567.60 $652.74 $531.85 $611.62 $583.45 $670.96 $472.59 $543.4872 $380.73 $437.84 $499.41 $574.33 $587.50 $675.63 $552.12 $634.94 $603.72 $694.28 $489.01 $562.3673 $392.53 $451.41 $516.74 $594.25 $607.04 $698.10 $571.66 $657.40 $623.63 $717.17 $505.13 $580.9174 $403.95 $464.54 $533.32 $613.32 $625.83 $719.71 $590.45 $679.02 $643.16 $739.63 $520.96 $599.1075 $414.64 $476.84 $549.17 $631.55 $643.89 $740.48 $608.51 $699.79 $661.59 $760.83 $535.89 $616.2776 $424.96 $488.70 $564.28 $648.92 $661.22 $760.40 $625.83 $719.71 $679.28 $781.17 $550.21 $632.7477 $434.18 $499.30 $578.29 $665.03 $677.44 $779.05 $642.06 $738.36 $696.23 $800.67 $563.95 $648.5478 $442.29 $508.63 $591.56 $680.29 $692.91 $796.85 $657.16 $755.74 $711.71 $818.47 $576.49 $662.9679 $449.66 $517.11 $603.72 $694.28 $706.92 $812.96 $671.17 $771.85 $726.46 $835.42 $588.43 $676.6980 $456.29 $524.73 $614.41 $706.57 $720.19 $828.22 $684.07 $786.68 $739.73 $850.69 $599.17 $689.0581 $461.45 $530.67 $624.36 $718.02 $731.98 $841.78 $695.50 $799.82 $751.89 $864.67 $609.03 $700.3882 $466.98 $537.03 $633.94 $729.04 $743.41 $854.93 $706.92 $812.96 $763.68 $878.24 $618.58 $711.3783 $472.51 $543.38 $643.16 $739.63 $754.83 $868.06 $717.98 $825.67 $775.47 $891.80 $628.13 $722.3684 $477.67 $549.32 $652.37 $750.23 $765.89 $880.78 $728.67 $837.97 $786.90 $904.94 $637.40 $733.0085 $483.20 $555.68 $661.59 $760.83 $776.58 $893.07 $738.99 $849.84 $797.96 $917.65 $646.34 $743.3086 $488.73 $562.03 $670.06 $770.57 $787.27 $905.36 $748.20 $860.43 $809.02 $930.37 $655.31 $753.6087 $494.25 $568.39 $678.91 $780.75 $797.59 $917.23 $756.68 $870.18 $819.34 $942.23 $663.66 $763.2288 $499.41 $574.33 $687.02 $790.07 $807.17 $928.25 $764.79 $879.50 $829.66 $954.11 $672.02 $772.8289 $504.94 $580.68 $694.76 $798.97 $816.76 $939.27 $772.90 $888.83 $839.24 $965.13 $679.79 $781.7590 $510.47 $587.04 $702.50 $807.88 $825.97 $949.86 $780.27 $897.31 $848.45 $975.72 $687.24 $790.3391 $515.63 $592.98 $709.87 $816.35 $834.44 $959.61 $787.27 $905.36 $857.30 $985.89 $694.41 $798.5792 $521.16 $599.33 $716.87 $824.40 $842.56 $968.94 $793.54 $912.57 $865.78 $995.64 $701.28 $806.4793 $526.69 $605.69 $723.51 $832.04 $850.66 $978.26 $799.80 $919.77 $873.89 $1,004.97 $707.85 $814.0294 $531.85 $611.62 $729.77 $839.24 $857.67 $986.32 $805.33 $926.13 $881.26 $1,013.45 $713.82 $820.8995 $537.37 $617.98 $736.04 $846.45 $864.67 $994.37 $810.49 $932.07 $888.26 $1,021.50 $719.49 $827.4196 $542.54 $623.92 $741.94 $853.23 $871.67 $1,002.43 $815.28 $937.58 $895.63 $1,029.98 $725.46 $834.2897 $548.06 $630.28 $748.20 $860.43 $878.68 $1,010.48 $820.44 $943.51 $902.63 $1,038.03 $731.13 $840.8098 $553.60 $636.64 $754.47 $867.64 $885.68 $1,018.53 $825.60 $949.44 $910.00 $1,046.50 $737.10 $847.6799 $559.13 $643.00 $760.36 $874.42 $893.05 $1,027.01 $831.13 $955.80 $917.38 $1,054.98 $743.07 $854.54





All Other Zip Codes


65 $254.88 $293.12 $328.93 $378.26 $394.45 $453.62 $361.03 $415.19 $405.26 $466.05 $328.26 $377.5066 $267.34 $307.44 $345.64 $397.48 $413.12 $475.10 $380.04 $437.04 $424.27 $487.91 $343.65 $395.2067 $279.46 $321.38 $362.34 $416.70 $431.47 $496.20 $398.71 $458.52 $443.27 $509.76 $359.05 $412.9068 $291.91 $335.69 $379.05 $435.91 $449.82 $517.30 $417.39 $479.99 $462.27 $531.62 $374.44 $430.6169 $304.03 $349.64 $395.76 $455.13 $468.50 $538.77 $436.06 $501.47 $481.27 $553.46 $389.83 $448.3070 $315.83 $363.20 $412.14 $473.97 $486.51 $559.49 $454.74 $522.95 $499.94 $574.94 $404.96 $465.7071 $327.29 $376.38 $428.20 $492.43 $504.53 $580.22 $472.75 $543.66 $518.62 $596.41 $420.08 $483.0972 $338.43 $389.19 $443.92 $510.51 $522.22 $600.56 $490.77 $564.39 $536.64 $617.14 $434.68 $499.8873 $348.91 $401.25 $459.32 $528.22 $539.59 $620.53 $508.14 $584.36 $554.33 $637.48 $449.01 $516.3674 $359.07 $412.93 $474.06 $545.17 $556.30 $639.74 $524.84 $603.57 $571.69 $657.45 $463.08 $532.5375 $368.57 $423.86 $488.15 $561.38 $572.35 $658.21 $540.90 $622.04 $588.08 $676.29 $476.34 $547.7976 $377.74 $434.40 $501.58 $576.82 $587.75 $675.91 $556.30 $639.74 $603.80 $694.37 $489.08 $562.4477 $385.93 $443.82 $514.03 $591.14 $602.16 $692.49 $570.72 $656.32 $618.87 $711.70 $501.29 $576.4878 $393.14 $452.11 $525.83 $604.71 $615.92 $708.32 $584.14 $671.77 $632.63 $727.53 $512.44 $589.3079 $399.70 $459.65 $536.64 $617.14 $628.37 $722.64 $596.60 $686.09 $645.74 $742.60 $523.05 $601.5180 $405.59 $466.43 $546.14 $628.06 $640.17 $736.19 $608.06 $699.27 $657.54 $756.17 $532.60 $612.4981 $410.18 $471.71 $554.99 $638.24 $650.65 $748.25 $618.22 $710.96 $668.34 $768.60 $541.36 $622.5682 $415.09 $477.36 $563.51 $648.03 $660.81 $759.94 $628.37 $722.64 $678.83 $780.65 $549.85 $632.3383 $420.01 $483.01 $571.69 $657.45 $670.96 $771.61 $638.20 $733.93 $689.31 $792.71 $558.34 $642.0984 $424.59 $488.29 $579.88 $666.87 $680.79 $782.91 $647.70 $744.86 $699.47 $804.39 $566.57 $651.5685 $429.51 $493.94 $588.08 $676.29 $690.30 $793.84 $656.88 $755.41 $709.30 $815.69 $574.53 $660.7186 $434.42 $499.59 $595.61 $684.95 $699.80 $804.77 $665.07 $764.83 $719.13 $827.00 $582.49 $669.8787 $439.33 $505.24 $603.47 $694.00 $708.97 $815.32 $672.60 $773.50 $728.30 $837.54 $589.92 $678.4188 $443.92 $510.51 $610.68 $702.29 $717.49 $825.11 $679.81 $781.78 $737.48 $848.10 $597.35 $686.9589 $448.83 $516.16 $617.56 $710.19 $726.01 $834.91 $687.02 $790.07 $745.99 $857.89 $604.25 $694.8990 $453.75 $521.81 $624.45 $718.11 $734.20 $844.32 $693.57 $797.61 $754.18 $867.31 $610.88 $702.5291 $458.34 $527.09 $631.00 $725.64 $741.73 $852.99 $699.80 $804.77 $762.04 $876.35 $617.26 $709.8492 $463.25 $532.74 $637.22 $732.80 $748.94 $861.28 $705.37 $811.17 $769.58 $885.02 $623.36 $716.8693 $468.17 $538.39 $643.12 $739.59 $756.14 $869.56 $710.94 $817.58 $776.79 $893.31 $629.20 $723.5894 $472.75 $543.66 $648.69 $745.99 $762.37 $876.73 $715.85 $823.22 $783.34 $900.84 $634.51 $729.6895 $477.67 $549.32 $654.26 $752.40 $768.60 $883.88 $720.43 $828.50 $789.57 $908.00 $639.55 $735.4896 $482.26 $554.60 $659.50 $758.43 $774.82 $891.04 $724.70 $833.40 $796.12 $915.54 $644.86 $741.5897 $487.17 $560.25 $665.07 $764.83 $781.05 $898.20 $729.28 $838.68 $802.34 $922.69 $649.89 $747.3898 $492.09 $565.90 $670.64 $771.24 $787.27 $905.36 $733.87 $843.95 $808.89 $930.23 $655.20 $753.4999 $497.00 $571.55 $675.88 $777.26 $793.82 $912.90 $738.78 $849.60 $815.45 $937.76 $660.51 $759.59




Quarterly Smoker Premium RatesFor Use In All Indiana Zip Codes

46400-46499


65 $373.89 $429.98 $482.42 $554.78 $579.07 $665.93 $530.33 $609.88 $595.04 $684.30 $481.98 $554.2866 $392.32 $451.17 $507.40 $583.51 $606.10 $697.01 $557.77 $641.43 $622.89 $716.33 $504.54 $580.2267 $410.34 $471.89 $531.97 $611.77 $633.54 $728.57 $585.21 $672.99 $650.73 $748.34 $527.09 $606.1668 $428.36 $492.62 $556.54 $640.02 $660.56 $759.65 $612.65 $704.54 $678.58 $780.37 $549.65 $632.1069 $446.38 $513.33 $580.71 $667.81 $687.59 $790.73 $640.09 $736.10 $706.42 $812.39 $572.21 $658.0470 $463.58 $533.12 $604.86 $695.60 $714.21 $821.34 $667.53 $767.66 $733.87 $843.95 $594.43 $683.5971 $480.37 $552.42 $628.62 $722.91 $740.83 $851.96 $694.14 $798.27 $761.31 $875.50 $616.65 $709.1572 $496.75 $571.26 $651.55 $749.29 $766.63 $881.63 $720.35 $828.41 $787.93 $906.12 $638.22 $733.9573 $512.32 $589.17 $674.08 $775.19 $792.02 $910.82 $745.75 $857.61 $813.72 $935.78 $659.11 $757.9874 $527.46 $606.59 $695.78 $800.15 $816.59 $939.09 $770.31 $885.86 $839.12 $964.98 $679.69 $781.6475 $541.39 $622.60 $716.67 $824.17 $840.34 $966.39 $794.07 $913.18 $863.28 $992.77 $699.25 $804.1476 $554.49 $637.67 $736.32 $846.77 $862.87 $992.30 $816.59 $939.09 $886.21 $1,019.15 $717.83 $825.5077 $566.37 $651.32 $754.75 $867.97 $884.16 $1,016.79 $837.89 $963.57 $908.33 $1,044.58 $735.74 $846.1078 $577.02 $663.57 $771.95 $887.74 $903.82 $1,039.40 $857.54 $986.17 $928.80 $1,068.12 $752.33 $865.1879 $586.85 $674.87 $787.52 $905.64 $922.66 $1,061.06 $875.98 $1,007.37 $948.05 $1,090.26 $767.92 $883.1180 $595.44 $684.76 $801.85 $922.13 $939.45 $1,080.37 $892.77 $1,026.68 $965.25 $1,110.04 $781.85 $899.1381 $602.41 $692.77 $814.54 $936.73 $955.01 $1,098.27 $907.51 $1,043.63 $981.23 $1,128.41 $794.78 $914.0182 $609.37 $700.78 $827.24 $951.33 $970.16 $1,115.69 $922.25 $1,060.59 $996.79 $1,146.30 $807.39 $928.5083 $616.33 $708.79 $839.52 $965.45 $984.91 $1,132.65 $936.58 $1,077.08 $1,011.93 $1,163.73 $819.67 $942.6284 $623.71 $717.26 $851.40 $979.11 $999.25 $1,149.13 $950.51 $1,093.09 $1,026.68 $1,180.69 $831.61 $956.3585 $630.67 $725.27 $863.28 $992.77 $1,013.57 $1,165.61 $964.43 $1,109.10 $1,041.42 $1,197.64 $843.55 $970.0986 $637.63 $733.27 $874.75 $1,005.96 $1,027.09 $1,181.15 $975.90 $1,122.28 $1,055.35 $1,213.65 $854.83 $983.0587 $644.59 $741.28 $885.80 $1,018.67 $1,040.61 $1,196.70 $987.36 $1,135.47 $1,069.27 $1,229.67 $866.11 $996.0388 $651.96 $749.76 $896.45 $1,030.91 $1,053.30 $1,211.30 $998.01 $1,147.72 $1,082.37 $1,244.73 $876.72 $1,008.2389 $658.92 $757.76 $906.69 $1,042.69 $1,065.58 $1,225.42 $1,008.25 $1,159.49 $1,095.07 $1,259.33 $887.01 $1,020.0690 $665.89 $765.77 $916.92 $1,054.47 $1,077.46 $1,239.08 $1,018.08 $1,170.79 $1,107.36 $1,273.46 $896.96 $1,031.5091 $672.85 $773.78 $926.34 $1,065.30 $1,088.93 $1,252.27 $1,027.09 $1,181.15 $1,118.83 $1,286.65 $906.25 $1,042.1892 $680.22 $782.26 $935.35 $1,075.66 $1,099.57 $1,264.51 $1,035.69 $1,191.04 $1,129.88 $1,299.36 $915.20 $1,052.4893 $687.18 $790.26 $944.37 $1,086.02 $1,109.81 $1,276.29 $1,043.47 $1,199.99 $1,140.12 $1,311.14 $923.50 $1,062.0294 $694.14 $798.27 $952.55 $1,095.44 $1,119.23 $1,287.12 $1,050.84 $1,208.47 $1,149.95 $1,322.44 $931.46 $1,071.1895 $701.11 $806.28 $960.34 $1,104.38 $1,128.25 $1,297.49 $1,057.39 $1,216.00 $1,159.37 $1,333.27 $939.09 $1,079.9496 $708.06 $814.28 $968.12 $1,113.33 $1,137.26 $1,307.84 $1,063.94 $1,223.54 $1,168.37 $1,343.64 $946.38 $1,088.3497 $715.03 $822.29 $976.31 $1,122.75 $1,146.67 $1,318.67 $1,070.91 $1,231.55 $1,177.80 $1,354.47 $954.01 $1,097.1298 $722.40 $830.76 $984.09 $1,131.70 $1,155.68 $1,329.03 $1,077.46 $1,239.08 $1,187.63 $1,365.77 $961.97 $1,106.2799 $729.77 $839.24 $992.28 $1,141.12 $1,165.10 $1,339.86 $1,084.42 $1,247.09 $1,197.04 $1,376.60 $969.60 $1,115.04




Quarterly Smoker Premium RatesFor Use In All Indiana Zip Codes

46000-46399, 47100-47199, 47800-47899


65 $336.50 $386.98 $434.18 $499.30 $521.16 $599.33 $477.30 $548.89 $535.53 $615.87 $433.78 $498.8566 $353.09 $406.05 $456.66 $525.16 $545.49 $627.31 $501.99 $577.29 $560.60 $644.69 $454.09 $522.2067 $369.31 $424.70 $478.77 $550.59 $570.18 $655.71 $526.69 $605.69 $585.66 $673.51 $474.39 $545.5568 $385.52 $443.35 $500.89 $576.02 $594.51 $683.68 $551.38 $634.09 $610.73 $702.33 $494.68 $568.8969 $401.74 $462.00 $522.63 $601.03 $618.83 $711.65 $576.08 $662.49 $635.78 $731.15 $514.99 $592.2370 $417.22 $479.81 $544.38 $626.04 $642.79 $739.21 $600.77 $690.89 $660.48 $759.56 $534.99 $615.2471 $432.33 $497.18 $565.75 $650.62 $666.75 $766.76 $624.73 $718.44 $685.17 $787.95 $554.99 $638.2472 $447.07 $514.14 $586.40 $674.36 $689.97 $793.47 $648.32 $745.57 $709.14 $815.50 $574.40 $660.5673 $461.09 $530.25 $606.67 $697.67 $712.82 $819.74 $671.17 $771.85 $732.35 $842.20 $593.20 $682.1874 $474.72 $545.93 $626.20 $720.13 $734.93 $845.18 $693.28 $797.28 $755.20 $868.49 $611.72 $703.4875 $487.25 $560.34 $645.00 $741.75 $756.31 $869.75 $714.66 $821.86 $776.95 $893.49 $629.33 $723.7376 $499.05 $573.90 $662.69 $762.10 $776.58 $893.07 $734.93 $845.18 $797.59 $917.23 $646.04 $742.9577 $509.74 $586.19 $679.28 $781.17 $795.75 $915.11 $754.10 $867.21 $817.49 $940.12 $662.17 $761.4978 $519.32 $597.21 $694.76 $798.97 $813.44 $935.46 $771.79 $887.55 $835.92 $961.31 $677.09 $778.6679 $528.16 $607.39 $708.76 $815.07 $830.39 $954.95 $788.38 $906.63 $853.25 $981.23 $691.13 $794.8080 $535.90 $616.29 $721.66 $829.91 $845.51 $972.33 $803.49 $924.02 $868.73 $999.04 $703.67 $809.2281 $542.17 $623.50 $733.09 $843.05 $859.51 $988.44 $816.76 $939.27 $883.10 $1,015.57 $715.31 $822.6182 $548.43 $630.70 $744.52 $856.20 $873.15 $1,004.12 $830.03 $954.53 $897.11 $1,031.67 $726.65 $835.6583 $554.70 $637.91 $755.57 $868.91 $886.42 $1,019.38 $842.93 $969.37 $910.74 $1,047.35 $737.70 $848.3684 $561.33 $645.53 $766.26 $881.20 $899.32 $1,034.22 $855.46 $983.78 $924.02 $1,062.62 $748.45 $860.7285 $567.60 $652.74 $776.95 $893.49 $912.22 $1,049.05 $867.99 $998.19 $937.28 $1,077.87 $759.20 $873.0886 $573.87 $659.95 $787.27 $905.36 $924.38 $1,063.04 $878.31 $1,010.06 $949.81 $1,092.29 $769.35 $884.7587 $580.13 $667.15 $797.22 $916.81 $936.55 $1,077.03 $888.63 $1,021.93 $962.35 $1,106.70 $779.50 $896.4288 $586.76 $674.78 $806.80 $927.82 $947.97 $1,090.17 $898.21 $1,032.94 $974.14 $1,120.26 $789.05 $907.4189 $593.03 $681.99 $816.02 $938.42 $959.02 $1,102.88 $907.43 $1,043.54 $985.56 $1,133.40 $798.31 $918.0590 $599.30 $689.19 $825.23 $949.02 $969.71 $1,115.17 $916.27 $1,053.71 $996.62 $1,146.11 $807.26 $928.3591 $605.56 $696.40 $833.71 $958.77 $980.03 $1,127.04 $924.38 $1,063.04 $1,006.94 $1,157.99 $815.62 $937.9692 $612.20 $704.03 $841.82 $968.09 $989.61 $1,138.06 $932.12 $1,071.94 $1,016.90 $1,169.43 $823.68 $947.2393 $618.46 $711.23 $849.93 $977.42 $998.83 $1,148.66 $939.12 $1,079.99 $1,026.11 $1,180.02 $831.15 $955.8294 $624.73 $718.44 $857.30 $985.89 $1,007.31 $1,158.40 $945.76 $1,087.62 $1,034.95 $1,190.20 $838.31 $964.0695 $631.00 $725.65 $864.30 $993.95 $1,015.42 $1,167.74 $951.66 $1,094.40 $1,043.43 $1,199.94 $845.18 $971.9596 $637.26 $732.85 $871.30 $1,002.00 $1,023.53 $1,177.06 $957.55 $1,101.18 $1,051.54 $1,209.27 $851.75 $979.5197 $643.53 $740.06 $878.68 $1,010.48 $1,032.00 $1,186.80 $963.82 $1,108.40 $1,060.02 $1,219.02 $858.61 $987.4198 $650.16 $747.69 $885.68 $1,018.53 $1,040.11 $1,196.13 $969.71 $1,115.17 $1,068.86 $1,229.19 $865.78 $995.6499 $656.80 $755.31 $893.05 $1,027.01 $1,048.59 $1,205.88 $975.98 $1,122.38 $1,077.34 $1,238.94 $872.64 $1,003.54




Quarterly Smoker Premium RatesFor Use In Indiana Zip Codes

All Other Zip Codes


65 $299.11 $343.98 $385.93 $443.82 $463.25 $532.74 $424.27 $487.91 $476.03 $547.44 $385.59 $443.4266 $313.86 $360.94 $405.92 $466.81 $484.88 $557.61 $446.21 $513.15 $498.31 $573.06 $403.63 $464.1867 $328.27 $377.51 $425.58 $489.41 $506.83 $582.85 $468.17 $538.39 $520.59 $598.67 $421.68 $484.9368 $342.69 $394.09 $445.23 $512.02 $528.45 $607.72 $490.12 $563.64 $542.87 $624.30 $439.72 $505.6869 $357.10 $410.67 $464.56 $534.25 $550.07 $632.58 $512.07 $588.88 $565.14 $649.91 $457.77 $526.4370 $370.87 $426.50 $483.89 $556.48 $571.37 $657.07 $534.02 $614.12 $587.09 $675.16 $475.55 $546.8871 $384.29 $441.94 $502.89 $578.33 $592.66 $681.57 $555.31 $638.61 $609.04 $700.40 $493.32 $567.3272 $397.40 $457.01 $521.24 $599.43 $613.31 $705.31 $576.28 $662.73 $630.34 $724.89 $510.58 $587.1673 $409.85 $471.33 $539.26 $620.15 $633.61 $728.66 $596.60 $686.09 $650.98 $748.62 $527.29 $606.3974 $421.97 $485.27 $556.62 $640.12 $653.27 $751.27 $616.25 $708.69 $671.29 $771.99 $543.75 $625.3175 $433.11 $498.08 $573.33 $659.33 $672.28 $773.12 $635.25 $730.54 $690.62 $794.21 $559.40 $643.3176 $443.60 $510.14 $589.06 $677.42 $690.30 $793.84 $653.27 $751.27 $708.97 $815.32 $574.26 $660.4077 $453.10 $521.06 $603.80 $694.37 $707.33 $813.43 $670.31 $770.86 $726.66 $835.66 $588.59 $676.8878 $461.61 $530.86 $617.56 $710.19 $723.06 $831.52 $686.03 $788.94 $743.04 $854.50 $601.86 $692.1479 $469.48 $539.90 $630.01 $724.51 $738.12 $848.85 $700.78 $805.90 $758.44 $872.21 $614.34 $706.4980 $476.36 $547.81 $641.48 $737.70 $751.56 $864.29 $714.21 $821.35 $772.20 $888.03 $625.48 $719.3081 $481.93 $554.22 $651.63 $749.38 $764.01 $878.61 $726.01 $834.91 $784.98 $902.72 $635.83 $731.2182 $487.49 $560.62 $661.79 $761.06 $776.13 $892.55 $737.80 $848.47 $797.43 $917.04 $645.91 $742.8083 $493.07 $567.03 $671.62 $772.36 $787.93 $906.12 $749.27 $861.66 $809.55 $930.98 $655.73 $754.1084 $498.96 $573.81 $681.12 $783.29 $799.40 $919.30 $760.41 $874.47 $821.35 $944.55 $665.29 $765.0885 $504.53 $580.22 $690.62 $794.21 $810.86 $932.49 $771.55 $887.28 $833.14 $958.11 $674.84 $776.0786 $510.10 $586.62 $699.80 $804.77 $821.67 $944.92 $780.72 $897.83 $844.28 $970.92 $683.86 $786.4487 $515.67 $593.02 $708.64 $814.94 $832.49 $957.36 $789.89 $908.38 $855.42 $983.73 $692.89 $796.8288 $521.57 $599.81 $717.16 $824.73 $842.64 $969.04 $798.41 $918.17 $865.90 $995.78 $701.38 $806.5889 $527.14 $606.21 $725.35 $834.15 $852.47 $980.34 $806.60 $927.59 $876.06 $1,007.47 $709.61 $816.0590 $532.71 $612.62 $733.54 $843.57 $861.97 $991.26 $814.46 $936.63 $885.89 $1,018.76 $717.57 $825.2091 $538.28 $619.02 $741.08 $852.24 $871.14 $1,001.82 $821.67 $944.92 $895.06 $1,029.32 $725.00 $833.7592 $544.18 $625.80 $748.28 $860.53 $879.66 $1,011.61 $828.55 $952.84 $903.91 $1,039.49 $732.16 $841.9893 $549.75 $632.21 $755.49 $868.81 $887.85 $1,021.03 $834.77 $959.99 $912.10 $1,048.91 $738.80 $849.6294 $555.31 $638.61 $762.04 $876.35 $895.39 $1,029.69 $840.67 $966.77 $919.96 $1,057.95 $745.16 $856.9495 $560.89 $645.02 $768.27 $883.51 $902.60 $1,037.99 $845.92 $972.80 $927.49 $1,066.62 $751.27 $863.9596 $566.45 $651.42 $774.49 $890.67 $909.80 $1,046.27 $851.16 $978.83 $934.70 $1,074.91 $757.11 $870.6797 $572.03 $657.83 $781.05 $898.20 $917.33 $1,054.94 $856.73 $985.24 $942.24 $1,083.57 $763.21 $877.7098 $577.92 $664.61 $787.27 $905.36 $924.54 $1,063.23 $861.97 $991.26 $950.10 $1,092.61 $769.58 $885.0299 $583.82 $671.39 $793.82 $912.90 $932.08 $1,071.89 $867.54 $997.67 $957.63 $1,101.28 $775.68 $892.04




Direct Monthly Non-Smoker Premium RatesFor Use In Indiana Zip Codes

46400-46499


65 $121.37 $139.58 $156.63 $180.13 $187.84 $216.01 $171.92 $197.71 $192.98 $221.93 $156.32 $179.7666 $127.30 $146.40 $164.59 $189.28 $196.73 $226.24 $180.97 $208.12 $202.03 $232.34 $163.64 $188.1967 $133.08 $153.04 $172.54 $198.43 $205.46 $236.28 $189.86 $218.34 $211.08 $242.74 $170.97 $196.6268 $139.00 $159.85 $180.50 $207.58 $214.20 $246.33 $198.76 $228.57 $220.13 $253.15 $178.30 $205.0569 $144.78 $166.49 $188.46 $216.73 $223.09 $256.56 $207.65 $238.80 $229.18 $263.55 $185.63 $213.4870 $150.39 $172.95 $196.26 $225.70 $231.67 $266.42 $216.54 $249.02 $238.07 $273.78 $192.84 $221.7671 $155.85 $179.23 $203.91 $234.49 $240.25 $276.29 $225.12 $258.89 $246.96 $284.01 $200.04 $230.0572 $161.16 $185.33 $211.39 $243.10 $248.68 $285.98 $233.70 $268.76 $255.54 $293.88 $206.99 $238.0473 $166.15 $191.07 $218.73 $251.53 $256.95 $295.49 $241.97 $278.27 $263.97 $303.56 $213.81 $245.8974 $170.99 $196.63 $225.75 $259.61 $264.90 $304.64 $249.93 $287.41 $272.24 $313.07 $220.51 $253.5975 $175.51 $201.84 $232.45 $267.32 $272.55 $313.43 $257.57 $296.21 $280.04 $322.04 $226.83 $260.8576 $179.88 $206.86 $238.85 $274.68 $279.88 $321.86 $264.90 $304.64 $287.53 $330.65 $232.90 $267.8377 $183.78 $211.35 $244.78 $281.50 $286.75 $329.76 $271.77 $312.54 $294.70 $338.91 $238.71 $274.5278 $187.21 $215.29 $250.40 $287.96 $293.30 $337.29 $278.16 $319.89 $301.25 $346.44 $244.02 $280.6279 $190.33 $218.88 $255.54 $293.88 $299.23 $344.11 $284.09 $326.71 $307.50 $353.62 $249.07 $286.4380 $193.14 $222.11 $260.07 $299.08 $304.84 $350.57 $289.55 $332.99 $313.11 $360.08 $253.62 $291.6681 $195.32 $224.62 $264.28 $303.92 $309.83 $356.31 $294.39 $338.55 $318.26 $366.00 $257.79 $296.4682 $197.66 $227.31 $268.34 $308.59 $314.67 $361.88 $299.23 $344.11 $323.25 $371.74 $261.83 $301.1183 $200.00 $230.00 $272.24 $313.07 $319.51 $367.43 $303.91 $349.49 $328.24 $377.48 $265.88 $305.7684 $202.19 $232.52 $276.14 $317.56 $324.19 $372.82 $308.43 $354.70 $333.08 $383.04 $269.80 $310.2785 $204.53 $235.21 $280.04 $322.04 $328.71 $378.02 $312.80 $359.72 $337.76 $388.42 $273.59 $314.6286 $206.87 $237.90 $283.62 $326.17 $333.24 $383.22 $316.70 $364.20 $342.44 $393.81 $277.38 $318.9887 $209.21 $240.59 $287.37 $330.48 $337.61 $388.25 $320.29 $368.33 $346.81 $398.83 $280.91 $323.0588 $211.39 $243.10 $290.80 $334.42 $341.66 $392.91 $323.72 $372.28 $351.18 $403.86 $284.45 $327.1289 $213.73 $245.79 $294.08 $338.19 $345.72 $397.57 $327.15 $376.23 $355.24 $408.52 $287.74 $330.9090 $216.07 $248.48 $297.36 $341.96 $349.62 $402.06 $330.27 $379.81 $359.13 $413.01 $290.90 $334.5391 $218.26 $251.00 $300.48 $345.55 $353.20 $406.19 $333.24 $383.22 $362.88 $417.31 $293.93 $338.0292 $220.60 $253.69 $303.44 $348.95 $356.64 $410.13 $335.89 $386.27 $366.47 $421.44 $296.84 $341.3693 $222.94 $256.38 $306.25 $352.19 $360.07 $414.08 $338.54 $389.32 $369.90 $425.38 $299.62 $344.5694 $225.12 $258.89 $308.90 $355.23 $363.03 $417.49 $340.88 $392.01 $373.02 $428.97 $302.15 $347.4795 $227.46 $261.58 $311.55 $358.29 $366.00 $420.90 $343.06 $394.53 $375.98 $432.38 $304.55 $350.2396 $229.65 $264.09 $314.05 $361.16 $368.96 $424.31 $345.09 $396.86 $379.10 $435.97 $307.08 $353.1497 $231.99 $266.78 $316.70 $364.20 $371.93 $427.72 $347.28 $399.37 $382.07 $439.38 $309.47 $355.9098 $234.33 $269.48 $319.35 $367.26 $374.89 $431.12 $349.46 $401.88 $385.19 $442.97 $312.00 $358.8099 $236.67 $272.17 $321.85 $370.12 $378.01 $434.71 $351.80 $404.57 $388.31 $446.55 $314.53 $361.71





46000-46399, 47100-47199, 47800-47899


65 $109.24 $125.62 $140.97 $162.11 $169.05 $194.41 $154.73 $177.94 $173.68 $199.74 $140.68 $161.7966 $114.57 $131.76 $148.13 $170.35 $177.05 $203.61 $162.87 $187.30 $181.83 $209.10 $147.28 $169.3767 $119.77 $137.73 $155.29 $178.59 $184.92 $212.66 $170.88 $196.51 $189.97 $218.47 $153.88 $176.9668 $125.10 $143.87 $162.45 $186.82 $192.78 $221.70 $178.88 $205.71 $198.12 $227.84 $160.47 $184.5569 $130.30 $149.84 $169.61 $195.06 $200.78 $230.90 $186.88 $214.92 $206.26 $237.20 $167.07 $192.1370 $135.35 $155.66 $176.63 $203.13 $208.51 $239.78 $194.89 $224.12 $214.26 $246.40 $173.55 $199.5871 $140.27 $161.31 $183.51 $211.04 $216.23 $248.66 $202.61 $233.00 $222.26 $255.60 $180.04 $207.0472 $145.04 $166.80 $190.25 $218.79 $223.81 $257.38 $210.33 $241.88 $229.99 $264.49 $186.29 $214.2373 $149.53 $171.96 $196.85 $226.38 $231.25 $265.94 $217.77 $250.44 $237.57 $273.21 $192.43 $221.3074 $153.89 $176.97 $203.17 $233.65 $238.41 $274.17 $224.93 $258.67 $245.01 $281.76 $198.46 $228.2375 $157.96 $181.65 $209.21 $240.59 $245.29 $282.09 $231.81 $266.59 $252.03 $289.84 $204.15 $234.7776 $161.89 $186.17 $214.96 $247.21 $251.89 $289.68 $238.41 $274.17 $258.77 $297.59 $209.61 $241.0577 $165.40 $190.21 $220.30 $253.35 $258.07 $296.78 $244.59 $281.28 $265.23 $305.02 $214.84 $247.0678 $168.49 $193.76 $225.36 $259.16 $263.97 $303.56 $250.35 $287.90 $271.13 $311.80 $219.62 $252.5679 $171.30 $196.99 $229.99 $264.49 $269.30 $309.70 $255.68 $294.04 $276.75 $318.26 $224.16 $257.7980 $173.82 $199.90 $234.06 $269.17 $274.36 $315.51 $260.60 $299.69 $281.80 $324.07 $228.26 $262.5081 $175.79 $202.16 $237.85 $273.53 $278.85 $320.68 $264.95 $304.70 $286.43 $329.40 $232.01 $266.8182 $177.90 $204.58 $241.50 $277.73 $283.21 $325.69 $269.30 $309.70 $290.93 $334.57 $235.65 $271.0083 $180.00 $207.00 $245.01 $281.76 $287.56 $330.69 $273.52 $314.54 $295.42 $339.73 $239.29 $275.1884 $181.97 $209.27 $248.52 $285.80 $291.77 $335.53 $277.59 $319.23 $299.77 $344.74 $242.82 $279.2485 $184.08 $211.69 $252.03 $289.84 $295.84 $340.22 $281.52 $323.75 $303.98 $349.58 $246.23 $283.1686 $186.18 $214.11 $255.26 $293.55 $299.91 $344.90 $285.03 $327.78 $308.20 $354.43 $249.64 $287.0987 $188.29 $216.53 $258.63 $297.43 $303.84 $349.42 $288.26 $331.50 $312.13 $358.95 $252.82 $290.7588 $190.25 $218.79 $261.72 $300.98 $307.49 $353.62 $291.35 $335.05 $316.06 $363.47 $256.01 $294.4189 $192.36 $221.21 $264.67 $304.37 $311.15 $357.82 $294.44 $338.60 $319.71 $367.67 $258.97 $297.8190 $194.46 $223.63 $267.62 $307.76 $314.66 $361.85 $297.25 $341.83 $323.22 $371.70 $261.81 $301.0891 $196.43 $225.90 $270.43 $310.99 $317.88 $365.57 $299.91 $344.90 $326.59 $375.58 $264.54 $304.2292 $198.54 $228.32 $273.09 $314.06 $320.97 $369.12 $302.30 $347.64 $329.82 $379.29 $267.15 $307.2393 $200.64 $230.74 $275.62 $316.97 $324.06 $372.67 $304.69 $350.39 $332.91 $382.85 $269.66 $310.1094 $202.61 $233.00 $278.01 $319.71 $326.73 $375.74 $306.79 $352.81 $335.72 $386.07 $271.93 $312.7295 $204.71 $235.42 $280.40 $322.46 $329.40 $378.81 $308.76 $355.07 $338.39 $389.14 $274.09 $315.2196 $206.68 $237.68 $282.64 $325.04 $332.07 $381.88 $310.58 $357.17 $341.19 $392.37 $276.37 $317.8297 $208.79 $240.11 $285.03 $327.78 $334.74 $384.94 $312.55 $359.43 $343.86 $395.44 $278.53 $320.3198 $210.89 $242.53 $287.42 $330.53 $337.40 $388.01 $314.52 $361.69 $346.67 $398.67 $280.80 $322.9299 $213.00 $244.95 $289.66 $333.11 $340.21 $391.24 $316.62 $364.11 $349.48 $401.90 $283.08 $325.54





All Other Zip Codes


65 $97.10 $111.66 $125.30 $144.10 $150.27 $172.81 $137.54 $158.17 $154.39 $177.54 $125.05 $143.8166 $101.84 $117.12 $131.67 $151.42 $157.38 $180.99 $144.78 $166.49 $161.63 $185.87 $130.92 $150.5567 $106.46 $122.43 $138.04 $158.74 $164.37 $189.03 $151.89 $174.67 $168.86 $194.19 $136.78 $157.3068 $111.20 $127.88 $144.40 $166.06 $171.36 $197.06 $159.00 $182.86 $176.10 $202.52 $142.64 $164.0469 $115.82 $133.19 $150.77 $173.38 $178.47 $205.25 $166.12 $191.04 $183.34 $210.84 $148.51 $170.7870 $120.31 $138.36 $157.01 $180.56 $185.34 $213.14 $173.23 $199.22 $190.46 $219.02 $154.27 $177.4171 $124.68 $143.38 $163.12 $187.59 $192.20 $221.03 $180.10 $207.11 $197.57 $227.20 $160.03 $184.0472 $128.92 $148.26 $169.11 $194.48 $198.94 $228.79 $186.96 $215.01 $204.43 $235.10 $165.59 $190.4373 $132.92 $152.86 $174.98 $201.23 $205.56 $236.39 $193.58 $222.61 $211.18 $242.85 $171.05 $196.7174 $136.79 $157.31 $180.60 $207.69 $211.92 $243.71 $199.94 $229.93 $217.79 $250.46 $176.41 $202.8775 $140.41 $161.47 $185.96 $213.86 $218.04 $250.74 $206.06 $236.97 $224.03 $257.64 $181.46 $208.6876 $143.90 $165.49 $191.08 $219.74 $223.90 $257.49 $211.92 $243.71 $230.02 $264.52 $186.32 $214.2677 $147.02 $169.08 $195.82 $225.20 $229.40 $263.80 $217.42 $250.03 $235.76 $271.12 $190.97 $219.6178 $149.77 $172.23 $200.32 $230.36 $234.64 $269.83 $222.53 $255.91 $241.00 $277.15 $195.21 $224.5079 $152.26 $175.10 $204.43 $235.10 $239.38 $275.29 $227.28 $261.37 $246.00 $282.89 $199.26 $229.1480 $154.51 $177.69 $208.05 $239.26 $243.87 $280.45 $231.64 $266.39 $250.49 $288.06 $202.90 $233.3381 $156.26 $179.70 $211.42 $243.14 $247.87 $285.05 $235.51 $270.84 $254.61 $292.80 $206.23 $237.1782 $158.13 $181.85 $214.67 $246.87 $251.74 $289.50 $239.38 $275.29 $258.60 $297.39 $209.47 $240.8983 $160.00 $184.00 $217.79 $250.46 $255.60 $293.95 $243.12 $279.59 $262.59 $301.98 $212.70 $244.6184 $161.75 $186.01 $220.91 $254.04 $259.35 $298.25 $246.74 $283.76 $266.46 $306.43 $215.84 $248.2185 $163.62 $188.17 $224.03 $257.64 $262.97 $302.42 $250.24 $287.78 $270.21 $310.74 $218.87 $251.7086 $165.49 $190.32 $226.90 $260.94 $266.59 $306.58 $253.36 $291.36 $273.95 $315.05 $221.90 $255.1987 $167.37 $192.47 $229.89 $264.38 $270.08 $310.60 $256.23 $294.66 $277.45 $319.06 $224.73 $258.4488 $169.11 $194.48 $232.64 $267.54 $273.33 $314.33 $258.98 $297.82 $280.94 $323.08 $227.56 $261.7089 $170.98 $196.63 $235.26 $270.55 $276.57 $318.06 $261.72 $300.98 $284.19 $326.82 $230.19 $264.7290 $172.86 $198.79 $237.88 $273.57 $279.69 $321.65 $264.22 $303.85 $287.31 $330.40 $232.72 $267.6391 $174.60 $200.80 $240.38 $276.44 $282.56 $324.95 $266.59 $306.58 $290.30 $333.85 $235.15 $270.4292 $176.48 $202.95 $242.75 $279.16 $285.31 $328.11 $268.71 $309.02 $293.17 $337.15 $237.47 $273.0993 $178.35 $205.10 $245.00 $281.75 $288.06 $331.26 $270.83 $311.46 $295.92 $340.31 $239.69 $275.6594 $180.10 $207.11 $247.12 $284.19 $290.43 $333.99 $272.70 $313.61 $298.42 $343.18 $241.72 $277.9795 $181.97 $209.26 $249.24 $286.63 $292.80 $336.72 $274.45 $315.62 $300.79 $345.90 $243.64 $280.1896 $183.72 $211.27 $251.24 $288.92 $295.17 $339.45 $276.07 $317.49 $303.28 $348.78 $245.66 $282.5197 $185.59 $213.43 $253.36 $291.36 $297.54 $342.17 $277.82 $319.50 $305.65 $351.50 $247.58 $284.7298 $187.46 $215.58 $255.48 $293.80 $299.91 $344.90 $279.57 $321.50 $308.15 $354.37 $249.60 $287.0499 $189.33 $217.73 $257.48 $296.10 $302.41 $347.77 $281.44 $323.66 $310.65 $357.24 $251.62 $289.37




Direct Monthly Smoker Premium RatesFor Use In All Indiana Zip Codes

46400-46499


65 $142.43 $163.80 $183.78 $211.35 $220.60 $253.69 $202.03 $232.34 $226.68 $260.68 $183.61 $211.1566 $149.46 $171.88 $193.29 $222.29 $230.89 $265.53 $212.48 $244.36 $237.29 $272.89 $192.21 $221.0467 $156.32 $179.77 $202.66 $233.05 $241.35 $277.55 $222.94 $256.38 $247.90 $285.08 $200.80 $230.9268 $163.18 $187.66 $212.02 $243.82 $251.64 $289.39 $233.39 $268.40 $258.51 $297.28 $209.39 $240.8069 $170.05 $195.56 $221.22 $254.41 $261.94 $301.23 $243.84 $280.42 $269.11 $309.48 $217.98 $250.6870 $176.60 $203.09 $230.42 $264.99 $272.08 $312.89 $254.30 $292.44 $279.57 $321.51 $226.45 $260.4271 $183.00 $210.45 $239.47 $275.40 $282.22 $324.56 $264.44 $304.10 $290.02 $333.52 $234.92 $270.1572 $189.24 $217.62 $248.21 $285.44 $292.05 $335.86 $274.42 $315.58 $300.16 $345.19 $243.13 $279.6073 $195.17 $224.44 $256.79 $295.31 $301.72 $346.98 $284.09 $326.71 $309.99 $356.49 $251.09 $288.7674 $200.94 $231.08 $265.06 $304.82 $311.08 $357.75 $293.45 $337.47 $319.66 $367.61 $258.93 $297.7775 $206.24 $237.18 $273.02 $313.97 $320.13 $368.15 $302.50 $347.88 $328.87 $378.20 $266.38 $306.3476 $211.24 $242.92 $280.50 $322.58 $328.71 $378.02 $311.08 $357.75 $337.61 $388.25 $273.46 $314.4877 $215.76 $248.12 $287.53 $330.65 $336.82 $387.35 $319.20 $367.08 $346.03 $397.94 $280.28 $322.3278 $219.82 $252.79 $294.08 $338.19 $344.31 $395.96 $326.68 $375.68 $353.83 $406.90 $286.60 $329.5979 $223.56 $257.10 $300.01 $345.01 $351.49 $404.21 $333.71 $383.76 $361.16 $415.34 $292.54 $336.4280 $226.84 $260.86 $305.47 $351.29 $357.89 $411.57 $340.10 $391.12 $367.72 $422.87 $297.85 $342.5381 $229.49 $263.91 $310.30 $356.85 $363.81 $418.39 $345.72 $397.57 $373.80 $429.87 $302.78 $348.1982 $232.14 $266.96 $315.14 $362.41 $369.59 $425.02 $351.33 $404.04 $379.73 $436.69 $307.58 $353.7283 $234.79 $270.01 $319.82 $367.79 $375.20 $431.48 $356.79 $410.32 $385.50 $443.32 $312.25 $359.0984 $237.60 $273.24 $324.34 $373.00 $380.67 $437.76 $362.10 $416.42 $391.12 $449.79 $316.80 $364.3285 $240.25 $276.29 $328.87 $378.20 $386.12 $444.04 $367.40 $422.51 $396.73 $456.24 $321.35 $369.5686 $242.91 $279.34 $333.24 $383.22 $391.27 $449.96 $371.77 $427.54 $402.04 $462.34 $325.65 $374.5087 $245.56 $282.39 $337.45 $388.07 $396.42 $455.88 $376.14 $432.56 $407.34 $468.44 $329.95 $379.4488 $248.37 $285.62 $341.50 $392.73 $401.26 $461.45 $380.20 $437.23 $412.33 $474.18 $333.99 $384.0989 $251.02 $288.67 $345.41 $397.22 $405.94 $466.83 $384.10 $441.71 $417.17 $479.75 $337.91 $388.5990 $253.67 $291.72 $349.30 $401.70 $410.46 $472.03 $387.84 $446.02 $421.85 $485.13 $341.70 $392.9591 $256.32 $294.77 $352.89 $405.83 $414.83 $477.06 $391.27 $449.96 $426.22 $490.15 $345.24 $397.0292 $259.13 $298.00 $356.32 $409.78 $418.88 $481.72 $394.55 $453.73 $430.43 $495.00 $348.65 $400.9593 $261.78 $301.05 $359.76 $413.72 $422.79 $486.20 $397.51 $457.14 $434.33 $499.48 $351.81 $404.5894 $264.44 $304.10 $362.88 $417.31 $426.38 $490.33 $400.32 $460.37 $438.08 $503.79 $354.84 $408.0795 $267.09 $307.15 $365.84 $420.72 $429.81 $494.28 $402.82 $463.24 $441.66 $507.91 $357.75 $411.4196 $269.74 $310.20 $368.81 $424.13 $433.24 $498.23 $405.31 $466.11 $445.10 $511.86 $360.53 $414.6197 $272.39 $313.25 $371.93 $427.72 $436.83 $502.35 $407.97 $469.16 $448.68 $515.99 $363.43 $417.9598 $275.20 $316.48 $374.89 $431.12 $440.26 $506.30 $410.46 $472.03 $452.43 $520.29 $366.47 $421.4499 $278.01 $319.71 $378.01 $434.71 $443.85 $510.42 $413.11 $475.08 $456.02 $524.42 $369.37 $424.78




Direct Monthly Smoker Premium RatesFor Use In All Indiana Zip Codes

46000-46399, 47100-47199, 47800-47899


65 $128.19 $147.42 $165.40 $190.21 $198.54 $228.32 $181.83 $209.10 $204.01 $234.62 $165.25 $190.0466 $134.51 $154.69 $173.96 $200.06 $207.80 $238.98 $191.23 $219.92 $213.56 $245.60 $172.99 $198.9367 $140.69 $161.79 $182.39 $209.75 $217.21 $249.79 $200.64 $230.74 $223.11 $256.57 $180.72 $207.8368 $146.87 $168.90 $190.81 $219.44 $226.48 $260.45 $210.05 $241.56 $232.66 $267.56 $188.45 $216.7269 $153.04 $176.00 $199.10 $228.96 $235.75 $271.11 $219.46 $252.38 $242.20 $278.53 $196.19 $225.6170 $158.94 $182.78 $207.38 $238.49 $244.87 $281.60 $228.87 $263.20 $251.61 $289.36 $203.81 $234.3871 $164.70 $189.40 $215.53 $247.86 $254.00 $292.10 $237.99 $273.69 $261.02 $300.17 $211.42 $243.1472 $170.31 $195.86 $223.39 $256.90 $262.85 $302.27 $246.98 $284.03 $270.15 $310.67 $218.82 $251.6473 $175.65 $202.00 $231.11 $265.78 $271.55 $312.28 $255.68 $294.04 $278.99 $320.84 $225.98 $259.8874 $180.84 $207.97 $238.55 $274.34 $279.97 $321.97 $264.11 $303.72 $287.70 $330.85 $233.04 $267.9975 $185.62 $213.46 $245.71 $282.57 $288.12 $331.34 $272.25 $313.09 $295.98 $340.38 $239.74 $275.7176 $190.11 $218.63 $252.45 $290.32 $295.84 $340.22 $279.97 $321.97 $303.84 $349.42 $246.11 $283.0377 $194.18 $223.31 $258.77 $297.59 $303.14 $348.61 $287.28 $330.37 $311.43 $358.14 $252.25 $290.0978 $197.83 $227.51 $264.67 $304.37 $309.88 $356.37 $294.01 $338.12 $318.45 $366.21 $257.94 $296.6379 $201.20 $231.39 $270.01 $310.50 $316.34 $363.79 $300.33 $345.38 $325.05 $373.80 $263.29 $302.7880 $204.15 $234.78 $274.92 $316.16 $322.10 $370.41 $306.09 $352.01 $330.94 $380.58 $268.06 $308.2781 $206.54 $237.52 $279.27 $321.16 $327.43 $376.55 $311.15 $357.82 $336.42 $386.88 $272.50 $313.3782 $208.93 $240.27 $283.63 $326.17 $332.63 $382.52 $316.20 $363.63 $341.76 $393.02 $276.82 $318.3483 $211.31 $243.01 $287.84 $331.01 $337.68 $388.34 $321.11 $369.28 $346.95 $398.99 $281.03 $323.1884 $213.84 $245.92 $291.91 $335.70 $342.60 $393.99 $325.89 $374.77 $352.01 $404.81 $285.12 $327.8985 $216.23 $248.66 $295.98 $340.38 $347.51 $399.64 $330.66 $380.26 $357.06 $410.62 $289.22 $332.6086 $218.62 $251.41 $299.91 $344.90 $352.14 $404.97 $334.59 $384.78 $361.83 $416.11 $293.08 $337.0587 $221.00 $254.15 $303.70 $349.26 $356.78 $410.30 $338.53 $389.30 $366.61 $421.60 $296.95 $341.5088 $223.53 $257.06 $307.35 $353.46 $361.13 $415.30 $342.18 $393.50 $371.10 $426.76 $300.59 $345.6889 $225.92 $259.80 $310.86 $357.49 $365.34 $420.15 $345.69 $397.54 $375.45 $431.77 $304.12 $349.7390 $228.30 $262.55 $314.37 $361.53 $369.41 $424.83 $349.06 $401.41 $379.67 $436.61 $307.53 $353.6691 $230.69 $265.29 $317.60 $365.24 $373.35 $429.35 $352.14 $404.97 $383.60 $441.14 $310.71 $357.3292 $233.22 $268.20 $320.69 $368.80 $377.00 $433.55 $355.09 $408.36 $387.39 $445.50 $313.78 $360.8593 $235.61 $270.95 $323.78 $372.35 $380.51 $437.58 $357.76 $411.42 $390.90 $449.53 $316.63 $364.1294 $237.99 $273.69 $326.59 $375.58 $383.74 $441.30 $360.29 $414.33 $394.27 $453.41 $319.36 $367.2695 $240.38 $276.44 $329.26 $378.65 $386.83 $444.85 $362.54 $416.92 $397.50 $457.12 $321.97 $370.2796 $242.77 $279.18 $331.93 $381.71 $389.92 $448.40 $364.78 $419.50 $400.59 $460.67 $324.47 $373.1597 $245.15 $281.93 $334.74 $384.94 $393.14 $452.12 $367.17 $422.25 $403.82 $464.39 $327.09 $376.1698 $247.68 $284.83 $337.40 $388.01 $396.23 $455.67 $369.41 $424.83 $407.19 $468.26 $329.82 $379.2999 $250.21 $287.74 $340.21 $391.24 $399.46 $459.38 $371.80 $427.57 $410.41 $471.98 $332.43 $382.30




Direct Monthly Smoker Premium RatesFor Use In Indiana Zip Codes

All Other Zip Codes


65 $113.95 $131.04 $147.02 $169.08 $176.48 $202.95 $161.63 $185.87 $181.34 $208.55 $146.89 $168.9266 $119.56 $137.50 $154.64 $177.83 $184.72 $212.42 $169.99 $195.48 $189.83 $218.31 $153.76 $176.8367 $125.06 $143.82 $162.12 $186.44 $193.08 $222.04 $178.35 $205.10 $198.32 $228.07 $160.64 $184.7468 $130.55 $150.13 $169.61 $195.05 $201.31 $231.51 $186.71 $214.72 $206.81 $237.83 $167.51 $192.6469 $136.04 $156.44 $176.98 $203.52 $209.55 $240.98 $195.07 $224.34 $215.29 $247.58 $174.39 $200.5470 $141.28 $162.48 $184.34 $211.99 $217.66 $250.31 $203.44 $233.95 $223.66 $257.20 $181.16 $208.3371 $146.40 $168.36 $191.58 $220.32 $225.78 $259.64 $211.55 $243.28 $232.02 $266.82 $187.93 $216.1272 $151.39 $174.10 $198.57 $228.35 $233.64 $268.69 $219.54 $252.47 $240.13 $276.15 $194.50 $223.6873 $156.14 $179.56 $205.43 $236.25 $241.38 $277.58 $227.28 $261.37 $247.99 $285.19 $200.87 $231.0074 $160.75 $184.86 $212.05 $243.85 $248.87 $286.20 $234.76 $269.98 $255.73 $294.09 $207.14 $238.2175 $165.00 $189.74 $218.41 $251.18 $256.10 $294.52 $242.00 $278.30 $263.09 $302.56 $213.10 $245.0776 $168.99 $194.34 $224.40 $258.06 $262.97 $302.42 $248.87 $286.20 $270.08 $310.60 $218.77 $251.5877 $172.61 $198.50 $230.02 $264.52 $269.46 $309.88 $255.36 $293.66 $276.82 $318.35 $224.23 $257.8678 $175.85 $202.23 $235.26 $270.55 $275.45 $316.77 $261.35 $300.55 $283.06 $325.52 $229.28 $263.6779 $178.85 $205.68 $240.00 $276.00 $281.19 $323.37 $266.96 $307.01 $288.93 $332.27 $234.03 $269.1480 $181.47 $208.69 $244.37 $281.03 $286.31 $329.26 $272.08 $312.89 $294.17 $338.30 $238.28 $274.0281 $183.59 $211.13 $248.24 $285.48 $291.05 $334.71 $276.57 $318.06 $299.04 $343.90 $242.22 $278.5682 $185.71 $213.57 $252.11 $289.93 $295.67 $340.02 $281.07 $323.23 $303.78 $349.35 $246.06 $282.9783 $187.84 $216.01 $255.86 $294.23 $300.16 $345.19 $285.44 $328.25 $308.40 $354.66 $249.80 $287.2884 $190.08 $218.59 $259.47 $298.40 $304.53 $350.21 $289.68 $333.13 $312.89 $359.83 $253.44 $291.4685 $192.20 $221.03 $263.09 $302.56 $308.90 $355.23 $293.92 $338.01 $317.39 $364.99 $257.08 $295.6586 $194.32 $223.47 $266.59 $306.58 $313.02 $359.97 $297.42 $342.03 $321.63 $369.88 $260.52 $299.6087 $196.45 $225.91 $269.96 $310.45 $317.14 $364.71 $300.91 $346.05 $325.87 $374.76 $263.96 $303.5588 $198.69 $228.50 $273.20 $314.18 $321.01 $369.16 $304.16 $349.78 $329.87 $379.35 $267.19 $307.2789 $200.81 $230.94 $276.32 $317.77 $324.75 $373.46 $307.28 $353.37 $333.74 $383.80 $270.33 $310.8890 $202.94 $233.38 $279.44 $321.36 $328.37 $377.62 $310.27 $356.81 $337.48 $388.10 $273.36 $314.3691 $205.06 $235.82 $282.31 $324.66 $331.86 $381.64 $313.02 $359.97 $340.98 $392.12 $276.19 $317.6292 $207.31 $238.40 $285.06 $327.82 $335.11 $385.37 $315.64 $362.98 $344.35 $396.00 $278.92 $320.7693 $209.43 $240.84 $287.81 $330.98 $338.23 $388.96 $318.01 $365.71 $347.46 $399.58 $281.45 $323.6694 $211.55 $243.28 $290.30 $333.85 $341.10 $392.26 $320.26 $368.30 $350.46 $403.03 $283.87 $326.4595 $213.67 $245.72 $292.67 $336.57 $343.85 $395.42 $322.25 $370.59 $353.33 $406.33 $286.20 $329.1396 $215.79 $248.16 $295.04 $339.30 $346.59 $398.58 $324.25 $372.89 $356.08 $409.49 $288.42 $331.6897 $217.91 $250.60 $297.54 $342.17 $349.46 $401.88 $326.37 $375.33 $358.95 $412.79 $290.75 $334.3698 $220.16 $253.18 $299.91 $344.90 $352.21 $405.04 $328.37 $377.62 $361.94 $416.23 $293.17 $337.1599 $222.41 $255.77 $302.41 $347.77 $355.08 $408.34 $330.49 $380.06 $364.81 $419.53 $295.50 $339.82




Monthly EFT Non-Smoker Premium RatesFor Use In Indiana Zip Codes

46400-46499


65 $101.14 $116.31 $130.52 $150.10 $156.52 $180.00 $143.26 $164.75 $160.81 $184.93 $130.26 $149.8066 $106.08 $121.99 $137.15 $157.73 $163.93 $188.52 $150.80 $173.42 $168.35 $193.61 $136.36 $156.8267 $110.89 $127.52 $143.78 $165.35 $171.21 $196.90 $158.21 $181.95 $175.89 $202.28 $142.47 $163.8468 $115.83 $133.21 $150.41 $172.97 $178.49 $205.27 $165.62 $190.47 $183.43 $210.95 $148.58 $170.8769 $120.64 $138.74 $157.04 $180.60 $185.90 $213.79 $173.03 $198.99 $190.97 $219.62 $154.69 $177.8970 $125.32 $144.12 $163.54 $188.07 $193.05 $222.01 $180.44 $207.51 $198.38 $228.14 $160.69 $184.7971 $129.87 $149.35 $169.91 $195.40 $200.20 $230.23 $187.59 $215.73 $205.79 $236.66 $166.69 $191.7072 $134.29 $154.44 $176.15 $202.58 $207.22 $238.31 $194.74 $223.96 $212.94 $244.89 $172.48 $198.3673 $138.45 $159.22 $182.26 $209.60 $214.11 $246.23 $201.63 $231.88 $219.97 $252.96 $178.17 $204.9074 $142.48 $163.85 $188.11 $216.33 $220.74 $253.85 $208.26 $239.50 $226.85 $260.88 $183.75 $211.3175 $146.25 $168.19 $193.70 $222.76 $227.11 $261.18 $214.63 $246.83 $233.36 $268.36 $189.02 $217.3776 $149.89 $172.38 $199.03 $228.89 $233.22 $268.21 $220.74 $253.85 $239.59 $275.53 $194.07 $223.1877 $153.14 $176.11 $203.97 $234.57 $238.94 $274.79 $226.47 $260.44 $245.57 $282.41 $198.92 $228.7578 $156.00 $179.40 $208.65 $239.95 $244.40 $281.07 $231.79 $266.56 $251.03 $288.69 $203.34 $233.8479 $158.60 $182.39 $212.94 $244.89 $249.35 $286.75 $236.74 $272.25 $256.24 $294.67 $207.55 $238.6880 $160.94 $185.08 $216.71 $249.22 $254.03 $292.13 $241.28 $277.48 $260.92 $300.05 $211.34 $243.0481 $162.76 $187.18 $220.22 $253.26 $258.18 $296.91 $245.32 $282.11 $265.21 $304.99 $214.82 $247.0482 $164.71 $189.42 $223.60 $257.15 $262.22 $301.55 $249.35 $286.75 $269.37 $309.77 $218.18 $250.9183 $166.66 $191.66 $226.85 $260.88 $266.24 $306.18 $253.24 $291.23 $273.52 $314.55 $221.56 $254.7984 $168.48 $193.76 $230.10 $264.62 $270.15 $310.67 $257.01 $295.57 $277.56 $319.19 $224.82 $258.5485 $170.43 $196.00 $233.36 $268.36 $273.92 $315.00 $260.66 $299.75 $281.46 $323.67 $227.98 $262.1886 $172.38 $198.24 $236.34 $271.80 $277.69 $319.34 $263.90 $303.49 $285.36 $328.16 $231.14 $265.8187 $174.33 $200.48 $239.46 $275.38 $281.33 $323.53 $266.90 $306.93 $289.00 $332.34 $234.09 $269.2088 $176.15 $202.58 $242.32 $278.67 $284.71 $327.41 $269.76 $310.22 $292.64 $336.53 $237.03 $272.5989 $178.10 $204.82 $245.05 $281.81 $288.09 $331.30 $272.62 $313.51 $296.02 $340.42 $239.77 $275.7490 $180.05 $207.06 $247.79 $284.95 $291.34 $335.04 $275.22 $316.50 $299.27 $344.16 $242.40 $278.7791 $181.87 $209.15 $250.39 $287.94 $294.32 $338.47 $277.69 $319.34 $302.39 $347.74 $244.93 $281.6792 $183.82 $211.40 $252.85 $290.78 $297.19 $341.76 $279.90 $321.88 $305.38 $351.18 $247.36 $284.4693 $185.77 $213.64 $255.19 $293.48 $300.05 $345.05 $282.11 $324.42 $308.24 $354.47 $249.67 $287.1294 $187.59 $215.73 $257.41 $296.02 $302.52 $347.89 $284.05 $326.66 $310.84 $357.46 $251.78 $289.5595 $189.54 $217.97 $259.62 $298.56 $304.99 $350.73 $285.88 $328.76 $313.31 $360.30 $253.78 $291.8496 $191.36 $220.07 $261.70 $300.95 $307.46 $353.58 $287.57 $330.70 $315.91 $363.29 $255.89 $294.2797 $193.31 $222.31 $263.90 $303.49 $309.93 $356.42 $289.39 $332.80 $318.38 $366.13 $257.88 $296.5798 $195.26 $224.55 $266.12 $306.03 $312.40 $359.26 $291.21 $334.89 $320.98 $369.12 $259.99 $298.9999 $197.21 $226.80 $268.20 $308.42 $315.00 $362.25 $293.16 $337.13 $323.58 $372.11 $262.10 $301.41





46000-46399, 47100-47199, 47800-47899


65 $91.03 $104.68 $117.47 $135.09 $140.87 $162.00 $128.94 $148.28 $144.73 $166.44 $117.23 $134.8266 $95.47 $109.79 $123.44 $141.95 $147.54 $169.67 $135.72 $156.08 $151.52 $174.25 $122.73 $141.1467 $99.80 $114.77 $129.40 $148.82 $154.09 $177.21 $142.39 $163.75 $158.30 $182.05 $128.23 $147.4668 $104.25 $119.89 $135.37 $155.68 $160.64 $184.74 $149.06 $171.42 $165.09 $189.85 $133.72 $153.7869 $108.58 $124.86 $141.34 $162.54 $167.31 $192.41 $155.73 $179.09 $171.88 $197.66 $139.22 $160.1070 $112.79 $129.71 $147.19 $169.27 $173.75 $199.81 $162.40 $186.76 $178.54 $205.33 $144.62 $166.3171 $116.88 $134.42 $152.92 $175.86 $180.18 $207.21 $168.83 $194.16 $185.21 $213.00 $150.02 $172.5372 $120.86 $138.99 $158.54 $182.32 $186.50 $214.48 $175.27 $201.56 $191.65 $220.40 $155.24 $178.5273 $124.61 $143.30 $164.04 $188.64 $192.70 $221.61 $181.47 $208.69 $197.97 $227.66 $160.35 $184.4174 $128.23 $147.47 $169.30 $194.70 $198.67 $228.47 $187.44 $215.55 $204.17 $234.79 $165.38 $190.1875 $131.63 $151.37 $174.33 $200.48 $204.40 $235.06 $193.17 $222.15 $210.02 $241.52 $170.12 $195.6376 $134.90 $155.14 $179.13 $206.00 $209.90 $241.39 $198.67 $228.47 $215.64 $247.98 $174.66 $200.8677 $137.83 $158.50 $183.58 $211.11 $215.05 $247.31 $203.82 $234.39 $221.02 $254.17 $179.02 $205.8878 $140.40 $161.46 $187.79 $215.96 $219.96 $252.96 $208.61 $239.91 $225.93 $259.82 $183.01 $210.4679 $142.74 $164.15 $191.65 $220.40 $224.41 $258.07 $213.06 $245.02 $230.61 $265.20 $186.80 $214.8180 $144.85 $166.58 $195.04 $224.30 $228.62 $262.92 $217.16 $249.73 $234.83 $270.05 $190.21 $218.7481 $146.49 $168.46 $198.20 $227.93 $232.37 $267.22 $220.78 $253.90 $238.68 $274.49 $193.33 $222.3382 $148.24 $170.48 $201.24 $231.43 $236.00 $271.40 $224.41 $258.07 $242.43 $278.79 $196.37 $225.8283 $150.00 $172.50 $204.17 $234.79 $239.62 $275.56 $227.92 $262.11 $246.17 $283.10 $199.40 $229.3184 $151.63 $174.38 $207.09 $238.16 $243.13 $279.60 $231.31 $266.01 $249.80 $287.27 $202.34 $232.6985 $153.39 $176.40 $210.02 $241.52 $246.52 $283.50 $234.59 $269.78 $253.31 $291.31 $205.18 $235.9686 $155.14 $178.42 $212.71 $244.62 $249.92 $287.41 $237.51 $273.14 $256.82 $295.34 $208.03 $239.2387 $156.90 $180.44 $215.52 $247.85 $253.19 $291.17 $240.21 $276.24 $260.10 $299.11 $210.68 $242.2888 $158.54 $182.32 $218.09 $250.81 $256.24 $294.67 $242.78 $279.20 $263.37 $302.88 $213.33 $245.3389 $160.29 $184.34 $220.55 $253.63 $259.28 $298.17 $245.35 $282.16 $266.42 $306.38 $215.80 $248.1790 $162.05 $186.35 $223.01 $256.46 $262.20 $301.53 $247.69 $284.85 $269.34 $309.74 $218.16 $250.8991 $163.69 $188.24 $225.35 $259.15 $264.89 $304.63 $249.92 $287.41 $272.15 $312.97 $220.44 $253.5092 $165.44 $190.26 $227.57 $261.70 $267.47 $307.59 $251.91 $289.69 $274.84 $316.06 $222.62 $256.0193 $167.20 $192.28 $229.68 $264.13 $270.04 $310.55 $253.90 $291.98 $277.41 $319.03 $224.70 $258.4194 $168.83 $194.16 $231.66 $266.41 $272.26 $313.10 $255.65 $294.00 $279.75 $321.72 $226.60 $260.5995 $170.59 $196.18 $233.65 $268.70 $274.49 $315.66 $257.29 $295.88 $281.98 $324.27 $228.40 $262.6696 $172.23 $198.06 $235.53 $270.86 $276.71 $318.22 $258.81 $297.63 $284.32 $326.96 $230.30 $264.8497 $173.98 $200.08 $237.51 $273.14 $278.93 $320.77 $260.45 $299.52 $286.54 $329.52 $232.10 $266.9198 $175.74 $202.10 $239.51 $275.43 $281.16 $323.33 $262.09 $301.40 $288.88 $332.21 $233.99 $269.0999 $177.49 $204.12 $241.38 $277.58 $283.50 $326.02 $263.84 $303.42 $291.22 $334.90 $235.89 $271.27





All Other Zip Codes


65 $80.91 $93.05 $104.42 $120.08 $125.22 $144.00 $114.61 $131.80 $128.65 $147.95 $104.21 $119.8466 $84.87 $97.60 $109.72 $126.18 $131.15 $150.82 $120.64 $138.74 $134.68 $154.88 $109.09 $125.4667 $88.71 $102.02 $115.02 $132.28 $136.97 $157.52 $126.57 $145.56 $140.72 $161.82 $113.98 $131.0868 $92.66 $106.57 $120.33 $138.38 $142.79 $164.21 $132.50 $152.37 $146.75 $168.76 $118.86 $136.6969 $96.51 $110.99 $125.63 $144.48 $148.72 $171.03 $138.43 $159.19 $152.78 $175.69 $123.75 $142.3170 $100.26 $115.30 $130.83 $150.46 $154.44 $177.61 $144.36 $166.01 $158.71 $182.51 $128.55 $147.8371 $103.90 $119.48 $135.93 $156.32 $160.16 $184.19 $150.07 $172.59 $164.63 $189.33 $133.35 $153.3672 $107.43 $123.55 $140.92 $162.06 $165.78 $190.65 $155.80 $179.16 $170.35 $195.91 $137.99 $158.6973 $110.76 $127.38 $145.81 $167.68 $171.29 $196.99 $161.31 $185.50 $175.97 $202.37 $142.54 $163.9274 $113.99 $131.08 $150.49 $173.06 $176.59 $203.08 $166.61 $191.60 $181.48 $208.71 $147.00 $169.0575 $117.00 $134.55 $154.96 $178.21 $181.69 $208.95 $171.71 $197.46 $186.68 $214.69 $151.21 $173.9076 $119.91 $137.90 $159.23 $183.11 $186.58 $214.57 $176.59 $203.08 $191.68 $220.43 $155.26 $178.5477 $122.51 $140.89 $163.18 $187.66 $191.16 $219.83 $181.17 $208.35 $196.46 $225.93 $159.13 $183.0078 $124.80 $143.52 $166.92 $191.96 $195.52 $224.85 $185.44 $213.25 $200.83 $230.95 $162.67 $187.0779 $126.88 $145.91 $170.35 $195.91 $199.48 $229.40 $189.39 $217.80 $204.99 $235.74 $166.04 $190.9580 $128.75 $148.07 $173.37 $199.38 $203.22 $233.70 $193.03 $221.98 $208.73 $240.04 $169.07 $194.4381 $130.21 $149.74 $176.18 $202.61 $206.55 $237.53 $196.25 $225.69 $212.16 $243.99 $171.85 $197.6382 $131.77 $151.54 $178.88 $205.72 $209.77 $241.24 $199.48 $229.40 $215.49 $247.82 $174.55 $200.7383 $133.33 $153.33 $181.48 $208.71 $213.00 $244.94 $202.60 $232.98 $218.82 $251.64 $177.24 $203.8384 $134.79 $155.01 $184.08 $211.70 $216.12 $248.53 $205.61 $236.45 $222.05 $255.35 $179.86 $206.8485 $136.35 $156.80 $186.68 $214.69 $219.13 $252.00 $208.52 $239.80 $225.16 $258.94 $182.38 $209.7486 $137.91 $158.59 $189.08 $217.44 $222.15 $255.47 $211.12 $242.79 $228.28 $262.53 $184.91 $212.6587 $139.47 $160.39 $191.57 $220.31 $225.06 $258.82 $213.52 $245.54 $231.20 $265.88 $187.27 $215.3688 $140.92 $162.06 $193.86 $222.94 $227.76 $261.93 $215.80 $248.17 $234.11 $269.23 $189.63 $218.0789 $142.48 $163.85 $196.04 $225.45 $230.47 $265.04 $218.09 $250.81 $236.81 $272.34 $191.82 $220.5990 $144.04 $165.65 $198.23 $227.96 $233.07 $268.03 $220.17 $253.20 $239.41 $275.33 $193.92 $223.0191 $145.50 $167.32 $200.31 $230.35 $235.46 $270.78 $222.15 $255.47 $241.91 $278.19 $195.95 $225.3492 $147.06 $169.12 $202.28 $232.63 $237.75 $273.41 $223.92 $257.50 $244.30 $280.95 $197.88 $227.5793 $148.62 $170.91 $204.16 $234.78 $240.04 $276.04 $225.68 $259.54 $246.59 $283.58 $199.74 $229.7094 $150.07 $172.59 $205.92 $236.81 $242.01 $278.32 $227.24 $261.33 $248.67 $285.97 $201.42 $231.6495 $151.63 $174.38 $207.69 $238.85 $243.99 $280.59 $228.70 $263.01 $250.65 $288.24 $203.02 $233.4896 $153.09 $176.05 $209.36 $240.76 $245.96 $282.86 $230.05 $264.56 $252.73 $290.64 $204.71 $235.4197 $154.65 $177.85 $211.12 $242.79 $247.94 $285.13 $231.51 $266.24 $254.70 $292.91 $206.31 $237.2598 $156.21 $179.64 $212.89 $244.83 $249.92 $287.40 $232.97 $267.91 $256.78 $295.30 $207.99 $239.1999 $157.77 $181.44 $214.56 $246.74 $252.00 $289.80 $234.53 $269.70 $258.86 $297.69 $209.68 $241.13




Monthly EFT Smoker Premium RatesFor Use In All Indiana Zip Codes

46400-46499


65 $118.69 $136.49 $153.14 $176.11 $183.82 $211.40 $168.35 $193.61 $188.89 $217.23 $153.00 $175.9566 $124.54 $143.22 $161.07 $185.23 $192.40 $221.27 $177.06 $203.62 $197.73 $227.40 $160.17 $184.1967 $130.26 $149.80 $168.87 $194.20 $201.12 $231.28 $185.77 $213.64 $206.57 $237.56 $167.32 $192.4268 $135.98 $156.38 $176.67 $203.17 $209.69 $241.15 $194.48 $223.66 $215.41 $247.73 $174.48 $200.6669 $141.70 $162.96 $184.34 $212.00 $218.27 $251.01 $203.19 $233.67 $224.25 $257.89 $181.65 $208.8970 $147.16 $169.24 $192.01 $220.82 $226.72 $260.73 $211.90 $243.69 $232.96 $267.91 $188.70 $217.0171 $152.49 $175.36 $199.55 $229.49 $235.17 $270.45 $220.35 $253.41 $241.67 $277.93 $195.76 $225.1272 $157.69 $181.35 $206.83 $237.86 $243.37 $279.87 $228.67 $262.98 $250.13 $287.64 $202.60 $232.9973 $162.63 $187.03 $213.98 $246.08 $251.42 $289.14 $236.74 $272.25 $258.31 $297.06 $209.23 $240.6274 $167.44 $192.56 $220.87 $254.00 $259.23 $298.11 $244.53 $281.22 $266.38 $306.33 $215.76 $248.1375 $171.86 $197.64 $227.50 $261.63 $266.77 $306.78 $252.07 $289.89 $274.04 $315.15 $221.98 $255.2776 $176.02 $202.43 $233.74 $268.81 $273.92 $315.00 $259.23 $298.11 $281.33 $323.53 $227.87 $262.0577 $179.79 $206.76 $239.59 $275.53 $280.68 $322.78 $265.99 $305.88 $288.35 $331.60 $233.56 $268.5978 $183.17 $210.65 $245.05 $281.81 $286.92 $329.96 $272.22 $313.06 $294.85 $339.07 $238.82 $274.6579 $186.29 $214.24 $249.99 $287.49 $292.89 $336.83 $278.08 $319.79 $300.96 $346.10 $243.77 $280.3480 $189.02 $217.38 $254.54 $292.73 $298.23 $342.96 $283.41 $325.92 $306.42 $352.38 $248.20 $285.4381 $191.23 $219.92 $258.57 $297.36 $303.17 $348.64 $288.09 $331.30 $311.49 $358.21 $252.30 $290.1582 $193.44 $222.46 $262.61 $302.00 $307.98 $354.17 $292.77 $336.68 $316.43 $363.89 $256.30 $294.7583 $195.65 $225.00 $266.51 $306.48 $312.66 $359.56 $297.32 $341.92 $321.24 $369.42 $260.20 $299.2384 $197.99 $227.69 $270.28 $310.82 $317.21 $364.79 $301.74 $347.00 $325.92 $374.81 $263.99 $303.5985 $200.20 $230.23 $274.04 $315.15 $321.76 $370.02 $306.16 $352.08 $330.60 $380.19 $267.78 $307.9586 $202.41 $232.78 $277.69 $319.34 $326.05 $374.95 $309.80 $356.27 $335.02 $385.27 $271.36 $312.0787 $204.62 $235.32 $281.20 $323.38 $330.34 $379.89 $313.44 $360.45 $339.44 $390.35 $274.94 $316.1988 $206.96 $238.01 $284.57 $327.26 $334.37 $384.52 $316.82 $364.34 $343.60 $395.14 $278.31 $320.0689 $209.17 $240.55 $287.83 $331.00 $338.27 $389.01 $320.07 $368.08 $347.63 $399.77 $281.58 $323.8290 $211.38 $243.09 $291.08 $334.74 $342.04 $393.34 $323.19 $371.66 $351.53 $404.26 $284.74 $327.4591 $213.59 $245.63 $294.07 $338.18 $345.68 $397.53 $326.05 $374.95 $355.17 $408.44 $287.69 $330.8492 $215.93 $248.33 $296.92 $341.47 $349.06 $401.42 $328.78 $378.09 $358.68 $412.48 $290.53 $334.1193 $218.14 $250.87 $299.79 $344.75 $352.31 $405.15 $331.25 $380.93 $361.93 $416.22 $293.16 $337.1494 $220.35 $253.41 $302.39 $347.74 $355.30 $408.59 $333.59 $383.63 $365.05 $419.81 $295.69 $340.0495 $222.57 $255.95 $304.86 $350.58 $358.16 $411.88 $335.67 $386.02 $368.04 $423.24 $298.11 $342.8396 $224.77 $258.49 $307.33 $353.43 $361.02 $415.17 $337.75 $388.41 $370.90 $426.53 $300.43 $345.4997 $226.99 $261.03 $309.93 $356.42 $364.01 $418.61 $339.96 $390.95 $373.89 $429.97 $302.85 $348.2898 $229.32 $263.72 $312.40 $359.26 $366.87 $421.90 $342.04 $393.34 $377.01 $433.56 $305.38 $351.1899 $231.66 $266.41 $315.00 $362.25 $369.86 $425.34 $344.25 $395.88 $380.00 $437.00 $307.80 $353.97




Monthly EFT Smoker Premium RatesFor Use In All Indiana Zip Codes

46000-46399, 47100-47199, 47800-47899


65 $106.82 $122.85 $137.83 $158.50 $165.44 $190.26 $151.52 $174.25 $170.00 $195.51 $137.70 $158.3666 $112.09 $128.90 $144.96 $166.71 $173.16 $199.14 $159.36 $183.26 $177.96 $204.66 $144.15 $165.7767 $117.24 $134.82 $151.99 $174.78 $181.00 $208.15 $167.20 $192.28 $185.92 $213.80 $150.59 $173.1868 $122.38 $140.74 $159.01 $182.86 $188.72 $217.03 $175.03 $201.29 $193.87 $222.95 $157.04 $180.5969 $127.53 $146.66 $165.91 $190.80 $196.45 $225.91 $182.87 $210.31 $201.83 $232.10 $163.48 $188.0070 $132.45 $152.31 $172.81 $198.73 $204.05 $234.66 $190.71 $219.32 $209.67 $241.12 $169.83 $195.3071 $137.24 $157.83 $179.60 $206.54 $211.66 $243.41 $198.32 $228.07 $217.51 $250.13 $176.18 $202.6172 $141.92 $163.21 $186.15 $214.07 $219.03 $251.88 $205.81 $236.68 $225.11 $258.88 $182.34 $209.6973 $146.37 $168.33 $192.59 $221.47 $226.28 $260.22 $213.06 $245.02 $232.48 $267.35 $188.31 $216.5674 $150.70 $173.30 $198.79 $228.60 $233.30 $268.30 $220.08 $253.09 $239.74 $275.70 $194.19 $223.3275 $154.68 $177.88 $204.75 $235.47 $240.09 $276.10 $226.87 $260.90 $246.64 $283.64 $199.78 $229.7576 $158.42 $182.18 $210.37 $241.93 $246.52 $283.50 $233.30 $268.30 $253.19 $291.17 $205.09 $235.8577 $161.81 $186.08 $215.64 $247.98 $252.61 $290.50 $239.39 $275.30 $259.51 $298.44 $210.20 $241.7378 $164.86 $189.58 $220.55 $253.63 $258.22 $296.96 $245.00 $281.75 $265.36 $305.17 $214.94 $247.1879 $167.66 $192.81 $225.00 $258.74 $263.61 $303.15 $250.27 $287.81 $270.86 $311.49 $219.40 $252.3180 $170.12 $195.64 $229.09 $263.45 $268.40 $308.66 $255.07 $293.33 $275.78 $317.14 $223.38 $256.8881 $172.11 $197.93 $232.72 $267.63 $272.85 $313.78 $259.28 $298.17 $280.34 $322.39 $227.07 $261.1482 $174.10 $200.21 $236.34 $271.80 $277.18 $318.76 $263.49 $303.01 $284.78 $327.50 $230.67 $265.2883 $176.09 $202.50 $239.85 $275.83 $281.39 $323.60 $267.58 $307.72 $289.11 $332.48 $234.18 $269.3184 $178.19 $204.92 $243.25 $279.74 $285.49 $328.31 $271.56 $312.30 $293.33 $337.33 $237.59 $273.2385 $180.18 $207.21 $246.64 $283.64 $289.58 $333.02 $275.54 $316.87 $297.54 $342.17 $241.01 $277.1686 $182.17 $209.50 $249.92 $287.41 $293.44 $337.46 $278.82 $320.64 $301.52 $346.74 $244.23 $280.8687 $184.16 $211.79 $253.08 $291.04 $297.30 $341.90 $282.09 $324.41 $305.49 $351.32 $247.45 $284.5788 $186.27 $214.21 $256.12 $294.53 $300.93 $346.07 $285.13 $327.91 $309.24 $355.62 $250.48 $288.0589 $188.26 $216.50 $259.04 $297.90 $304.44 $350.11 $288.06 $331.27 $312.86 $359.80 $253.42 $291.4390 $190.25 $218.78 $261.97 $301.26 $307.83 $354.01 $290.87 $334.50 $316.37 $363.83 $256.26 $294.7091 $192.23 $221.07 $264.66 $304.36 $311.11 $357.78 $293.44 $337.46 $319.65 $367.60 $258.92 $297.7592 $194.34 $223.49 $267.23 $307.32 $314.15 $361.27 $295.90 $340.28 $322.81 $371.23 $261.48 $300.7093 $196.33 $225.78 $269.81 $310.28 $317.08 $364.64 $298.12 $342.84 $325.74 $374.60 $263.85 $303.4294 $198.32 $228.07 $272.15 $312.97 $319.77 $367.73 $300.23 $345.26 $328.54 $377.83 $266.12 $306.0495 $200.31 $230.36 $274.37 $315.53 $322.34 $370.70 $302.10 $347.42 $331.23 $380.92 $268.30 $308.5496 $202.30 $232.64 $276.59 $318.08 $324.92 $373.65 $303.97 $349.57 $333.81 $383.88 $270.38 $310.9497 $204.29 $234.93 $278.93 $320.77 $327.61 $376.75 $305.96 $351.86 $336.50 $386.98 $272.56 $313.4598 $206.39 $237.35 $281.16 $323.33 $330.18 $379.71 $307.83 $354.01 $339.31 $390.20 $274.84 $316.0699 $208.50 $239.77 $283.50 $326.02 $332.87 $382.80 $309.82 $356.30 $342.00 $393.30 $277.02 $318.57




Monthly EFT Smoker Premium RatesFor Use In Indiana Zip Codes

All Other Zip Codes


65 $94.95 $109.20 $122.51 $140.89 $147.06 $169.12 $134.68 $154.88 $151.11 $173.78 $122.40 $140.7666 $99.63 $114.58 $128.86 $148.19 $153.92 $177.01 $141.65 $162.90 $158.19 $181.92 $128.13 $147.3567 $104.21 $119.84 $135.10 $155.36 $160.89 $185.03 $148.62 $170.91 $165.26 $190.05 $133.86 $153.9468 $108.78 $125.10 $141.34 $162.54 $167.76 $192.92 $155.59 $178.92 $172.33 $198.18 $139.59 $160.5369 $113.36 $130.37 $147.47 $169.60 $174.62 $200.81 $162.55 $186.94 $179.40 $206.31 $145.32 $167.1170 $117.73 $135.39 $153.61 $176.65 $181.38 $208.59 $169.52 $194.95 $186.37 $214.33 $150.96 $173.6071 $121.99 $140.29 $159.64 $183.59 $188.14 $216.36 $176.28 $202.73 $193.34 $222.34 $156.60 $180.1072 $126.15 $145.08 $165.47 $190.29 $194.69 $223.90 $182.94 $210.38 $200.10 $230.12 $162.08 $186.3973 $130.11 $149.62 $171.19 $196.87 $201.14 $231.31 $189.39 $217.80 $206.65 $237.65 $167.39 $192.5074 $133.95 $154.05 $176.70 $203.20 $207.38 $238.49 $195.63 $224.97 $213.10 $245.07 $172.61 $198.5075 $137.49 $158.11 $182.00 $209.30 $213.41 $245.42 $201.66 $231.91 $219.24 $252.12 $177.58 $204.2276 $140.82 $161.94 $186.99 $215.04 $219.13 $252.00 $207.38 $238.49 $225.06 $258.82 $182.30 $209.6477 $143.83 $165.41 $191.68 $220.43 $224.54 $258.22 $212.79 $244.71 $230.68 $265.28 $186.85 $214.8778 $146.54 $168.52 $196.04 $225.45 $229.53 $263.96 $217.78 $250.45 $235.88 $271.26 $191.06 $219.7279 $149.03 $171.39 $200.00 $229.99 $234.32 $269.46 $222.46 $255.83 $240.77 $276.88 $195.02 $224.2780 $151.22 $173.90 $203.64 $234.18 $238.58 $274.37 $226.72 $260.73 $245.13 $281.90 $198.56 $228.3481 $152.99 $175.94 $206.86 $237.89 $242.53 $278.91 $230.47 $265.04 $249.19 $286.57 $201.84 $232.1282 $154.75 $177.97 $210.08 $241.60 $246.38 $283.34 $234.21 $269.35 $253.14 $291.11 $205.04 $235.8083 $156.52 $180.00 $213.20 $245.18 $250.13 $287.64 $237.85 $273.53 $256.99 $295.54 $208.16 $239.3984 $158.39 $182.15 $216.22 $248.65 $253.77 $291.83 $241.39 $277.60 $260.73 $299.85 $211.19 $242.8785 $160.16 $184.19 $219.24 $252.12 $257.41 $296.02 $244.93 $281.66 $264.48 $304.15 $214.23 $246.3686 $161.93 $186.22 $222.15 $255.47 $260.84 $299.96 $247.84 $285.01 $268.01 $308.22 $217.09 $249.6587 $163.70 $188.25 $224.96 $258.70 $264.27 $303.91 $250.75 $288.36 $271.55 $312.28 $219.96 $252.9588 $165.57 $190.41 $227.66 $261.81 $267.49 $307.62 $253.45 $291.47 $274.88 $316.11 $222.65 $256.0589 $167.34 $192.44 $230.26 $264.80 $270.61 $311.21 $256.05 $294.46 $278.10 $319.82 $225.26 $259.0590 $169.11 $194.47 $232.86 $267.79 $273.63 $314.67 $258.55 $297.33 $281.22 $323.40 $227.79 $261.9691 $170.87 $196.51 $235.25 $270.54 $276.54 $318.02 $260.84 $299.96 $284.14 $326.76 $230.15 $264.6792 $172.75 $198.66 $237.54 $273.17 $279.24 $321.13 $263.02 $302.48 $286.94 $329.98 $232.42 $267.2993 $174.52 $200.69 $239.83 $275.80 $281.85 $324.12 $265.00 $304.75 $289.54 $332.97 $234.53 $269.7194 $176.28 $202.73 $241.91 $278.19 $284.24 $326.87 $266.87 $306.90 $292.04 $335.84 $236.55 $272.0395 $178.05 $204.76 $243.88 $280.47 $286.53 $329.51 $268.53 $308.81 $294.43 $338.59 $238.49 $274.2696 $179.82 $206.79 $245.86 $282.74 $288.82 $332.14 $270.20 $310.73 $296.72 $341.23 $240.34 $276.3997 $181.59 $208.83 $247.94 $285.13 $291.21 $334.89 $271.97 $312.76 $299.11 $343.98 $242.28 $278.6298 $183.46 $210.98 $249.92 $287.40 $293.49 $337.52 $273.63 $314.67 $301.61 $346.85 $244.30 $280.9599 $185.33 $213.13 $252.00 $289.80 $295.89 $340.27 $275.40 $316.71 $304.00 $349.60 $246.24 $283.17



PREMIUM INFORMATION

We, The Order of United Commercial Travelers of America, can only raise your premium if we raise the premium for all policies like yours in this State. Premiums are based on your attained age and will change on your policy anniversary date.

DISCLOSURES

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 your insurance company.

RIGHT TO RETURN POLICY

If you find that you are not satisfied with your policy, you may return it to: The Order of United Commercial Travelers of America, 1801 Watermark Drive, Suite 100, P.O. Box 159019, Columbus, Ohio 43215-8619, or to the representative through whom the policy was purchased. 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 The Order of United Commercial Travelers of America nor its agents are connected with Medicare.

This outline of coverage does not give all of 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.

MSA OC 10 IN Page 33

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 received skilled care in any other facility for 60 days in a row.

SERVICES MEDICARE PAYS PLAN A PAYS YOU PAYHOSPITALIZATION*Semi-private room and board, general nursing and miscellaneous services and supplies:First 60 days61st - 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

All but $1,100All but $275 a day

All but $550 a day

$0

$0

$0$275 a day

$550 a day

100% of Medicare Eligible Expenses$0

$1,100 (Part A Deductible)$0

$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 days21st - 100th day101st day and after

All approved amountsAll but $137.50 a day$0

$0$0$0

$0Up to $137.50 a dayAll costs

BLOODFirst 3 pintsAdditional amounts

$0100%

3 pints$0

$0$0

HOSPICE CAREAvailable as long as your doctor certifies that you are terminally ill and you elect to receive these services

All but very limited coinsurance for outpatient drugs and inpatient respite care $0 Balance

**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 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 AMEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR

* Once you have been billed $155 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.

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 equipment:First $155 of Medicare Approved Amounts*Remainder of Medicare Approved Amounts

$0

Generally 80%

$0

Generally 20%

$155 (Part B Deductible)

$0Part B Excess Charges (Above Medicare Approved Amounts) $0 $0 All costsBLOODFirst 3 pintsNext $155 of Medicare Approved Amounts*Remainder of Medicare Approved Amounts

$0

$0

80%

All costs

$0

20%

$0


$0CLINICAL LABORATORY SERVICES – TESTS FOR DIAGNOSTIC SERVICES 100% $0 $0

MEDICARE (PARTS A & B)

SERVICES MEDICARE PAYS PLAN A PAYS YOU PAYHOME HEALTH CARE MEDICARE APPROVED SERVICES- Medically necessary skilled care services and medical supplies- Durable medical equipment First $155 of Medicare Approved Amounts*Remainder of Medicare Approved Amounts

100%

$0

80%

$0

$0

20%

$0


$0


PLAN BMEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD


SERVICES MEDICARE PAYS PLAN B PAYS YOU PAYHOSPITALIZATION*Semi-private room and board, general nursing and miscellaneous services and supplies:First 60 days61st - 90th day91st day and after:- While using 60 lifetime reserve days- Once lifetime reserve days are used:- Additional 365 days



All but $550 a day

$0

$0

$1,100 (Part A Deductible)$275 a day

$550 a day


$0$0

$0

$0**



$0$0$0

$0Up to $137.50 a dayAll costs


$0100%

3 pints$0

$0$0





PLAN BMEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR


SERVICES MEDICARE PAYS PLAN B 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 equipment:First $155 of Medicare Approved Amounts*Remainder of MedicareApproved Amounts

$0

Generally 80%

$0

Generally 20%



$0

$0

80%

All costs

$0

20%

$0



MEDICARE (PARTS A & B)

SERVICES MEDICARE PAYS PLAN B PAYS YOU PAYHOME HEALTH CAREMEDICARE APPROVED SERVICES- Medically necessary skilled care services and medical supplies- Durable medical equipmentFirst $155 of Medicare Approved Amounts*Remainder of Medicare Approved Amounts

100%

$0

80%

$0

$0

20%

$0


$0


PLAN CMEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD


SERVICES MEDICARE PAYS PLAN C PAYS YOU PAYHOSPITALIZATION*Semi-private room and board, general nursing and miscellaneous services and supplies:First 60 days61st - 90th day91st day and after:- While using 60 lifetime reserve days- Once lifetime reserve days are used:- Additional 365 days



All but $550 a day

$0

$0


$550 a day


$0$0

$0

$0**



$0Up to $137.50 a day$0

$0$0All costs


$0100%

3 pints$0

$0$0





PLAN CMEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR


SERVICES MEDICARE PAYS PLAN C 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 equipment:First $155 of Medicare Approved Amounts*Remainder of MedicareApproved Amounts

$0

Generally 80%


Generally 20%

$0


$0

$0

80%

All costs


20%

$0

$0


MEDICARE (PARTS A & B)HOME HEALTH CAREMEDICARE APPROVED SERVICES- Medically necessary skilled care services and medical supplies- Durable medical equipmentFirst $155 of Medicare Approved Amounts*Remainder of Medicare Approved Amounts

100%

$0

80%

$0


20%

$0

$0

$0OTHER BENEFITS – NOT COVERED BY MEDICARE

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 yearRemainder of charges

$0$0

$080% to a lifetime maximum benefit of $50,000.

$25020% and amounts over the $50,000 lifetime maximum


PLAN DMEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD


SERVICES MEDICARE PAYS PLAN D PAYS YOU PAYHOSPITALIZATION*Semi-private room and board, general nursing and miscellaneous services and supplies:First 60 days61st - 90th day91st day and after:- While using 60 lifetime reserve days- Once lifetime reserve days are used:- Additional 365 days



All but $550 a day

$0

$0


$550 a day


$0$0

$0

$0**



$0Up to $137.50 a day$0

$0$0All costs


$0100%

3 pints$0

$0$0





PLAN DMEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR


SERVICES MEDICARE PAYS PLAN D 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 equipment:First $155 of Medicare Approved Amounts*Remainder of MedicareApproved Amounts

$0

Generally 80%

$0

Generally 20%



$0

$0

80%

All costs

$0

20%

$0




PLAN DMEDICARE (PARTS A & B)

SERVICES MEDICARE PAYS PLAN D PAYS YOU PAYHOME HEALTH CAREMEDICARE APPROVED SERVICES- Medically necessary skilled care services and medical supplies- Durable medical equipmentFirst $155 of Medicare Approved Amounts*Remainder of Medicare Approved Amounts

AT-HOME RECOVERY SERVICES – NOT COVERED BY MEDICAREHome care certified by your doctor, for personal care during recovery from an injury or sickness for which Medicare approved a Home Care Treatment Plan- Benefit for each visit

- Number of visits covered (Must be received within 8 weeks of last Medicare Approved visit)

- Calendar year maximum

100%

$0

80%

$0

$0

$0

$0

$0

20%

Actual charges to $40 a visit

Up to the number of Medicare Approved visits, not to exceed 7 each week.$1,600

$0


$0

Balance

OTHER BENEFITS – NOT COVERED BY MEDICARE


$0$0

$080% to a lifetime maximum benefit of $50,000



PLAN FMEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD


SERVICES MEDICARE PAYS PLAN F PAYS YOU PAYHOSPITALIZATION*Semi-private room and board, general nursing and miscellaneous services and supplies:First 60 days61st - 90th day91st day and after:- While using 60 lifetime reserve days- Once lifetime reserve days are used:- Additional 365 days



All but $550 a day

$0

$0


$550 a day


$0$0

$0

$0**



$0Up to $137.50 a day$0

$0$0All costs


$0100%

3 pints$0

$0$0





PLAN FMEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR


SERVICES MEDICARE PAYS PLAN F 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 equipment:First $155 of Medicare Approved Amounts*Remainder of Medicare Approved Amounts

$0

Generally 80%


Generally 20%

$0

$0Part B Excess Charges (Above Medicare Approved Amounts) $0 100% $0BLOODFirst 3 pintsNext $155 of Medicare Approved Amounts*Remainder of Medicare Approved Amounts

$0

$0

80%

All costs


20%

$0

$0


MEDICARE (PARTS A & B)HOME HEALTH CAREMEDICARE APPROVED SERVICES- Medically necessary skilled care services and medical supplies- Durable medical equipmentFirst $155 of Medicare Approved Amounts*Remainder of Medicare Approved Amounts

100%

$0

80%

$0


20%

$0

$0

$0OTHER BENEFITS – NOT COVERED BY MEDICARE


$0$0




PLAN GMEDICARE (PART A) – HOSPITAL SERVICES – PER BENEFIT PERIOD


SERVICES MEDICARE PAYS PLAN G PAYS YOU PAYHOSPITALIZATION*Semi-private room and board, general nursing and miscellaneous services and supplies:First 60 days61st - 90th day91st day and after:- While using 60 lifetime reserve days- Once lifetime reserve days are used:- Additional 365 days



All but $550 a day

$0

$0


$550 a day


$0$0

$0

$0**



$0Up to $137.50 a day$0

$0$0All costs


$0100%

3 pints$0

$0$0





PLAN GMEDICARE (PART B) – MEDICAL SERVICES – PER CALENDAR YEAR


SERVICES MEDICARE PAYS PLAN G 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 equipment:First $155 of Medicare Approved Amounts*Remainder of Medicare Approved Amounts

$0

Generally 80%

$0

Generally 20%


$0Part B Excess Charges (Above Medicare Approved Amounts) $0 80% 20%BLOODFirst 3 pintsNext $155 of Medicare Approved Amounts*Remainder of Medicare Approved Amounts

$0

$0

80%

All costs

$0

20%

$0




PLAN GMEDICARE (PARTS A & B)

SERVICES MEDICARE PAYS PLAN G PAYS YOU PAYHOME HEALTH CAREMEDICARE APPROVED SERVICES- Medically necessary skilled care services and medical supplies- Durable medical equipmentFirst $155 of Medicare Approved Amounts*Remainder of Medicare Approved Amounts

AT-HOME RECOVERY SERVICES – NOT COVERED BY MEDICAREHome care certified by your doctor, for personal care during recovery from an injury or sickness for which Medicare approved a Home Care Treatment Plan- Benefit for each visit

- Number of visits covered (Must be received within 8 weeks of last Medicare Approved visit)

- Calendar year maximum

100%

$0

80%

$0

$0

$0

$0

$0

20%

Actual charges to $40 a visit

Up to the number of Medicare Approved visits, not to exceed 7 each week.$1,600

$0


$0

Balance

OTHER BENEFITS – NOT COVERED BY MEDICARE


$0$0




Documents

Form Title: 18 pt - Member Login - United Commercial …access.uct.org/agentdownloadformspdf/Microsoft Word Docs... · Web viewOutline of Medicare Supplement Coverage – Cover Page: