-
OC1040A-PA (2017)
Guarantee Trust Life Insurance Company
Benefit Chart of Medicare Supplement Plans Sold on or After June
1, 2010
This chart shows the benefits included in each of the standard
Medicare Supplement plans. Every company must make Plan “A”
available. Some plans may not be available in your state.
Basic Benefits: * Hospitalization - Part A coinsurance plus
coverage for 365 additional days after Medicare benefits end.*
Medical Expenses - Part B coinsurance (generally 20% of
Medicare-approved expenses) or copayments for hospital outpatient
services. Plans K, L and N
require insureds to pay a portion of Part B coinsurance or
copayments.* Blood – First three pints of blood each year.* Hospice
– Part A coinsurance
A B C D F F* G K L M N Basic, including 100% Part B
coinsurance
Basic, including 100% Part B coinsurance
Basic, including 100% Part B coinsurance
Basic, including 100% Part B coinsurance
Basic, including 100% Part B coinsurance*
Basic, including 100% Part B coinsurance
Hospitalization and preventive care paid at 100%; other basic
benefits paid at 50%
Hospitalization and preventive care paid at 100%; other basic
benefits paid at 75%
Basic, including 100% Part B coinsurance
Basic, including 100% Part B coinsurance, except up to $20
copayment for office visit, and up to $50 co-payment for ER
Skilled Nursing Facility Coinsurance
Skilled Nursing Facility Coinsurance
Skilled Nursing Facility Coinsurance
Skilled Nursing Facility Coinsurance
50% Skilled Nursing Facility Coinsurance
75% Skilled Nursing Facility
Coinsurance
Skilled Nursing Facility Coinsurance
Skilled Nursing Facility Coinsurance
Part A Deductible
Part A Deductible
Part A Deductible
Part A Deductible
Part A Deductible
50% Part A Deductible
75% Part A Deductible
50% Part A Deductible
Part A Deductible
Part B Deductible
Part B Deductible
Part B Excess (100%)
Part B Excess (100%)
Foreign Travel Emergency
Foreign Travel Emergency
Foreign Travel Emergency
Foreign Travel Emergency
Foreign Travel
Emergency
Foreign Travel Emergency
Out-of-pocket limit $5,120 paid at 100% after limit reached.
Out-of-pocket limit $2,560; paid at 100% after limit
reached.
* Plan F also has an option called a high deductible Plan F.
This high deductible plan pays the same benefits as Plan F after
one has paid a calendar year$2,200 deductible. Benefits from high
deductible Plan F will not begin until out-of-pocket expenses
exceed $2,200. Out-of-pocket expenses for thisdeductible are
expenses that would ordinarily be paid by the policy. These
expenses include the Medicare Deductibles for Part A and Part B,
but do notinclude the plan’s separate foreign travel emergency
deductible.
PENNSYLVANIA – 15O039
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Guarantee Trust Life Insurance Company
Standardized Medicare Supplement Attained Age Premium Rates
Pennsylavania Annual Rates - Effective 2016
Form G1040A, G1040B, G1040F, G1040G, G1040N
Zips
All Others
Attained
Age Plan A Plan B Plan F Plan G Plan N Plan A Plan B Plan F Plan
G Plan N
0-64 1,307.99 1,347.23 1,658.16 1,372.39 1,127.55 1,464.95
1,508.90 1,857.14 1,537.08 1,262.85 65 1,307.99 1,347.23 1,658.16
1,372.39 1,127.55 1,464.95 1,508.90 1,857.14 1,537.08 1,262.85 66
1,307.99 1,347.23 1,658.16 1,372.39 1,127.55 1,464.95 1,508.90
1,857.14 1,537.08 1,262.85 67 1,307.99 1,347.23 1,658.16 1,372.39
1,127.55 1,464.95 1,508.90 1,857.14 1,537.08 1,262.85 68 1,307.99
1,347.23 1,658.16 1,372.39 1,127.55 1,464.95 1,508.90 1,857.14
1,537.08 1,262.85 69 1,332.84 1,374.17 1,689.66 1,399.84 1,148.97
1,494.25 1,539.07 1,892.42 1,567.82 1,286.85 70 1,358.17 1,401.66
1,723.46 1,427.84 1,171.95 1,524.13 1,569.86 1,930.27 1,599.18
1,312.59 71 1,377.18 1,429.69 1,757.93 1,456.40 1,195.39 1,546.99
1,601.25 1,968.88 1,631.16 1,338.84 72 1,408.85 1,479.73 1,819.45
1,507.37 1,237.23 1,584.12 1,657.30 2,037.79 1,688.25 1,385.70 73
1,442.67 1,531.52 1,883.14 1,560.13 1,280.53 1,623.73 1,715.30
2,109.11 1,747.34 1,434.20 74 1,484.50 1,592.78 1,958.46 1,622.53
1,331.75 1,672.44 1,783.91 2,193.48 1,817.24 1,491.56 75 1,530.52
1,666.05 2,048.55 1,697.17 1,393.01 1,729.30 1,865.98 2,294.38
1,900.83 1,560.18 76 1,577.97 1,739.36 2,138.69 1,771.84 1,454.31
1,784.64 1,948.08 2,395.33 1,984.47 1,628.82 77 1,628.47 1,826.32
2,245.62 1,860.44 1,527.02 1,843.53 2,045.48 2,515.10 2,083.69
1,710.26 78 1,678.95 1,908.51 2,346.67 1,944.16 1,595.74 1,902.52
2,137.53 2,628.27 2,177.45 1,787.23 79 1,724.28 1,994.39 2,452.27
2,031.64 1,667.55 1,955.79 2,233.72 2,746.55 2,275.44 1,867.65 80
1,769.11 2,084.14 2,562.63 2,123.07 1,742.59 2,006.64 2,334.23
2,870.14 2,377.83 1,951.70 81 1,813.34 2,157.08 2,652.32 2,197.37
1,803.58 2,056.81 2,415.93 2,970.60 2,461.06 2,020.01 82 1,853.23
2,221.80 2,731.89 2,263.30 1,857.68 2,102.06 2,488.41 3,059.71
2,534.89 2,080.61 83 1,884.74 2,277.34 2,800.19 2,319.88 1,904.13
2,137.80 2,550.62 3,136.21 2,598.26 2,132.62 84 1,907.35 2,322.89
2,856.19 2,366.28 1,942.21 2,163.45 2,601.63 3,198.93 2,650.23
2,175.27 85 1,914.98 2,346.12 2,884.75 2,389.94 1,961.63 2,172.10
2,627.65 3,230.92 2,676.73 2,197.03 86 1,922.64 2,362.54 2,904.94
2,406.67 1,975.36 2,180.79 2,646.04 3,253.54 2,695.47 2,212.41 87
1,930.33 2,371.99 2,916.56 2,416.29 1,983.26 2,189.51 2,656.63
3,266.55 2,706.25 2,221.26 88 1,938.06 2,381.48 2,928.23 2,425.96
1,991.20 2,198.27 2,667.25 3,279.62 2,717.07 2,230.14 89 1,945.81
2,391.00 2,939.94 2,435.66 1,999.16 2,207.07 2,677.92 3,292.74
2,727.94 2,239.06 90 1,949.70 2,395.78 2,945.82 2,440.53 2,003.16
2,211.48 2,683.28 3,299.32 2,733.40 2,243.54 91 1,949.70 2,395.78
2,945.82 2,440.53 2,003.16 2,211.48 2,683.28 3,299.32 2,733.40
2,243.54 92 1,949.70 2,395.78 2,945.82 2,440.53 2,003.16 2,211.48
2,683.28 3,299.32 2,733.40 2,243.54 93 1,949.70 2,395.78 2,945.82
2,440.53 2,003.16 2,211.48 2,683.28 3,299.32 2,733.40 2,243.54 94
1,949.70 2,395.78 2,945.82 2,440.53 2,003.16 2,211.48 2,683.28
3,299.32 2,733.40 2,243.54 95 1,949.70 2,395.78 2,945.82 2,440.53
2,003.16 2,211.48 2,683.28 3,299.32 2,733.40 2,243.54 96 1,949.70
2,395.78 2,945.82 2,440.53 2,003.16 2,211.48 2,683.28 3,299.32
2,733.40 2,243.54 97 1,949.70 2,395.78 2,945.82 2,440.53 2,003.16
2,211.48 2,683.28 3,299.32 2,733.40 2,243.54 98 1,949.70 2,395.78
2,945.82 2,440.53 2,003.16 2,211.48 2,683.28 3,299.32 2,733.40
2,243.54 99 1,949.70 2,395.78 2,945.82 2,440.53 2,003.16 2,211.48
2,683.28 3,299.32 2,733.40 2,243.54
Modal Factors: Annual = 1.00000Semi-annual = 0.50000 Add a
One-Time Policy Fee of $25Quarterly = 0.25000 A household discount
factor of 0.93 is applied to qualified applicantsMonthly =
0.08333
Female / Preferred Male / Preferred
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Guarantee Trust Life Insurance Company
Standardized Medicare Supplement Attained Age Premium Rates
Pennsylavania Semi-Annual Rates - Effective 2016
Form G1040A, G1040B, G1040F, G1040G, G1040N
Zips
All Others
Attained
Age Plan A Plan B Plan F Plan G Plan N Plan A Plan B Plan F Plan
G Plan N
0-64 654.00 673.62 829.08 686.20 563.78 732.48 754.45 928.57
768.54 631.43 65 654.00 673.62 829.08 686.20 563.78 732.48 754.45
928.57 768.54 631.43 66 654.00 673.62 829.08 686.20 563.78 732.48
754.45 928.57 768.54 631.43 67 654.00 673.62 829.08 686.20 563.78
732.48 754.45 928.57 768.54 631.43 68 654.00 673.62 829.08 686.20
563.78 732.48 754.45 928.57 768.54 631.43 69 666.42 687.09 844.83
699.92 574.49 747.13 769.54 946.21 783.91 643.43 70 679.09 700.83
861.73 713.92 585.98 762.07 784.93 965.14 799.59 656.30 71 688.59
714.85 878.97 728.20 597.70 773.50 800.63 984.44 815.58 669.42 72
704.43 739.87 909.73 753.69 618.62 792.06 828.65 1,018.90 844.13
692.85 73 721.34 765.76 941.57 780.07 640.27 811.87 857.65 1,054.56
873.67 717.10 74 742.25 796.39 979.23 811.27 665.88 836.22 891.96
1,096.74 908.62 745.78 75 765.26 833.03 1,024.28 848.59 696.51
864.65 932.99 1,147.19 950.42 780.09 76 788.99 869.68 1,069.35
885.92 727.16 892.32 974.04 1,197.67 992.24 814.41 77 814.24 913.16
1,122.81 930.22 763.51 921.77 1,022.74 1,257.55 1,041.85 855.13 78
839.48 954.26 1,173.34 972.08 797.87 951.26 1,068.77 1,314.14
1,088.73 893.62 79 862.14 997.20 1,226.14 1,015.82 833.78 977.90
1,116.86 1,373.28 1,137.72 933.83 80 884.56 1,042.07 1,281.32
1,061.54 871.30 1,003.32 1,167.12 1,435.07 1,188.92 975.85 81
906.67 1,078.54 1,326.16 1,098.69 901.79 1,028.41 1,207.97 1,485.30
1,230.53 1,010.01 82 926.62 1,110.90 1,365.95 1,131.65 928.84
1,051.03 1,244.21 1,529.86 1,267.45 1,040.31 83 942.37 1,138.67
1,400.10 1,159.94 952.07 1,068.90 1,275.31 1,568.11 1,299.13
1,066.31 84 953.68 1,161.45 1,428.10 1,183.14 971.11 1,081.73
1,300.82 1,599.47 1,325.12 1,087.64 85 957.49 1,173.06 1,442.38
1,194.97 980.82 1,086.05 1,313.83 1,615.46 1,338.37 1,098.52 86
961.32 1,181.27 1,452.47 1,203.34 987.68 1,090.40 1,323.02 1,626.77
1,347.74 1,106.21 87 965.17 1,186.00 1,458.28 1,208.15 991.63
1,094.76 1,328.32 1,633.28 1,353.13 1,110.63 88 969.03 1,190.74
1,464.12 1,212.98 995.60 1,099.14 1,333.63 1,639.81 1,358.54
1,115.07 89 972.91 1,195.50 1,469.97 1,217.83 999.58 1,103.54
1,338.96 1,646.37 1,363.97 1,119.53 90 974.85 1,197.89 1,472.91
1,220.27 1,001.58 1,105.74 1,341.64 1,649.66 1,366.70 1,121.77 91
974.85 1,197.89 1,472.91 1,220.27 1,001.58 1,105.74 1,341.64
1,649.66 1,366.70 1,121.77 92 974.85 1,197.89 1,472.91 1,220.27
1,001.58 1,105.74 1,341.64 1,649.66 1,366.70 1,121.77 93 974.85
1,197.89 1,472.91 1,220.27 1,001.58 1,105.74 1,341.64 1,649.66
1,366.70 1,121.77 94 974.85 1,197.89 1,472.91 1,220.27 1,001.58
1,105.74 1,341.64 1,649.66 1,366.70 1,121.77 95 974.85 1,197.89
1,472.91 1,220.27 1,001.58 1,105.74 1,341.64 1,649.66 1,366.70
1,121.77 96 974.85 1,197.89 1,472.91 1,220.27 1,001.58 1,105.74
1,341.64 1,649.66 1,366.70 1,121.77 97 974.85 1,197.89 1,472.91
1,220.27 1,001.58 1,105.74 1,341.64 1,649.66 1,366.70 1,121.77 98
974.85 1,197.89 1,472.91 1,220.27 1,001.58 1,105.74 1,341.64
1,649.66 1,366.70 1,121.77 99 974.85 1,197.89 1,472.91 1,220.27
1,001.58 1,105.74 1,341.64 1,649.66 1,366.70 1,121.77
Modal Factors: Annual = 1.00000 Add a One-Time Policy Fee of
$25Semi-annual = 0.50000 A household discount factor of 0.93 is
applied to qualified applicantsQuarterly = 0.25000Monthly =
0.08333
Female / Preferred Male / Preferred
-
Guarantee Trust Life Insurance Company
Standardized Medicare Supplement Attained Age Premium Rates
Pennsylavania Quarterly Rates - Effective 2016
Form G1040A, G1040B, G1040F, G1040G, G1040N
Zips
All Others
Attained
Age Plan A Plan B Plan F Plan G Plan N Plan A Plan B Plan F Plan
G Plan N
0-64 327.00 336.81 414.54 343.10 281.89 366.24 377.23 464.29
384.27 315.71 65 327.00 336.81 414.54 343.10 281.89 366.24 377.23
464.29 384.27 315.71 66 327.00 336.81 414.54 343.10 281.89 366.24
377.23 464.29 384.27 315.71 67 327.00 336.81 414.54 343.10 281.89
366.24 377.23 464.29 384.27 315.71 68 327.00 336.81 414.54 343.10
281.89 366.24 377.23 464.29 384.27 315.71 69 333.21 343.54 422.42
349.96 287.24 373.56 384.77 473.11 391.96 321.71 70 339.54 350.42
430.87 356.96 292.99 381.03 392.47 482.57 399.80 328.15 71 344.30
357.42 439.48 364.10 298.85 386.75 400.31 492.22 407.79 334.71 72
352.21 369.93 454.86 376.84 309.31 396.03 414.33 509.45 422.06
346.43 73 360.67 382.88 470.79 390.03 320.13 405.93 428.83 527.28
436.84 358.55 74 371.13 398.20 489.62 405.63 332.94 418.11 445.98
548.37 454.31 372.89 75 382.63 416.51 512.14 424.29 348.25 432.33
466.50 573.60 475.21 390.05 76 394.49 434.84 534.67 442.96 363.58
446.16 487.02 598.83 496.12 407.21 77 407.12 456.58 561.41 465.11
381.76 460.88 511.37 628.78 520.92 427.57 78 419.74 477.13 586.67
486.04 398.94 475.63 534.38 657.07 544.36 446.81 79 431.07 498.60
613.07 507.91 416.89 488.95 558.43 686.64 568.86 466.91 80 442.28
521.04 640.66 530.77 435.65 501.66 583.56 717.54 594.46 487.93 81
453.34 539.27 663.08 549.34 450.90 514.20 603.98 742.65 615.27
505.00 82 463.31 555.45 682.97 565.83 464.42 525.52 622.10 764.93
633.72 520.15 83 471.19 569.34 700.05 579.97 476.03 534.45 637.66
784.05 649.57 533.16 84 476.84 580.72 714.05 591.57 485.55 540.86
650.41 799.73 662.56 543.82 85 478.75 586.53 721.19 597.49 490.41
543.03 656.91 807.73 669.18 549.26 86 480.66 590.64 726.24 601.67
493.84 545.20 661.51 813.39 673.87 553.10 87 482.58 593.00 729.14
604.07 495.82 547.38 664.16 816.64 676.56 555.32 88 484.52 595.37
732.06 606.49 497.80 549.57 666.81 819.91 679.27 557.54 89 486.45
597.75 734.99 608.92 499.79 551.77 669.48 823.19 681.99 559.77 90
487.43 598.95 736.46 610.13 500.79 552.87 670.82 824.83 683.35
560.89 91 487.43 598.95 736.46 610.13 500.79 552.87 670.82 824.83
683.35 560.89 92 487.43 598.95 736.46 610.13 500.79 552.87 670.82
824.83 683.35 560.89 93 487.43 598.95 736.46 610.13 500.79 552.87
670.82 824.83 683.35 560.89 94 487.43 598.95 736.46 610.13 500.79
552.87 670.82 824.83 683.35 560.89 95 487.43 598.95 736.46 610.13
500.79 552.87 670.82 824.83 683.35 560.89 96 487.43 598.95 736.46
610.13 500.79 552.87 670.82 824.83 683.35 560.89 97 487.43 598.95
736.46 610.13 500.79 552.87 670.82 824.83 683.35 560.89 98 487.43
598.95 736.46 610.13 500.79 552.87 670.82 824.83 683.35 560.89 99
487.43 598.95 736.46 610.13 500.79 552.87 670.82 824.83 683.35
560.89
Modal Factors: Annual = 1.00000Semi-annual = 0.50000 Add a
One-Time Policy Fee of $25Quarterly = 0.25000 A household discount
factor of 0.93 is applied to qualified applicantsMonthly =
0.08333
Female / Preferred Male / Preferred
-
Guarantee Trust Life Insurance Company
Standardized Medicare Supplement Attained Age Premium Rates
Pennsylavania Monthly Rates - Effective 2016
Form G1040A, G1040B, G1040F, G1040G, G1040N
Zips
All Others
Attained
Age Plan A Plan B Plan F Plan G Plan N Plan A Plan B Plan F Plan
G Plan N
0-64 108.99 112.26 138.17 114.36 93.96 122.07 125.74 154.76
128.08 105.23 65 108.99 112.26 138.17 114.36 93.96 122.07 125.74
154.76 128.08 105.23 66 108.99 112.26 138.17 114.36 93.96 122.07
125.74 154.76 128.08 105.23 67 108.99 112.26 138.17 114.36 93.96
122.07 125.74 154.76 128.08 105.23 68 108.99 112.26 138.17 114.36
93.96 122.07 125.74 154.76 128.08 105.23 69 111.07 114.51 140.80
116.65 95.74 124.52 128.25 157.70 130.65 107.23 70 113.18 116.80
143.62 118.98 97.66 127.01 130.82 160.85 133.26 109.38 71 114.76
119.14 146.49 121.36 99.61 128.91 133.43 164.07 135.92 111.57 72
117.40 123.31 151.61 125.61 103.10 132.00 138.10 169.81 140.68
115.47 73 120.22 127.62 156.92 130.01 106.71 135.31 142.94 175.75
145.61 119.51 74 123.70 132.73 163.20 135.21 110.97 139.36 148.65
182.78 151.43 124.29 75 127.54 138.83 170.71 141.43 116.08 144.10
155.49 191.19 158.40 130.01 76 131.49 144.94 178.22 147.65 121.19
148.71 162.33 199.60 165.37 135.73 77 135.70 152.19 187.13 155.03
127.25 153.62 170.45 209.58 173.63 142.52 78 139.91 159.04 195.55
162.01 132.97 158.54 178.12 219.01 181.45 148.93 79 143.68 166.19
204.35 169.30 138.96 162.98 186.14 228.87 189.61 155.63 80 147.42
173.67 213.54 176.92 145.21 167.21 194.51 239.17 198.14 162.64 81
151.11 179.75 221.02 183.11 150.29 171.39 201.32 247.54 205.08
168.33 82 154.43 185.14 227.65 188.60 154.80 175.16 207.36 254.97
211.23 173.38 83 157.06 189.77 233.34 193.32 158.67 178.14 212.54
261.34 216.51 177.71 84 158.94 193.57 238.01 197.18 161.84 180.28
216.79 266.57 220.84 181.27 85 159.58 195.50 240.39 199.15 163.46
181.00 218.96 269.23 223.05 183.08 86 160.21 196.87 242.07 200.55
164.61 181.73 220.49 271.12 224.61 184.36 87 160.85 197.66 243.04
201.35 165.27 182.45 221.38 272.20 225.51 185.10 88 161.50 198.45
244.01 202.16 165.93 183.18 222.26 273.29 226.41 185.84 89 162.14
199.24 244.99 202.96 166.59 183.92 223.15 274.38 227.32 186.58 90
162.47 199.64 245.48 203.37 166.92 184.28 223.60 274.93 227.77
186.95 91 162.47 199.64 245.48 203.37 166.92 184.28 223.60 274.93
227.77 186.95 92 162.47 199.64 245.48 203.37 166.92 184.28 223.60
274.93 227.77 186.95 93 162.47 199.64 245.48 203.37 166.92 184.28
223.60 274.93 227.77 186.95 94 162.47 199.64 245.48 203.37 166.92
184.28 223.60 274.93 227.77 186.95 95 162.47 199.64 245.48 203.37
166.92 184.28 223.60 274.93 227.77 186.95 96 162.47 199.64 245.48
203.37 166.92 184.28 223.60 274.93 227.77 186.95 97 162.47 199.64
245.48 203.37 166.92 184.28 223.60 274.93 227.77 186.95 98 162.47
199.64 245.48 203.37 166.92 184.28 223.60 274.93 227.77 186.95 99
162.47 199.64 245.48 203.37 166.92 184.28 223.60 274.93 227.77
186.95
Modal Factors: Annual = 1.00000Semi-annual = 0.50000 Add a
One-Time Policy Fee of $25Quarterly = 0.25000 A household discount
factor of 0.93 is applied to qualified applicantsMonthly =
0.08333
Female / Preferred Male / Preferred
-
Guarantee Trust Life Insurance Company
Standardized Medicare Supplement Attained Age Premium Rates
Pennsylavania Annual Rates - Effective 2016
Form G1040A, G1040B, G1040F, G1040G, G1040N
Zips
150-153,156
Female / Preferred
Attained
Age Plan A Plan B Plan F Plan G Plan N Plan A Plan B Plan F Plan
G Plan N
0-64 1,445.20 1,488.56 1,832.11 1,516.36 1,245.83 1,618.63
1,667.19 2,051.96 1,698.33 1,395.33 65 1,445.20 1,488.56 1,832.11
1,516.36 1,245.83 1,618.63 1,667.19 2,051.96 1,698.33 1,395.33 66
1,445.20 1,488.56 1,832.11 1,516.36 1,245.83 1,618.63 1,667.19
2,051.96 1,698.33 1,395.33 67 1,445.20 1,488.56 1,832.11 1,516.36
1,245.83 1,618.63 1,667.19 2,051.96 1,698.33 1,395.33 68 1,445.20
1,488.56 1,832.11 1,516.36 1,245.83 1,618.63 1,667.19 2,051.96
1,698.33 1,395.33 69 1,472.66 1,518.33 1,866.92 1,546.69 1,269.50
1,651.00 1,700.53 2,090.95 1,732.29 1,421.84 70 1,500.64 1,548.70
1,904.26 1,577.62 1,294.89 1,684.02 1,734.54 2,132.77 1,766.94
1,450.28 71 1,521.65 1,579.67 1,942.34 1,609.18 1,320.79 1,709.28
1,769.23 2,175.42 1,802.28 1,479.29 72 1,556.65 1,634.96 2,010.32
1,665.50 1,367.02 1,750.30 1,831.15 2,251.56 1,865.36 1,531.06 73
1,594.01 1,692.18 2,080.68 1,723.79 1,414.87 1,794.06 1,895.25
2,330.37 1,930.65 1,584.65 74 1,640.24 1,759.87 2,163.91 1,792.74
1,471.46 1,847.88 1,971.06 2,423.58 2,007.87 1,648.04 75 1,691.08
1,840.82 2,263.45 1,875.21 1,539.15 1,910.71 2,061.72 2,535.07
2,100.23 1,723.85 76 1,743.51 1,921.82 2,363.04 1,957.72 1,606.87
1,971.85 2,152.44 2,646.61 2,192.64 1,799.69 77 1,799.30 2,017.91
2,481.20 2,055.60 1,687.21 2,036.92 2,260.06 2,778.94 2,302.28
1,889.68 78 1,855.08 2,108.72 2,592.85 2,148.11 1,763.14 2,102.11
2,361.76 2,903.99 2,405.88 1,974.71 79 1,905.16 2,203.61 2,709.53
2,244.77 1,842.48 2,160.97 2,468.04 3,034.67 2,514.14 2,063.58 80
1,954.70 2,302.77 2,831.46 2,345.79 1,925.39 2,217.15 2,579.11
3,171.23 2,627.28 2,156.44 81 2,003.57 2,383.37 2,930.56 2,427.89
1,992.78 2,272.58 2,669.37 3,282.22 2,719.23 2,231.91 82 2,047.64
2,454.87 3,018.47 2,500.72 2,052.56 2,322.58 2,749.46 3,380.69
2,800.81 2,298.87 83 2,082.45 2,516.24 3,093.94 2,563.24 2,103.88
2,362.06 2,818.19 3,465.21 2,870.83 2,356.34 84 2,107.44 2,566.57
3,155.82 2,614.51 2,145.95 2,390.40 2,874.56 3,534.51 2,928.25
2,403.47 85 2,115.87 2,592.23 3,187.37 2,640.65 2,167.41 2,399.97
2,903.30 3,569.86 2,957.53 2,427.50 86 2,124.34 2,610.38 3,209.69
2,659.14 2,182.59 2,409.57 2,923.62 3,594.85 2,978.23 2,444.50 87
2,132.83 2,620.82 3,222.52 2,669.77 2,191.32 2,419.20 2,935.32
3,609.23 2,990.15 2,454.27 88 2,141.37 2,631.30 3,235.41 2,680.45
2,200.08 2,428.88 2,947.06 3,623.66 3,002.11 2,464.09 89 2,149.93
2,641.83 3,248.36 2,691.17 2,208.88 2,438.60 2,958.85 3,638.16
3,014.12 2,473.95 90 2,154.23 2,647.11 3,254.85 2,696.56 2,213.30
2,443.47 2,964.77 3,645.43 3,020.14 2,478.90 91 2,154.23 2,647.11
3,254.85 2,696.56 2,213.30 2,443.47 2,964.77 3,645.43 3,020.14
2,478.90 92 2,154.23 2,647.11 3,254.85 2,696.56 2,213.30 2,443.47
2,964.77 3,645.43 3,020.14 2,478.90 93 2,154.23 2,647.11 3,254.85
2,696.56 2,213.30 2,443.47 2,964.77 3,645.43 3,020.14 2,478.90 94
2,154.23 2,647.11 3,254.85 2,696.56 2,213.30 2,443.47 2,964.77
3,645.43 3,020.14 2,478.90 95 2,154.23 2,647.11 3,254.85 2,696.56
2,213.30 2,443.47 2,964.77 3,645.43 3,020.14 2,478.90 96 2,154.23
2,647.11 3,254.85 2,696.56 2,213.30 2,443.47 2,964.77 3,645.43
3,020.14 2,478.90 97 2,154.23 2,647.11 3,254.85 2,696.56 2,213.30
2,443.47 2,964.77 3,645.43 3,020.14 2,478.90 98 2,154.23 2,647.11
3,254.85 2,696.56 2,213.30 2,443.47 2,964.77 3,645.43 3,020.14
2,478.90 99 2,154.23 2,647.11 3,254.85 2,696.56 2,213.30 2,443.47
2,964.77 3,645.43 3,020.14 2,478.90
Modal Factors: Annual = 1.00000Semi-annual = 0.50000 Add a
One-Time Policy Fee of $25Quarterly = 0.25000 A household discount
factor of 0.93 is applied to qualified applicantsMonthly =
0.08333
Male / Preferred
-
Guarantee Trust Life Insurance Company
Standardized Medicare Supplement Attained Age Premium Rates
Pennsylavania Semi-Annual Rates - Effective 2016
Form G1040A, G1040B, G1040F, G1040G, G1040N
Zips
150-153,156
Female / Preferred
Attained
Age Plan A Plan B Plan F Plan G Plan N Plan A Plan B Plan F Plan
G Plan N
0-64 722.60 744.28 916.06 758.18 622.92 809.32 833.60 1,025.98
849.17 697.67 65 722.60 744.28 916.06 758.18 622.92 809.32 833.60
1,025.98 849.17 697.67 66 722.60 744.28 916.06 758.18 622.92 809.32
833.60 1,025.98 849.17 697.67 67 722.60 744.28 916.06 758.18 622.92
809.32 833.60 1,025.98 849.17 697.67 68 722.60 744.28 916.06 758.18
622.92 809.32 833.60 1,025.98 849.17 697.67 69 736.33 759.17 933.46
773.35 634.75 825.50 850.27 1,045.48 866.15 710.92 70 750.32 774.35
952.13 788.81 647.45 842.01 867.27 1,066.39 883.47 725.14 71 760.83
789.84 971.17 804.59 660.40 854.64 884.62 1,087.71 901.14 739.65 72
778.33 817.48 1,005.16 832.75 683.51 875.15 915.58 1,125.78 932.68
765.53 73 797.01 846.09 1,040.34 861.90 707.44 897.03 947.63
1,165.19 965.33 792.33 74 820.12 879.94 1,081.96 896.37 735.73
923.94 985.53 1,211.79 1,003.94 824.02 75 845.54 920.41 1,131.73
937.61 769.58 955.36 1,030.86 1,267.54 1,050.12 861.93 76 871.76
960.91 1,181.52 978.86 803.44 985.93 1,076.22 1,323.31 1,096.32
899.85 77 899.65 1,008.96 1,240.60 1,027.80 843.61 1,018.46
1,130.03 1,389.47 1,151.14 944.84 78 927.54 1,054.36 1,296.43
1,074.06 881.57 1,051.06 1,180.88 1,452.00 1,202.94 987.36 79
952.58 1,101.81 1,354.77 1,122.39 921.24 1,080.49 1,234.02 1,517.34
1,257.07 1,031.79 80 977.35 1,151.39 1,415.73 1,172.90 962.70
1,108.58 1,289.56 1,585.62 1,313.64 1,078.22 81 1,001.79 1,191.69
1,465.28 1,213.95 996.39 1,136.29 1,334.69 1,641.11 1,359.62
1,115.96 82 1,023.82 1,227.44 1,509.24 1,250.36 1,026.28 1,161.29
1,374.73 1,690.35 1,400.41 1,149.44 83 1,041.23 1,258.12 1,546.97
1,281.62 1,051.94 1,181.03 1,409.10 1,732.61 1,435.42 1,178.17 84
1,053.72 1,283.29 1,577.91 1,307.26 1,072.98 1,195.20 1,437.28
1,767.26 1,464.13 1,201.74 85 1,057.94 1,296.12 1,593.69 1,320.33
1,083.71 1,199.99 1,451.65 1,784.93 1,478.77 1,213.75 86 1,062.17
1,305.19 1,604.85 1,329.57 1,091.30 1,204.79 1,461.81 1,797.43
1,489.12 1,222.25 87 1,066.42 1,310.41 1,611.26 1,334.89 1,095.66
1,209.60 1,467.66 1,804.62 1,495.08 1,227.14 88 1,070.69 1,315.65
1,617.71 1,340.23 1,100.04 1,214.44 1,473.53 1,811.83 1,501.06
1,232.05 89 1,074.97 1,320.92 1,624.18 1,345.59 1,104.44 1,219.30
1,479.43 1,819.08 1,507.06 1,236.98 90 1,077.12 1,323.56 1,627.43
1,348.28 1,106.65 1,221.74 1,482.39 1,822.72 1,510.07 1,239.45 91
1,077.12 1,323.56 1,627.43 1,348.28 1,106.65 1,221.74 1,482.39
1,822.72 1,510.07 1,239.45 92 1,077.12 1,323.56 1,627.43 1,348.28
1,106.65 1,221.74 1,482.39 1,822.72 1,510.07 1,239.45 93 1,077.12
1,323.56 1,627.43 1,348.28 1,106.65 1,221.74 1,482.39 1,822.72
1,510.07 1,239.45 94 1,077.12 1,323.56 1,627.43 1,348.28 1,106.65
1,221.74 1,482.39 1,822.72 1,510.07 1,239.45 95 1,077.12 1,323.56
1,627.43 1,348.28 1,106.65 1,221.74 1,482.39 1,822.72 1,510.07
1,239.45 96 1,077.12 1,323.56 1,627.43 1,348.28 1,106.65 1,221.74
1,482.39 1,822.72 1,510.07 1,239.45 97 1,077.12 1,323.56 1,627.43
1,348.28 1,106.65 1,221.74 1,482.39 1,822.72 1,510.07 1,239.45 98
1,077.12 1,323.56 1,627.43 1,348.28 1,106.65 1,221.74 1,482.39
1,822.72 1,510.07 1,239.45 99 1,077.12 1,323.56 1,627.43 1,348.28
1,106.65 1,221.74 1,482.39 1,822.72 1,510.07 1,239.45
Modal Factors: Annual = 1.00000Semi-annual = 0.50000 Add a
One-Time Policy Fee of $25Quarterly = 0.25000 A household discount
factor of 0.93 is applied to qualified applicantsMonthly =
0.08333
Male / Preferred
-
Guarantee Trust Life Insurance Company
Standardized Medicare Supplement Attained Age Premium Rates
Pennsylavania Quarterly Rates - Effective 2016
Form G1040A, G1040B, G1040F, G1040G, G1040N
Zips
150-153,156
Female / Preferred
Attained
Age Plan A Plan B Plan F Plan G Plan N Plan A Plan B Plan F Plan
G Plan N
0-64 361.30 372.14 458.03 379.09 311.46 404.66 416.80 512.99
424.58 348.83 65 361.30 372.14 458.03 379.09 311.46 404.66 416.80
512.99 424.58 348.83 66 361.30 372.14 458.03 379.09 311.46 404.66
416.80 512.99 424.58 348.83 67 361.30 372.14 458.03 379.09 311.46
404.66 416.80 512.99 424.58 348.83 68 361.30 372.14 458.03 379.09
311.46 404.66 416.80 512.99 424.58 348.83 69 368.17 379.58 466.73
386.67 317.38 412.75 425.13 522.74 433.07 355.46 70 375.16 387.18
476.07 394.41 323.72 421.01 433.64 533.19 441.74 362.57 71 380.41
394.92 485.59 402.30 330.20 427.32 442.31 543.86 450.57 369.82 72
389.16 408.74 502.58 416.38 341.76 437.58 457.79 562.89 466.34
382.77 73 398.50 423.05 520.17 430.95 353.72 448.52 473.81 582.59
482.66 396.16 74 410.06 439.97 540.98 448.19 367.87 461.97 492.77
605.90 501.97 412.01 75 422.77 460.21 565.86 468.80 384.79 477.68
515.43 633.77 525.06 430.96 76 435.88 480.46 590.76 489.43 401.72
492.96 538.11 661.65 548.16 449.92 77 449.83 504.48 620.30 513.90
421.80 509.23 565.02 694.74 575.57 472.42 78 463.77 527.18 648.21
537.03 440.79 525.53 590.44 726.00 601.47 493.68 79 476.29 550.90
677.38 561.19 460.62 540.24 617.01 758.67 628.54 515.90 80 488.68
575.69 707.87 586.45 481.35 554.29 644.78 792.81 656.82 539.11 81
500.89 595.84 732.64 606.97 498.20 568.15 667.34 820.56 679.81
557.98 82 511.91 613.72 754.62 625.18 513.14 580.65 687.37 845.17
700.20 574.72 83 520.61 629.06 773.49 640.81 525.97 590.52 704.55
866.30 717.71 589.09 84 526.86 641.64 788.96 653.63 536.49 597.60
718.64 883.63 732.06 600.87 85 528.97 648.06 796.84 660.16 541.85
599.99 725.83 892.47 739.38 606.88 86 531.09 652.60 802.42 664.79
545.65 602.39 730.91 898.71 744.56 611.13 87 533.21 655.21 805.63
667.44 547.83 604.80 733.83 902.31 747.54 613.57 88 535.34 657.83
808.85 670.11 550.02 607.22 736.77 905.92 750.53 616.02 89 537.48
660.46 812.09 672.79 552.22 609.65 739.71 909.54 753.53 618.49 90
538.56 661.78 813.71 674.14 553.33 610.87 741.19 911.36 755.04
619.73 91 538.56 661.78 813.71 674.14 553.33 610.87 741.19 911.36
755.04 619.73 92 538.56 661.78 813.71 674.14 553.33 610.87 741.19
911.36 755.04 619.73 93 538.56 661.78 813.71 674.14 553.33 610.87
741.19 911.36 755.04 619.73 94 538.56 661.78 813.71 674.14 553.33
610.87 741.19 911.36 755.04 619.73 95 538.56 661.78 813.71 674.14
553.33 610.87 741.19 911.36 755.04 619.73 96 538.56 661.78 813.71
674.14 553.33 610.87 741.19 911.36 755.04 619.73 97 538.56 661.78
813.71 674.14 553.33 610.87 741.19 911.36 755.04 619.73 98 538.56
661.78 813.71 674.14 553.33 610.87 741.19 911.36 755.04 619.73 99
538.56 661.78 813.71 674.14 553.33 610.87 741.19 911.36 755.04
619.73
Modal Factors: Annual = 1.00000Semi-annual = 0.50000 Add a
One-Time Policy Fee of $25Quarterly = 0.25000 A household discount
factor of 0.93 is applied to qualified applicantsMonthly =
0.08333
Male / Preferred
-
Guarantee Trust Life Insurance Company
Standardized Medicare Supplement Attained Age Premium Rates
Pennsylavania Monthly Rates - Effective 2016
Form G1040A, G1040B, G1040F, G1040G, G1040N
Zips
150-153,156
Female / Preferred
Attained
Age Plan A Plan B Plan F Plan G Plan N Plan A Plan B Plan F Plan
G Plan N
0-64 120.43 124.04 152.67 126.36 103.82 134.88 138.93 170.99
141.52 116.27 65 120.43 124.04 152.67 126.36 103.82 134.88 138.93
170.99 141.52 116.27 66 120.43 124.04 152.67 126.36 103.82 134.88
138.93 170.99 141.52 116.27 67 120.43 124.04 152.67 126.36 103.82
134.88 138.93 170.99 141.52 116.27 68 120.43 124.04 152.67 126.36
103.82 134.88 138.93 170.99 141.52 116.27 69 122.72 126.52 155.57
128.89 105.79 137.58 141.71 174.24 144.35 118.48 70 125.05 129.05
158.68 131.46 107.90 140.33 144.54 177.72 147.24 120.85 71 126.80
131.63 161.86 134.09 110.06 142.43 147.43 181.28 150.18 123.27 72
129.72 136.24 167.52 138.79 113.91 145.85 152.59 187.62 155.44
127.58 73 132.83 141.01 173.38 143.64 117.90 149.50 157.93 194.19
160.88 132.05 74 136.68 146.65 180.32 149.39 122.62 153.98 164.25
201.96 167.32 137.33 75 140.92 153.40 188.61 156.26 128.26 159.22
171.80 211.25 175.01 143.65 76 145.29 160.15 196.91 163.14 133.90
164.31 179.36 220.54 182.71 149.97 77 149.94 168.15 206.76 171.29
140.60 169.74 188.33 231.57 191.85 157.47 78 154.58 175.72 216.06
179.00 146.92 175.17 196.81 241.99 200.48 164.55 79 158.76 183.63
225.79 187.06 153.53 180.07 205.66 252.88 209.50 171.96 80 162.89
191.89 235.95 195.47 160.44 184.76 214.92 264.26 218.93 179.70 81
166.96 198.61 244.20 202.32 166.06 189.37 222.44 273.51 226.59
185.99 82 170.63 204.56 251.53 208.38 171.04 193.54 229.11 281.71
233.39 191.56 83 173.53 209.68 257.82 213.59 175.32 196.83 234.84
288.76 239.23 196.35 84 175.61 213.87 262.97 217.87 178.82 199.19
239.54 294.53 244.01 200.28 85 176.32 216.01 265.60 220.05 180.61
199.99 241.93 297.48 246.45 202.28 86 177.02 217.52 267.46 221.59
181.88 200.79 243.63 299.56 248.18 203.70 87 177.73 218.39 268.53
222.47 182.60 201.59 244.60 300.76 249.17 204.51 88 178.44 219.27
269.61 223.36 183.33 202.40 245.58 301.96 250.17 205.33 89 179.15
220.14 270.69 224.26 184.07 203.21 246.56 303.17 251.17 206.15 90
179.51 220.58 271.23 224.70 184.43 203.61 247.05 303.77 251.67
206.57 91 179.51 220.58 271.23 224.70 184.43 203.61 247.05 303.77
251.67 206.57 92 179.51 220.58 271.23 224.70 184.43 203.61 247.05
303.77 251.67 206.57 93 179.51 220.58 271.23 224.70 184.43 203.61
247.05 303.77 251.67 206.57 94 179.51 220.58 271.23 224.70 184.43
203.61 247.05 303.77 251.67 206.57 95 179.51 220.58 271.23 224.70
184.43 203.61 247.05 303.77 251.67 206.57 96 179.51 220.58 271.23
224.70 184.43 203.61 247.05 303.77 251.67 206.57 97 179.51 220.58
271.23 224.70 184.43 203.61 247.05 303.77 251.67 206.57 98 179.51
220.58 271.23 224.70 184.43 203.61 247.05 303.77 251.67 206.57 99
179.51 220.58 271.23 224.70 184.43 203.61 247.05 303.77 251.67
206.57
Modal Factors: Annual = 1.00000Semi-annual = 0.50000 Add a
One-Time Policy Fee of $25Quarterly = 0.25000 A household discount
factor of 0.93 is applied to qualified applicantsMonthly =
0.08333
Male / Preferred
-
Guarantee Trust Life Insurance Company
Standardized Medicare Supplement Attained Age Premium Rates
Pennsylavania Annual Rates - Effective 2016
Form G1040A, G1040B, G1040F, G1040G, G1040N
Zips
189-194
Female / Preferred
Attained
Age Plan A Plan B Plan F Plan G Plan N Plan A Plan B Plan F Plan
G Plan N
0-64 1,681.97 1,732.43 2,132.27 1,764.79 1,449.94 1,883.81
1,940.32 2,388.14 1,976.57 1,623.93 65 1,681.97 1,732.43 2,132.27
1,764.79 1,449.94 1,883.81 1,940.32 2,388.14 1,976.57 1,623.93 66
1,681.97 1,732.43 2,132.27 1,764.79 1,449.94 1,883.81 1,940.32
2,388.14 1,976.57 1,623.93 67 1,681.97 1,732.43 2,132.27 1,764.79
1,449.94 1,883.81 1,940.32 2,388.14 1,976.57 1,623.93 68 1,681.97
1,732.43 2,132.27 1,764.79 1,449.94 1,883.81 1,940.32 2,388.14
1,976.57 1,623.93 69 1,713.93 1,767.08 2,172.78 1,800.09 1,477.49
1,921.49 1,979.13 2,433.51 2,016.10 1,654.79 70 1,746.50 1,802.42
2,216.23 1,836.09 1,507.04 1,959.92 2,018.71 2,482.18 2,056.42
1,687.88 71 1,770.95 1,838.47 2,260.56 1,872.81 1,537.18 1,989.31
2,059.09 2,531.83 2,097.55 1,721.64 72 1,811.68 1,902.82 2,339.68
1,938.36 1,590.98 2,037.06 2,131.16 2,620.44 2,170.96 1,781.90 73
1,855.16 1,969.42 2,421.57 2,006.20 1,646.67 2,087.99 2,205.75
2,712.15 2,246.95 1,844.27 74 1,908.96 2,048.19 2,518.43 2,086.45
1,712.53 2,150.62 2,293.98 2,820.64 2,336.82 1,918.04 75 1,968.14
2,142.41 2,634.28 2,182.43 1,791.31 2,223.75 2,399.50 2,950.39
2,444.32 2,006.27 76 2,029.15 2,236.68 2,750.19 2,278.45 1,870.13
2,294.91 2,505.08 3,080.21 2,551.87 2,094.54 77 2,094.08 2,348.51
2,887.69 2,392.38 1,963.63 2,370.64 2,630.33 3,234.22 2,679.46
2,199.27 78 2,159.00 2,454.19 3,017.64 2,500.03 2,052.00 2,446.50
2,748.70 3,379.76 2,800.04 2,298.24 79 2,217.29 2,564.63 3,153.43
2,612.54 2,144.34 2,515.00 2,872.39 3,531.85 2,926.04 2,401.66 80
2,274.94 2,680.04 3,295.34 2,730.10 2,240.83 2,580.39 3,001.64
3,690.78 3,057.71 2,509.73 81 2,331.81 2,773.84 3,410.68 2,825.65
2,319.26 2,644.90 3,106.70 3,819.96 3,164.73 2,597.57 82 2,383.11
2,857.06 3,513.00 2,910.42 2,388.84 2,703.09 3,199.90 3,934.56
3,259.67 2,675.50 83 2,423.63 2,928.48 3,600.82 2,983.18 2,448.56
2,749.04 3,279.90 4,032.92 3,341.17 2,742.39 84 2,452.71 2,987.05
3,672.84 3,042.85 2,497.53 2,782.03 3,345.50 4,113.58 3,407.99
2,797.23 85 2,462.52 3,016.92 3,709.57 3,073.28 2,522.51 2,793.16
3,378.95 4,154.71 3,442.07 2,825.21 86 2,472.37 3,038.04 3,735.53
3,094.79 2,540.16 2,804.33 3,402.61 4,183.80 3,466.16 2,844.98 87
2,482.26 3,050.19 3,750.48 3,107.17 2,550.32 2,815.55 3,416.22
4,200.53 3,480.03 2,856.36 88 2,492.19 3,062.39 3,765.48 3,119.60
2,560.52 2,826.81 3,429.88 4,217.33 3,493.95 2,867.79 89 2,502.16
3,074.64 3,780.54 3,132.07 2,570.77 2,838.12 3,443.60 4,234.20
3,507.92 2,879.26 90 2,507.16 3,080.79 3,788.10 3,138.34 2,575.91
2,843.79 3,450.49 4,242.67 3,514.94 2,885.02 91 2,507.16 3,080.79
3,788.10 3,138.34 2,575.91 2,843.79 3,450.49 4,242.67 3,514.94
2,885.02 92 2,507.16 3,080.79 3,788.10 3,138.34 2,575.91 2,843.79
3,450.49 4,242.67 3,514.94 2,885.02 93 2,507.16 3,080.79 3,788.10
3,138.34 2,575.91 2,843.79 3,450.49 4,242.67 3,514.94 2,885.02 94
2,507.16 3,080.79 3,788.10 3,138.34 2,575.91 2,843.79 3,450.49
4,242.67 3,514.94 2,885.02 95 2,507.16 3,080.79 3,788.10 3,138.34
2,575.91 2,843.79 3,450.49 4,242.67 3,514.94 2,885.02 96 2,507.16
3,080.79 3,788.10 3,138.34 2,575.91 2,843.79 3,450.49 4,242.67
3,514.94 2,885.02 97 2,507.16 3,080.79 3,788.10 3,138.34 2,575.91
2,843.79 3,450.49 4,242.67 3,514.94 2,885.02 98 2,507.16 3,080.79
3,788.10 3,138.34 2,575.91 2,843.79 3,450.49 4,242.67 3,514.94
2,885.02 99 2,507.16 3,080.79 3,788.10 3,138.34 2,575.91 2,843.79
3,450.49 4,242.67 3,514.94 2,885.02
Modal Factors: Annual = 1.00000Semi-annual = 0.50000 Add a
One-Time Policy Fee of $25Quarterly = 0.25000 A household discount
factor of 0.93 is applied to qualified applicantsMonthly =
0.08333
Male / Preferred
-
Guarantee Trust Life Insurance Company
Standardized Medicare Supplement Attained Age Premium Rates
Pennsylavania Semi-Annual Rates - Effective 2016
Form G1040A, G1040B, G1040F, G1040G, G1040N
Zips
189-194
Female / Preferred
Attained
Age Plan A Plan B Plan F Plan G Plan N Plan A Plan B Plan F Plan
G Plan N
0-64 840.99 866.22 1,066.14 882.40 724.97 941.91 970.16 1,194.07
988.29 811.97 65 840.99 866.22 1,066.14 882.40 724.97 941.91 970.16
1,194.07 988.29 811.97 66 840.99 866.22 1,066.14 882.40 724.97
941.91
