AARP Medicare Supplement Application - Colorado Health Agents

Colorado
AARP Medicare Supplement
Insurance Plans
Enrollment Materials
Rates Shown are for Plan Effective dates
Jan 1 - Dec 1, 2013
2013
OA25080ST
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Instructions Page
Please Read Before Printing
This file contains an electronic version of the AARP Medicare Supplement Insurance Plans enrollment kit
booklet. It may be used in place of the AARP Medicare Supplement Enrollment Material booklet, which is
in the printed enrollment kit. This file may be e-mailed to prospects. The entire file must be provided to
the prospect. It includes:
Rates – Cover Page(s)
Overview of Available Plans
Your Guide to AARP’s Medicare Supplement Insurance Portfolio of Plans
Plan Benefit Tables
Value-Added Member Services Description
Enrollment Checklist
Enrollment Application
AARP Membership Application
Automatic Payments Authorization Form* (see below)
Replacement Notice** (see below)
The 2012 Choosing a Medigap Policy booklet is published by the federal government as an aid for people
with Medicare. Agents can get this document electronically through the agent portal by clicking Product
Information and Materials>Materials>Sales Materials >Year>State>Any County>Medicare Supplement.
A copy of the booklet must be delivered to the prospect at the time of application.
* Two copies of the Automatic Payments Authorization Form are also included in this file. If
the applicant is requesting the automatic payment option, the applicant must fill out and
sign both copies of the form. The applicant keeps one completed signed copy; the other
completed signed copy must be submitted with the enrollment application.
** Two copies of the Replacement Notice are included in this file. If the applicant is
replacing coverage, both copies are to be filled out and signed. The applicant keeps one
completed signed copy and the other completed signed copy must be submitted with
the enrollment application.
Please mail completed applications to:
Regular Mail:
Overnight Mail:
UnitedHealthcare Ins. Co.
Attn: Application Processing Dept.
PO Box 105331
UnitedHealthcare
Atlanta, GA 30348-5331 4868 GA Hwy 85, Ste 100
Forest Park, GA 30297
Phone: 404-751-9906
SA5094 (04-12)
For Agent Use Only
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Hello,
Thank you for your interest in the AARP ® Medicare Supplement
Insurance Plans, insured by UnitedHealthcare Insurance Company.
Inside this booklet, you will find everything you need to choose and
enroll in the plan that best meets your needs. The material in the booklet
is arranged in three sections:
• Rates – Use this section to find the rates for each plan, as well as
instructions on how to determine which rates apply to you.
• Eligibility & Benefits – This is where you’ll find a side-by-side
overview of the benefits included in each plan, as well as detailed
descriptions of each plan and the benefits it offers. The overview
can help you choose the plan that best fits your specific needs.
• Enrollment Forms – This section contains everything you need to
enroll in one of these plans, including a handy checklist explaining
each form.
Your Sales Representative (who is a licensed insurance agent contracted
with UnitedHealthcare) will review the information with you and answer
any questions you may have. Once you’ve chosen the plan that’s best
for your needs and budget, your Sales Representative can help you
complete and submit the Application Form, along with the first month’s
premium.
If you have any questions – or think of some later – please feel free to
call your Sales Representative. You can also call toll-free: 1-866-387-7550
any weekday from 7 a.m. to 11 p.m. and Saturdays from 9 a.m. to 5 p.m.,
Eastern Time.
Sincerely,
• Choose your own
doctor who accepts
Medicare patients
• No referrals for
specialists who
accept Medicare
patients
• Helps pay some or
all of the costs that
Medicare doesnʼt
Susan Morisato,
President, Insurance Solutions
UnitedHealthcare Insurance Company
P.S. If you’re not currently an AARP member, remember to join. The AARP Membership form
includes options: You can join online, by phone or by including the form and separate check
for the annual Membership dues with your application.
>
Important disclosure on back
LA26085ST
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AARP endorses the AARP Medicare Supplement Insurance Plans, insured by UnitedHealthcare Insurance Company.
UnitedHealthcare Insurance Company pays royalty fees to AARP for the use of its intellectual property. These fees
are used for the general purposes of AARP. AARP and its affiliates are not insurers.
AARP does not employ or endorse agents, brokers or producers.
Insured by UnitedHealthcare Insurance Company, Horsham, PA (UnitedHealthcare Insurance Company of New York, Islandia, NY
for New York residents). Policy Form No. GRP 79171 GPS-1 (G-36000-4). In some states, plans may be available to persons
eligible for Medicare by reason of disability.
Not connected with or endorsed by the U.S. Government or the federal Medicare program.
This is a solicitation of insurance. A licensed insurance agent/producer will contact you.
See the following materials for complete information including benefits, costs, eligibility requirements, exclusions and limitations.
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Your Plans and Rates
AARP ® Medicare Supplement Insurance Plans
insured by UnitedHealthcare Insurance Company
1 Review plan
Look over the Overview of Available Plans in this booklet to find the plans that include the benefits you need. You’ll
find all of the AARP Medicare Supplement Plans listed here.
For more detailed plan information, please see the Outlines of Coverage included in this booklet.
2 Find your rate
The rate you will pay is based on several factors including: the plan you select, your age at the time your coverage
will begin and the amount of time since you’ve enrolled in Medicare Part B.
Applicants Age 65 and older
• First – determine what your age will be as of the date you expect your coverage to begin and be sure to know
your Part B effective date.
• Then – go to the rate pages in this booklet to find your rate Group. There are descriptions for each Group to
help guide you.
• Use the following chart to help you figure out which rate Group on that rate page applies to you:
If the time period between your 65th birthday or your
Medicare Part B effective date, if later, is within:
Number of years:
You are in:
Less than 3 Group 1
3 or more but less than 6 Group 2
6ormore Group 3
There are separate rate pages for (Non-Tobacco User or Tobacco User) depending on whether or not you use
tobacco products. You are eligible for the Non-Tobacco User rates if you have not used tobacco products
within the past 12 months.
If you are in Group 1 or 2 and under age 75, you may be eligible for the Standard rates with Enrollment Discount.
You can find information about the Enrollment Discount on the next page. If you are in Group 2 or 3, your answers
to the medical questions on the application will also affect your rate as described on the rate page.
Applicants Age 50-64
If you are age 50-64 and eligible for Medicare due to disability, you are in Group 4.
3 Enroll
Once you’ve chosen a plan and found your rate, simply fill out the application and any additional required forms
included in this booklet and mail them in using the postage-paid reply envelope included in your kit. See the
Enrollment Checklist in this booklet for the list of items to complete and send in.
The AARP Medicare Supplement Insurance Plans carry the AARP name and UnitedHealthcare pays a royalty fee to AARP for
use of the AARP intellectual property. Amounts paid are used for the general purpose of AARP and its members. Neither AARP
nor its affiliate is the insurer.
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Enrollment Discount
AARP ® Medicare Supplement Insurance Plans
insured by UnitedHealthcare Insurance Company
You may qualify for an Enrollment Discount based on your age and your Medicare Part B effective date. Please see
the chart on the previous page. If you are eligible, you will find the discounted rates on the Cover Page - Rates charts
in this booklet.
Who is eligible?
You are eligible for the enrollment discount if you are between the ages of 65 and 67.
If you are between the ages of 68 and 74, you may also be eligible if your plan effective date is either:
• Within 3 years of your Medicare Part B effective date, or
• Between 3 and 6 years from your Medicare Part B effective date and you do not have any of the
medical conditions on the application.
Howitworks
The Enrollment Discount is based on the current Standard Rate. The Standard Rates usually change each year.
The discount you receive in your first year of coverage depends on your age on the date your coverage begins. The
discount decreases 3% each year on the anniversary date of your plan until the discount runs out.
Example #1:
JANE IS ELIGIBLE FOR THE ENROLLMENT DISCOUNT
- Jane’s Plan Effective Date: June 1st (This will also be her
plan anniversary date.)
- Jane’s Age When Her Plan Becomes Effective: 72
- Jane’s Age When She Enrolled in Part B: 70
Jane’s discount will begin at age of 72
• Starting discount will be 9%
• Discount will be 6% beginning June 1st of the next year
• Discount decreases 3% every year on the plan anniversary date
Example #2:
BILL IS NOT ELIGIBLE FOR THE ENROLLMENT DISCOUNT
- Bill’s Plan Effective Date: June 1st (This will also be his
JANE
plan anniversary date.)
- Bill’s Age When His Plan Becomes Effective: 72
- Bill’s Age When He Enrolled in Part B: 65
Bill is not eligible for the Enrollment Discount because he will have been
enrolled in Medicare Part B for more than six years on his Plan Effective Date.
Age on Plan
Effective Date
Starting
Discount
65 30%
66 27%
67 24%
68 21%
69 18%
70 15%
71 12%
72 9%
73 6%
74 3%
75 0%
AARP does not recommend health related products, services, insurance or programs. You are strongly encouraged to evaluate your needs.
AARP Medicare Supplement Plans insured by UnitedHealthcare Insurance Company, Horsham, PA (UnitedHealthcare Insurance Company
of New York, Islandia, NY for New York residents). Policy Form No. GRP 79171 GPS-1 (G-36000-4). In some states, AARP Medicare
Supplement Plans are available to eligible individuals under age 65 enrolled in Medicare due to disability. All plans may not be available in
your state/area.
Not connected with or endorsed by the U.S. Government or the federal Medicare program.
This is a solicitation of insurance. An agent/producer may contact you.
AARP and its affiliate are not insurance agencies or carriers and do not employ or endorse insurance agents, brokers, producers, representatives
or advisors.
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Cover Page - Rates for Colorado - Area 1
Non-Tobacco Monthly Plan Rates
AARP ® Medicare Supplement Insurance Plans insured by UnitedHealthcare Insurance Company
Group 1
Applies to individuals whose plan effective date will be within three years
following their 65th birthday or Medicare Part B effective date, if later.
Age 1 Plan A Plan B Plan C Plan F Plan K Plan L Plan N
Standard Rates with Enrollment Discount 2 for individuals ages 65-74
65 $65.62 $124.77 $149.27 $149.80 $52.50 $80.85 $107.27
66 $68.43 $130.12 $155.67 $156.22 $54.75 $84.31 $111.87
67 $71.25 $135.47 $162.07 $162.64 $57.00 $87.78 $116.47
68 $74.06 $140.81 $168.46 $169.06 $59.25 $91.24 $121.06
69 $76.87 $146.16 $174.86 $175.48 $61.50 $94.71 $125.66
70 $79.68 $151.51 $181.26 $181.90 $63.75 $98.17 $130.26
71 $82.50 $156.86 $187.66 $188.32 $66.00 $101.64 $134.86
72 $85.31 $162.20 $194.05 $194.74 $68.25 $105.10 $139.45
73 $88.12 $167.55 $200.45 $201.16 $70.50 $108.57 $144.05
74 $90.93 $172.90 $206.85 $207.58 $72.75 $112.03 $148.65
Standard Rates for ages 75 and older
75+ $93.75 $178.25 $213.25 $214.00 $75.00 $115.50 $153.25
Group 2
Applies to individuals whose plan effective date will be between 3 years and less than
6 years following their 65th birthday or Medicare Part B effective date, if later.
Age 1 Plan A Plan B Plan C Plan F Plan K Plan L Plan N
Standard Rates with Enrollment Discount 2 for individuals ages 68-74 who do
not have any of the medical conditions on the application. 3
68 $74.06 $140.81 $168.46 $169.06 $59.25 $91.24 $121.06
69 $76.87 $146.16 $174.86 $175.48 $61.50 $94.71 $125.66
70 $79.68 $151.51 $181.26 $181.90 $63.75 $98.17 $130.26
71 $82.50 $156.86 $187.66 $188.32 $66.00 $101.64 $134.86
72 $85.31 $162.20 $194.05 $194.74 $68.25 $105.10 $139.45
73 $88.12 $167.55 $200.45 $201.16 $70.50 $108.57 $144.05
74 $90.93 $172.90 $206.85 $207.58 $72.75 $112.03 $148.65
Standard Rates for individuals ages 75 and older who do not have any of the medical conditions on the application. 3
75+ $93.75 $178.25 $213.25 $214.00 $75.00 $115.50 $153.25
Level 2 Rates for individuals ages 68 and older who have one or more of the medical conditions on the application. 3
68+ $140.62 $267.37 $319.87 $321.00 $112.50 $173.25 $229.87
Group 3
Applies to individuals whose plan effective date will be 6 or more years
following their 65th birthday or Medicare Part B effective date, if later.
Age 1 Plan A Plan B Plan C Plan F Plan K Plan L Plan N
Level 1 Rates for individuals ages 71 and older who do not have any of the medical conditions on the application. 3
71+ $103.12 $196.07 $234.57 $235.40 $82.50 $127.05 $168.57
Level 2 Rates for individuals ages 71 and older who have one or more of the medical conditions on the application. 3
71+ $140.62 $267.37 $319.87 $321.00 $112.50 $173.25 $229.87
The rates above are for plan effective dates from January - December 2013 and may change.
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Cover Page - Rates for Colorado - Area 1
Tobacco Monthly Plan Rates
AARP ® Medicare Supplement Insurance Plans insured by UnitedHealthcare Insurance Company
Group 1
Applies to individuals whose plan effective date will be within three years
following their 65th birthday or Medicare Part B effective date, if later.
Age 1 Plan A Plan B Plan C Plan F Plan K Plan L Plan N
Standard Rates with Enrollment Discount 2 for individuals ages 65-74
65 $72.18 $137.24 $164.19 $164.78 $57.75 $88.93 $117.99
66 $75.27 $143.13 $171.23 $171.84 $60.22 $92.74 $123.05
67 $78.37 $149.01 $178.27 $178.90 $62.70 $96.55 $128.11
68 $81.46 $154.89 $185.31 $185.96 $65.17 $100.36 $133.17
69 $84.55 $160.77 $192.34 $193.02 $67.65 $104.18 $138.22
70 $87.65 $166.65 $199.38 $200.09 $70.12 $107.99 $143.28
71 $90.74 $172.54 $206.42 $207.15 $72.60 $111.80 $148.34
72 $93.83 $178.42 $213.45 $214.21 $75.07 $115.61 $153.39
73 $96.93 $184.30 $220.49 $221.27 $77.55 $119.42 $158.45
74 $100.02 $190.18 $227.53 $228.33 $80.02 $123.23 $163.51
Standard Rates for ages 75 and older
75+ $103.12 $196.07 $234.57 $235.40 $82.50 $127.05 $168.57
Group 2
Applies to individuals whose plan effective date will be between 3 years and less than
6 years following their 65th birthday or Medicare Part B effective date, if later.
Age 1 Plan A Plan B Plan C Plan F Plan K Plan L Plan N
Standard Rates with Enrollment Discount 2 for individuals ages 68-74 who do
not have any of the medical conditions on the application. 3
68 $81.46 $154.89 $185.31 $185.96 $65.17 $100.36 $133.17
69 $84.55 $160.77 $192.34 $193.02 $67.65 $104.18 $138.22
70 $87.65 $166.65 $199.38 $200.09 $70.12 $107.99 $143.28
71 $90.74 $172.54 $206.42 $207.15 $72.60 $111.80 $148.34
72 $93.83 $178.42 $213.45 $214.21 $75.07 $115.61 $153.39
73 $96.93 $184.30 $220.49 $221.27 $77.55 $119.42 $158.45
74 $100.02 $190.18 $227.53 $228.33 $80.02 $123.23 $163.51
Standard Rates for individuals ages 75 and older who do not have any of the medical conditions on the application. 3
75+ $103.12 $196.07 $234.57 $235.40 $82.50 $127.05 $168.57
Level 2 Rates for individuals ages 68 and older who have one or more of the medical conditions on the application. 3
68+ $154.68 $294.10 $351.85 $353.10 $123.75 $190.57 $252.85
Group 3
Applies to individuals whose plan effective date will be 6 or more years
following their 65th birthday or Medicare Part B effective date, if later.
Age 1 Plan A Plan B Plan C Plan F Plan K Plan L Plan N
Level 1 Rates for individuals ages 71 and older who do not have any of the medical conditions on the application. 3
71+ $113.43 $215.67 $258.02 $258.94 $90.75 $139.75 $185.42
Level 2 Rates for individuals ages 71 and older who have one or more of the medical conditions on the application. 3
71+ $154.68 $294.10 $351.85 $353.10 $123.75 $190.57 $252.85
The rates above are for plan effective dates from January - December 2013 and may change.
MRP0003 COA 1-13
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Cover Page - Rates for Colorado - Area 1
Under 65 Monthly Plan Rates
AARP ® Medicare Supplement Insurance Plans insured by UnitedHealthcare Insurance Company
Group 4
Applies to individuals under the age of 65 who are
eligible for Medicare by reason of disability
Age 1 Plan A Plan B Plan C Plan F Plan K Plan L Plan N
Non-Tobacco Rates
50-64 $168.75 $320.75 $383.75 $385.25 $135.00 $208.00 $275.75
Tobacco Rates
50-64 $185.62 $352.82 $422.12 $423.77 $148.50 $228.80 $303.32
The rates above are for plan effective dates from January - December 2013 and may change.
1 Your age as of your plan effective date.
2 The Enrollment Discount is available to applicants age 65 and over. You may qualify for an Enrollment Discount
based on your age and your Medicare Part B effective date.
The Enrollment Discount is applied to the current Standard Rate. The Standard Rates usually change each year.
The discount you receive in your first year of coverage depends on your age on your plan effective date. The
discount percentage reduces 3% each year on the anniversary date of your plan until the discount runs out.
3 Refer to Section 6 of the application.
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COLORADO Area 1 ZIP Codes, Effective August 1, 2012
Th e ZIP Codes Below Apply to Rates Included on the Page Headed “Cover Page – Rates”
80011
80216
80249
80601
80019
80217
80250
80602
80022
80218
80251
80603
80024
80219
80252
80614
80030
80220
80256
80640
80035
80221
80257
80036
80222
80259
80037
80223
80260
80040
80224
80261
80042
80227
80262
80045
80229
80263
80102
80230
80264
80136
80231
80265
80137
80233
80266
80201
80234
80271
80202
80235
80273
80203
80236
80274
80204
80237
80279
80205
80238
80280
80206
80239
80281
80207
80241
80290
80208
80243
80291
80209
80244
80293
80210
80246
80294
80211
80247
80295
80212
80248
80299
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Cover Page - Rates for Colorado - Area 2
Non-Tobacco Monthly Plan Rates
AARP ® Medicare Supplement Insurance Plans insured by UnitedHealthcare Insurance Company
Group 1
Applies to individuals whose plan effective date will be within three years
following their 65th birthday or Medicare Part B effective date, if later.
Age 1 Plan A Plan B Plan C Plan F Plan K Plan L Plan N
Standard Rates with Enrollment Discount 2 for individuals ages 65-74
65 $61.42 $116.72 $139.65 $140.17 $49.17 $75.77 $100.45
66 $64.05 $121.72 $145.63 $146.18 $51.28 $79.02 $104.75
67 $66.69 $126.73 $151.62 $152.19 $53.39 $82.27 $109.06
68 $69.32 $131.73 $157.60 $158.19 $55.49 $85.51 $113.36
69 $71.95 $136.73 $163.59 $164.20 $57.60 $88.76 $117.67
70 $74.58 $141.73 $169.57 $170.21 $59.71 $92.01 $121.97
71 $77.22 $146.74 $175.56 $176.22 $61.82 $95.26 $126.28
72 $79.85 $151.74 $181.54 $182.22 $63.92 $98.50 $130.58
73 $82.48 $156.74 $187.53 $188.23 $66.03 $101.75 $134.89
74 $85.11 $161.74 $193.51 $194.24 $68.14 $105.00 $139.19
Standard Rates for ages 75 and older
75+ $87.75 $166.75 $199.50 $200.25 $70.25 $108.25 $143.50
Group 2
Applies to individuals whose plan effective date will be between 3 years and less than
6 years following their 65th birthday or Medicare Part B effective date, if later.
Age 1 Plan A Plan B Plan C Plan F Plan K Plan L Plan N
Standard Rates with Enrollment Discount 2 for individuals ages 68-74 who do
not have any of the medical conditions on the application. 3
68 $69.32 $131.73 $157.60 $158.19 $55.49 $85.51 $113.36
69 $71.95 $136.73 $163.59 $164.20 $57.60 $88.76 $117.67
70 $74.58 $141.73 $169.57 $170.21 $59.71 $92.01 $121.97
71 $77.22 $146.74 $175.56 $176.22 $61.82 $95.26 $126.28
72 $79.85 $151.74 $181.54 $182.22 $63.92 $98.50 $130.58
73 $82.48 $156.74 $187.53 $188.23 $66.03 $101.75 $134.89
74 $85.11 $161.74 $193.51 $194.24 $68.14 $105.00 $139.19
Standard Rates for individuals ages 75 and older who do not have any of the medical conditions on the application. 3
75+ $87.75 $166.75 $199.50 $200.25 $70.25 $108.25 $143.50
Level 2 Rates for individuals ages 68 and older who have one or more of the medical conditions on the application. 3
68+ $131.62 $250.12 $299.25 $300.37 $105.37 $162.37 $215.25
Group 3
Applies to individuals whose plan effective date will be 6 or more years
following their 65th birthday or Medicare Part B effective date, if later.
Age 1 Plan A Plan B Plan C Plan F Plan K Plan L Plan N
Level 1 Rates for individuals ages 71 and older who do not have any of the medical conditions on the application. 3
71+ $96.52 $183.42 $219.45 $220.27 $77.27 $119.07 $157.85
Level 2 Rates for individuals ages 71 and older who have one or more of the medical conditions on the application. 3
71+ $131.62 $250.12 $299.25 $300.37 $105.37 $162.37 $215.25
The rates above are for plan effective dates from January - December 2013 and may change.
MRP0003 COB 1-13
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Cover Page - Rates for Colorado - Area 2
Tobacco Monthly Plan Rates
AARP ® Medicare Supplement Insurance Plans insured by UnitedHealthcare Insurance Company
Group 1
Applies to individuals whose plan effective date will be within three years
following their 65th birthday or Medicare Part B effective date, if later.
Age 1 Plan A Plan B Plan C Plan F Plan K Plan L Plan N
Standard Rates with Enrollment Discount 2 for individuals ages 65-74
65 $67.56 $128.39 $153.61 $154.18 $54.08 $83.34 $110.49
66 $70.45 $133.89 $160.19 $160.79 $56.40 $86.92 $115.23
67 $73.35 $139.39 $166.78 $167.40 $58.72 $90.49 $119.96
68 $76.25 $144.90 $173.36 $174.01 $61.04 $94.06 $124.70
69 $79.14 $150.40 $179.94 $180.62 $63.36 $97.63 $129.43
70 $82.04 $155.90 $186.53 $187.22 $65.67 $101.20 $134.17
71 $84.93 $161.40 $193.11 $193.83 $67.99 $104.78 $138.90
72 $87.83 $166.91 $199.69 $200.44 $70.31 $108.35 $143.64
73 $90.72 $172.41 $206.28 $207.05 $72.63 $111.92 $148.37
74 $93.62 $177.91 $212.86 $213.66 $74.95 $115.49 $153.11
Standard Rates for ages 75 and older
75+ $96.52 $183.42 $219.45 $220.27 $77.27 $119.07 $157.85
Group 2
Applies to individuals whose plan effective date will be between 3 years and less than
6 years following their 65th birthday or Medicare Part B effective date, if later.
Age 1 Plan A Plan B Plan C Plan F Plan K Plan L Plan N
Standard Rates with Enrollment Discount 2 for individuals ages 68-74 who do
not have any of the medical conditions on the application. 3
68 $76.25 $144.90 $173.36 $174.01 $61.04 $94.06 $124.70
69 $79.14 $150.40 $179.94 $180.62 $63.36 $97.63 $129.43
70 $82.04 $155.90 $186.53 $187.22 $65.67 $101.20 $134.17
71 $84.93 $161.40 $193.11 $193.83 $67.99 $104.78 $138.90
72 $87.83 $166.91 $199.69 $200.44 $70.31 $108.35 $143.64
73 $90.72 $172.41 $206.28 $207.05 $72.63 $111.92 $148.37
74 $93.62 $177.91 $212.86 $213.66 $74.95 $115.49 $153.11
Standard Rates for individuals ages 75 and older who do not have any of the medical conditions on the application. 3
75+ $96.52 $183.42 $219.45 $220.27 $77.27 $119.07 $157.85
Level 2 Rates for individuals ages 68 and older who have one or more of the medical conditions on the application. 3
68+ $144.78 $275.13 $329.17 $330.40 $115.90 $178.60 $236.77
Group 3
Applies to individuals whose plan effective date will be 6 or more years
following their 65th birthday or Medicare Part B effective date, if later.
Age 1 Plan A Plan B Plan C Plan F Plan K Plan L Plan N
Level 1 Rates for individuals ages 71 and older who do not have any of the medical conditions on the application. 3
71+ $106.17 $201.76 $241.39 $242.29 $84.99 $130.97 $173.63
Level 2 Rates for individuals ages 71 and older who have one or more of the medical conditions on the application. 3
71+ $144.78 $275.13 $329.17 $330.40 $115.90 $178.60 $236.77
The rates above are for plan effective dates from January - December 2013 and may change.
MRP0003 COB 1-13
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Cover Page - Rates for Colorado - Area 2
Under 65 Monthly Plan Rates
AARP ® Medicare Supplement Insurance Plans insured by UnitedHealthcare Insurance Company
Group 4
Applies to individuals under the age of 65 who are
eligible for Medicare by reason of disability
Age 1 Plan A Plan B Plan C Plan F Plan K Plan L Plan N
Non-Tobacco Rates
50-64 $158.00 $300.25 $359.00 $360.50 $126.50 $194.75 $258.25
Tobacco Rates
50-64 $173.80 $330.27 $394.90 $396.55 $139.15 $214.22 $284.07
The rates above are for plan effective dates from January - December 2013 and may change.
1 Your age as of your plan effective date.
2 The Enrollment Discount is available to applicants age 65 and over. You may qualify for an Enrollment Discount
based on your age and your Medicare Part B effective date.
The Enrollment Discount is applied to the current Standard Rate. The Standard Rates usually change each year.
The discount you receive in your first year of coverage depends on your age on your plan effective date. The
discount percentage reduces 3% each year on the anniversary date of your plan until the discount runs out.
3 Refer to Section 6 of the application.
MRP0003 COB 1-13
0000001 0000008 0015 0074 UMS1129 01 L

COLORADO Area 2 ZIP Codes, Effective August 1, 2012
Th e ZIP Codes Below Apply to Rates Included on the Page Headed “Cover Page – Rates”
80001
80002
80003
80004
80005
80006
80007
80010
80012
80013
80014
80015
80016
80017
80018
80021
80031
80033
80034
80041
80044
80046
80047
80103
80105
80110
80111
80112
80113
80120
80121
80122
80123
80127
80128
80150
80151
80155
80160
80161
80162
80165
80166
80214
80215
80225
80226
80228
80232
80401
80402
80403
80419
80422
80425
80427
80433
80436
80437
80438
80439
80444
80452
80453
80454
80457
80465
80470
80474
80476
SA5110 OB (08-12) Page 1 of 1
0000001 0000008 0016 0074 UMS1129 01 L

Cover Page - Rates for Colorado - Area 3
Non-Tobacco Monthly Plan Rates
AARP ® Medicare Supplement Insurance Plans insured by UnitedHealthcare Insurance Company
Group 1
Applies to individuals whose plan effective date will be within three years
following their 65th birthday or Medicare Part B effective date, if later.
Age 1 Plan A Plan B Plan C Plan F Plan K Plan L Plan N
Standard Rates with Enrollment Discount 2 for individuals ages 65-74
65 $58.45 $111.12 $133.00 $133.35 $46.90 $72.10 $95.55
66 $60.95 $115.88 $138.70 $139.06 $48.91 $75.19 $99.64
67 $63.46 $120.65 $144.40 $144.78 $50.92 $78.28 $103.74
68 $65.96 $125.41 $150.10 $150.49 $52.93 $81.37 $107.83
69 $68.47 $130.17 $155.80 $156.21 $54.94 $84.46 $111.93
70 $70.97 $134.93 $161.50 $161.92 $56.95 $87.55 $116.02
71 $73.48 $139.70 $167.20 $167.64 $58.96 $90.64 $120.12
72 $75.98 $144.46 $172.90 $173.35 $60.97 $93.73 $124.21
73 $78.49 $149.22 $178.60 $179.07 $62.98 $96.82 $128.31
74 $80.99 $153.98 $184.30 $184.78 $64.99 $99.91 $132.40
Standard Rates for ages 75 and older
75+ $83.50 $158.75 $190.00 $190.50 $67.00 $103.00 $136.50
Group 2
Applies to individuals whose plan effective date will be between 3 years and less than
6 years following their 65th birthday or Medicare Part B effective date, if later.
Age 1 Plan A Plan B Plan C Plan F Plan K Plan L Plan N
Standard Rates with Enrollment Discount 2 for individuals ages 68-74 who do
not have any of the medical conditions on the application. 3
68 $65.96 $125.41 $150.10 $150.49 $52.93 $81.37 $107.83
69 $68.47 $130.17 $155.80 $156.21 $54.94 $84.46 $111.93
70 $70.97 $134.93 $161.50 $161.92 $56.95 $87.55 $116.02
71 $73.48 $139.70 $167.20 $167.64 $58.96 $90.64 $120.12
72 $75.98 $144.46 $172.90 $173.35 $60.97 $93.73 $124.21
73 $78.49 $149.22 $178.60 $179.07 $62.98 $96.82 $128.31
74 $80.99 $153.98 $184.30 $184.78 $64.99 $99.91 $132.40
Standard Rates for individuals ages 75 and older who do not have any of the medical conditions on the application. 3
75+ $83.50 $158.75 $190.00 $190.50 $67.00 $103.00 $136.50
Level 2 Rates for individuals ages 68 and older who have one or more of the medical conditions on the application. 3
68+ $125.25 $238.12 $285.00 $285.75 $100.50 $154.50 $204.75
Group 3
Applies to individuals whose plan effective date will be 6 or more years
following their 65th birthday or Medicare Part B effective date, if later.
Age 1 Plan A Plan B Plan C Plan F Plan K Plan L Plan N
Level 1 Rates for individuals ages 71 and older who do not have any of the medical conditions on the application. 3
71+ $91.85 $174.62 $209.00 $209.55 $73.70 $113.30 $150.15
Level 2 Rates for individuals ages 71 and older who have one or more of the medical conditions on the application. 3
71+ $125.25 $238.12 $285.00 $285.75 $100.50 $154.50 $204.75
The rates above are for plan effective dates from January - December 2013 and may change.
MRP0003 COC 1-13
0000001 0000009 0017 0074 UMS1129 01 L

Cover Page - Rates for Colorado - Area 3
Tobacco Monthly Plan Rates
AARP ® Medicare Supplement Insurance Plans insured by UnitedHealthcare Insurance Company
Group 1
Applies to individuals whose plan effective date will be within three years
following their 65th birthday or Medicare Part B effective date, if later.
Age 1 Plan A Plan B Plan C Plan F Plan K Plan L Plan N
Standard Rates with Enrollment Discount 2 for individuals ages 65-74
65 $64.29 $122.23 $146.30 $146.68 $51.59 $79.31 $105.10
66 $67.05 $127.47 $152.57 $152.97 $53.80 $82.70 $109.60
67 $69.80 $132.71 $158.84 $159.25 $56.01 $86.10 $114.11
68 $72.56 $137.94 $165.11 $165.54 $58.22 $89.50 $118.61
69 $75.31 $143.18 $171.38 $171.83 $60.43 $92.90 $123.12
70 $78.07 $148.42 $177.65 $178.11 $62.64 $96.30 $127.62
71 $80.82 $153.66 $183.92 $184.40 $64.85 $99.70 $132.13
72 $83.58 $158.90 $190.19 $190.69 $67.06 $103.10 $136.63
73 $86.33 $164.14 $196.46 $196.97 $69.27 $106.50 $141.14
74 $89.09 $169.38 $202.73 $203.26 $71.48 $109.90 $145.64
Standard Rates for ages 75 and older
75+ $91.85 $174.62 $209.00 $209.55 $73.70 $113.30 $150.15
Group 2
Applies to individuals whose plan effective date will be between 3 years and less than
6 years following their 65th birthday or Medicare Part B effective date, if later.
Age 1 Plan A Plan B Plan C Plan F Plan K Plan L Plan N
Standard Rates with Enrollment Discount 2 for individuals ages 68-74 who do
not have any of the medical conditions on the application. 3
68 $72.56 $137.94 $165.11 $165.54 $58.22 $89.50 $118.61
69 $75.31 $143.18 $171.38 $171.83 $60.43 $92.90 $123.12
70 $78.07 $148.42 $177.65 $178.11 $62.64 $96.30 $127.62
71 $80.82 $153.66 $183.92 $184.40 $64.85 $99.70 $132.13
72 $83.58 $158.90 $190.19 $190.69 $67.06 $103.10 $136.63
73 $86.33 $164.14 $196.46 $196.97 $69.27 $106.50 $141.14
74 $89.09 $169.38 $202.73 $203.26 $71.48 $109.90 $145.64
Standard Rates for individuals ages 75 and older who do not have any of the medical conditions on the application. 3
75+ $91.85 $174.62 $209.00 $209.55 $73.70 $113.30 $150.15
Level 2 Rates for individuals ages 68 and older who have one or more of the medical conditions on the application. 3
68+ $137.77 $261.93 $313.50 $314.32 $110.55 $169.95 $225.22
Group 3
Applies to individuals whose plan effective date will be 6 or more years
following their 65th birthday or Medicare Part B effective date, if later.
Age 1 Plan A Plan B Plan C Plan F Plan K Plan L Plan N
Level 1 Rates for individuals ages 71 and older who do not have any of the medical conditions on the application. 3
71+ $101.03 $192.08 $229.90 $230.50 $81.07 $124.63 $165.16
Level 2 Rates for individuals ages 71 and older who have one or more of the medical conditions on the application. 3
71+ $137.77 $261.93 $313.50 $314.32 $110.55 $169.95 $225.22
The rates above are for plan effective dates from January - December 2013 and may change.
MRP0003 COC 1-13
0000001 0000009 0018 0074 UMS1129 01 L

Cover Page - Rates for Colorado - Area 3
Under 65 Monthly Plan Rates
AARP ® Medicare Supplement Insurance Plans insured by UnitedHealthcare Insurance Company
Group 4
Applies to individuals under the age of 65 who are
eligible for Medicare by reason of disability
Age 1 Plan A Plan B Plan C Plan F Plan K Plan L Plan N
Non-Tobacco Rates
50-64 $150.25 $285.75 $342.00 $343.00 $120.50 $185.50 $245.75
Tobacco Rates
50-64 $165.27 $314.32 $376.20 $377.30 $132.55 $204.05 $270.32
The rates above are for plan effective dates from January - December 2013 and may change.
1 Your age as of your plan effective date.
2 The Enrollment Discount is available to applicants age 65 and over. You may qualify for an Enrollment Discount
based on your age and your Medicare Part B effective date.
The Enrollment Discount is applied to the current Standard Rate. The Standard Rates usually change each year.
The discount you receive in your first year of coverage depends on your age on your plan effective date. The
discount percentage reduces 3% each year on the anniversary date of your plan until the discount runs out.
3 Refer to Section 6 of the application.
MRP0003 COC 1-13
0000001 0000010 0019 0074 UMS1129 01 L

COLORADO Area 3 ZIP Codes, Effective August 1, 2012
The ZIP Codes Below Apply to Rates Included on the Page Headed “Cover Page – Rates”
80020
80138
80481
80906
80927
80950
81015
80023
80163
80501
80907
80928
80951
81019
80025
80301
80502
80908
80929
80960
81022
80026
80302
80503
80909
80930
80962
81023
80027
80303
80510
80910
80931
80970
81025
80038
80304
80533
80911
80932
80977
81069
80104
80305
80544
80912
80933
80995
80108
80306
80808
80913
80934
81001
80109
80307
80809
80914
80935
81002
80116
80308
80817
80915
80936
81003
80118
80309
80819
80916
80937
81004
80124
80310
80829
80917
80938
81005
80125
80314
80831
80918
80939
81006
80126
80321
80840
80919
80941
81007
80129
80322
80841
80920
80942
81008
80130
80323
80864
80921
80943
81009
80131
80328
80901
80922
80944
81010
80132
80329
80902
80923
80945
81011
80133
80455
80903
80924
80946
81012
80134
80466
80904
80925
80947
81013
80135
80471
80905
80926
80949
81014
SA5110 OC (08-12) Page 1 of 1
0000001 0000010 0020 0074 UMS1129 01 L

Cover Page - Rates for Colorado - Area 4
Non-Tobacco Monthly Plan Rates
AARP ® Medicare Supplement Insurance Plans insured by UnitedHealthcare Insurance Company
Group 1
Applies to individuals whose plan effective date will be within three years
following their 65th birthday or Medicare Part B effective date, if later.
Age 1 Plan A Plan B Plan C Plan F Plan K Plan L Plan N
Standard Rates with Enrollment Discount 2 for individuals ages 65-74
65 $54.25 $103.25 $123.37 $123.90 $43.40 $66.85 $88.72
66 $56.57 $107.67 $128.66 $129.21 $45.26 $69.71 $92.52
67 $58.90 $112.10 $133.95 $134.52 $47.12 $72.58 $96.33
68 $61.22 $116.52 $139.23 $139.83 $48.98 $75.44 $100.13
69 $63.55 $120.95 $144.52 $145.14 $50.84 $78.31 $103.93
70 $65.87 $125.37 $149.81 $150.45 $52.70 $81.17 $107.73
71 $68.20 $129.80 $155.10 $155.76 $54.56 $84.04 $111.54
72 $70.52 $134.22 $160.38 $161.07 $56.42 $86.90 $115.34
73 $72.85 $138.65 $165.67 $166.38 $58.28 $89.77 $119.14
74 $75.17 $143.07 $170.96 $171.69 $60.14 $92.63 $122.94
Standard Rates for ages 75 and older
75+ $77.50 $147.50 $176.25 $177.00 $62.00 $95.50 $126.75
Group 2
Applies to individuals whose plan effective date will be between 3 years and less than
6 years following their 65th birthday or Medicare Part B effective date, if later.
Age 1 Plan A Plan B Plan C Plan F Plan K Plan L Plan N
Standard Rates with Enrollment Discount 2 for individuals ages 68-74 who do
not have any of the medical conditions on the application. 3
68 $61.22 $116.52 $139.23 $139.83 $48.98 $75.44 $100.13
69 $63.55 $120.95 $144.52 $145.14 $50.84 $78.31 $103.93
70 $65.87 $125.37 $149.81 $150.45 $52.70 $81.17 $107.73
71 $68.20 $129.80 $155.10 $155.76 $54.56 $84.04 $111.54
72 $70.52 $134.22 $160.38 $161.07 $56.42 $86.90 $115.34
73 $72.85 $138.65 $165.67 $166.38 $58.28 $89.77 $119.14
74 $75.17 $143.07 $170.96 $171.69 $60.14 $92.63 $122.94
Standard Rates for individuals ages 75 and older who do not have any of the medical conditions on the application. 3
75+ $77.50 $147.50 $176.25 $177.00 $62.00 $95.50 $126.75
Level 2 Rates for individuals ages 68 and older who have one or more of the medical conditions on the application. 3
68+ $116.25 $221.25 $264.37 $265.50 $93.00 $143.25 $190.12
Group 3
Applies to individuals whose plan effective date will be 6 or more years
following their 65th birthday or Medicare Part B effective date, if later.
Age 1 Plan A Plan B Plan C Plan F Plan K Plan L Plan N
Level 1 Rates for individuals ages 71 and older who do not have any of the medical conditions on the application. 3
71+ $85.25 $162.25 $193.87 $194.70 $68.20 $105.05 $139.42
Level 2 Rates for individuals ages 71 and older who have one or more of the medical conditions on the application. 3
71+ $116.25 $221.25 $264.37 $265.50 $93.00 $143.25 $190.12
The rates above are for plan effective dates from January - December 2013 and may change.
MRP0003 COD 1-13
0000001 0000011 0021 0074 UMS1129 01 L

Cover Page - Rates for Colorado - Area 4
Tobacco Monthly Plan Rates
AARP ® Medicare Supplement Insurance Plans insured by UnitedHealthcare Insurance Company
Group 1
Applies to individuals whose plan effective date will be within three years
following their 65th birthday or Medicare Part B effective date, if later.
Age 1 Plan A Plan B Plan C Plan F Plan K Plan L Plan N
Standard Rates with Enrollment Discount 2 for individuals ages 65-74
65 $59.67 $113.57 $135.70 $136.29 $47.74 $73.53 $97.59
66 $62.23 $118.44 $141.52 $142.13 $49.78 $76.68 $101.77
67 $64.79 $123.31 $147.34 $147.97 $51.83 $79.83 $105.95
68 $67.34 $128.17 $153.15 $153.81 $53.87 $82.98 $110.14
69 $69.90 $133.04 $158.97 $159.65 $55.92 $86.14 $114.32
70 $72.46 $137.91 $164.78 $165.49 $57.97 $89.29 $118.50
71 $75.02 $142.78 $170.60 $171.33 $60.01 $92.44 $122.68
72 $77.57 $147.64 $176.42 $177.17 $62.06 $95.59 $126.87
73 $80.13 $152.51 $182.23 $183.01 $64.10 $98.74 $131.05
74 $82.69 $157.38 $188.05 $188.85 $66.15 $101.89 $135.23
Standard Rates for ages 75 and older
75+ $85.25 $162.25 $193.87 $194.70 $68.20 $105.05 $139.42
Group 2
Applies to individuals whose plan effective date will be between 3 years and less than
6 years following their 65th birthday or Medicare Part B effective date, if later.
Age 1 Plan A Plan B Plan C Plan F Plan K Plan L Plan N
Standard Rates with Enrollment Discount 2 for individuals ages 68-74 who do
not have any of the medical conditions on the application. 3
68 $67.34 $128.17 $153.15 $153.81 $53.87 $82.98 $110.14
69 $69.90 $133.04 $158.97 $159.65 $55.92 $86.14 $114.32
70 $72.46 $137.91 $164.78 $165.49 $57.97 $89.29 $118.50
71 $75.02 $142.78 $170.60 $171.33 $60.01 $92.44 $122.68
72 $77.57 $147.64 $176.42 $177.17 $62.06 $95.59 $126.87
73 $80.13 $152.51 $182.23 $183.01 $64.10 $98.74 $131.05
74 $82.69 $157.38 $188.05 $188.85 $66.15 $101.89 $135.23
Standard Rates for individuals ages 75 and older who do not have any of the medical conditions on the application. 3
75+ $85.25 $162.25 $193.87 $194.70 $68.20 $105.05 $139.42
Level 2 Rates for individuals ages 68 and older who have one or more of the medical conditions on the application. 3
68+ $127.87 $243.37 $290.80 $292.05 $102.30 $157.57 $209.13
Group 3
Applies to individuals whose plan effective date will be 6 or more years
following their 65th birthday or Medicare Part B effective date, if later.
Age 1 Plan A Plan B Plan C Plan F Plan K Plan L Plan N
Level 1 Rates for individuals ages 71 and older who do not have any of the medical conditions on the application. 3
71+ $93.77 $178.47 $213.25 $214.17 $75.02 $115.55 $153.36
Level 2 Rates for individuals ages 71 and older who have one or more of the medical conditions on the application. 3
71+ $127.87 $243.37 $290.80 $292.05 $102.30 $157.57 $209.13
The rates above are for plan effective dates from January - December 2013 and may change.
MRP0003 COD 1-13
0000001 0000011 0022 0074 UMS1129 01 L

Cover Page - Rates for Colorado - Area 4
Under 65 Monthly Plan Rates
AARP ® Medicare Supplement Insurance Plans insured by UnitedHealthcare Insurance Company
Group 4
Applies to individuals under the age of 65 who are
eligible for Medicare by reason of disability
Age 1 Plan A Plan B Plan C Plan F Plan K Plan L Plan N
Non-Tobacco Rates
50-64 $139.50 $265.50 $317.25 $318.50 $111.50 $172.00 $228.25
Tobacco Rates
50-64 $153.45 $292.05 $348.97 $350.35 $122.65 $189.20 $251.07
The rates above are for plan effective dates from January - December 2013 and may change.
1 Your age as of your plan effective date.
2 The Enrollment Discount is available to applicants age 65 and over. You may qualify for an Enrollment Discount
based on your age and your Medicare Part B effective date.
The Enrollment Discount is applied to the current Standard Rate. The Standard Rates usually change each year.
The discount you receive in your first year of coverage depends on your age on your plan effective date. The
discount percentage reduces 3% each year on the anniversary date of your plan until the discount runs out.
3 Refer to Section 6 of the application.
MRP0003 COD 1-13
0000001 0000012 0023 0074 UMS1129 01 L

SA5110 OD (08-12) Page 1 of 1
80101
80106
80107
80117
80420
80421
80423
80424
80426
80428
80429
80430
80432
80434
80435
80440
80442
80443
80446
80447
80448
80449
80451
80456
80459
80461
80463
80467
80468
80469
80473
80475
80477
80478
80479
80480
80482
80483
80487
80488
80497
80498
80504
80511
80512
80513
80514
80515
80516
80517
80520
80521
80522
80523
80524
80525
80526
80527
80528
80530
80532
80534
80535
80536
80537
80538
80539
80540
80541
80542
80543
80545
80546
80547
80549
80550
80551
80553
80610
80611
80612
80615
80620
80621
80622
80623
80624
80631
80632
80633
80634
80638
80639
80642
80643
80644
80645
80646
80648
80649
80650
80651
80652
80653
80654
80701
80705
80720
80721
80722
80723
80726
80727
80728
80729
80731
80732
80733
80734
80735
80736
80737
80740
80741
80742
80743
80744
80745
80746
80747
80749
80750
80751
80754
80755
80757
80758
80759
80801
80802
80804
80805
80807
80810
80812
80813
80814
80815
80816
80818
80820
80821
80822
80823
80824
80825
80826
80827
80828
80830
80832
80833
80834
80835
80836
80860
80861
80862
80863
80866
80997
81020
81021
81024
81027
81029
81030
81033
81034
81036
81038
81039
81040
81041
81043
81044
81045
81046
81047
81049
81050
81052
81054
81055
81057
81058
81059
81062
81063
81064
81067
81071
81073
81076
81077
81081
81082
81084
81087
81089
81090
81091
81092
81101
81102
81120
81121
81122
81123
81124
81125
81126
81128
81129
81130
81131
81132
81133
81135
81136
81137
81138
81140
81141
81143
81144
81146
81147
81148
81149
81151
81152
81154
81155
81157
81201
81210
81211
81212
81215
81220
81221
81222
81223
81224
81225
81226
81227
81228
81230
81231
81232
81233
81235
81236
81237
81239
81240
81241
81242
81243
81244
81247
81248
81251
81252
81253
81290
81301
81302
81303
81320
81321
81323
81324
81325
81326
81327
81328
81329
81330
81331
81332
81334
81335
81401
81402
81403
81410
81411
81413
81414
81415
81416
81418
81419
81420
81422
81423
81424
81425
81426
81427
81428
81429
81430
81431
81432
81433
81434
81435
81501
81502
81503
81504
81505
81506
81507
81520
81521
81522
81523
81524
81525
81526
81527
81601
81602
81610
81611
81612
81615
81620
81621
81623
81624
81625
81626
81630
81631
81632
81633
81635
81636
81637
81638
81639
81640
81641
81642
81643
81645
81646
81647
81648
81649
81650
81652
81653
81654
81655
81656
81657
81658
COLORADO Area 4 ZIP Codes, Effective August 1, 2012
The ZIP Codes Below Apply to Rates Included on the Page Headed “Cover Page – Rates”
0000001 0000012 0024 0074 UMS1129 01 L

Outline of Coverage | UnitedHealthcare Insurance Company
Overview of Available Plans
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. Medicare Supplement Plans A, B, C, F, K, L,
N are currently being offered by UnitedHealthcare Insurance Company.
Basic Benefits:
• Hospitalization: Part A co-insurance plus coverage for 365 additional days after Medicare benefits end.
• Medical Expenses: Part B co-insurance (generally 20% of Medicare-approved expenses) or co-payments for
hospital outpatient services. Plans K, L, and N require insureds to pay a portion of Part B coinsurance or
co-payments.
• Blood: First 3 pints of blood each year.
• Hospice: Part A coinsurance
Plan
A
Basic,
including
100%
Part B coinsurance
Plan
B
Basic,
including
100%
Part B coinsurance
Part A
deductible
Plan
C
Basic,
including
100%
Part B coinsurance
Skilled
nursing
facility coinsurance
Part A
deductible
Part B
deductible
Foreign
travel
emergency
Plan
D
Basic,
including
100%
Part B coinsurance
Skilled
nursing
facility coinsurance
Part A
deductible
Foreign
travel
emergency
Plan
F*
Basic,
including
100%
Part B coinsurance
Skilled
nursing
facility coinsurance
Part A
deductible
Part B
deductible
Part B
excess
(100%)
Foreign
travel
emergency
Plan
G
Basic,
including
100%
Part B coinsurance
Part A
deductible
Part B
excess
(100%)
Foreign
travel
emergency
*Plan F also has an option called a high deductible Plan F.
This option is not currently offered by UnitedHealthcare
Insurance Company. This high deductible plan pays the
same benefits as Plan F after you have paid a calendar
year $2110 deductible. Benefits from high deductible Plan
F will not begin until out-of-pocket expenses exceed
$2110. Out-of-pocket expenses for this deductible are
expenses that would ordinarily be paid by the policy.
These expenses include the Medicare deductibles for Part
A and Part B, but do not include the plan’s separate
foreign travel emergency deductible.
Plan
K
Hospitalization
and
preventive
care paid at
100%; other
basic benefits
paid at 50%
50% Skilled
nursing
facility
coinsurance
50% Part A
deductible
Skilled
nursing
facility coinsurance
Out-ofpocket
limit
$4800; paid
at 100%
after limit
reached
Plan
L
Hospitalization
and
preventive
care paid at
100%; other
basic benefits
paid at 75%
75% Skilled
nursing
facility
coinsurance
75% Part A
deductible
Out-ofpocket
limit
$2400; paid
at 100%
after limit
reached
Plan
M
Basic,
including
100%
Part B
coinsurance
Skilled
nursing
facility
coinsurance
50% Part A
deductible
Foreign
travel
emergency
Plan
N
Basic,
including
100% Part B
coinsurance,
except up
to $20
co-payment
for office visit,
and up to $50
copayment
for ER
Skilled
nursing
facility
coinsurance
Part A
deductible
Foreign
travel
emergency
POV3 1/13
0000001 0000013 0025 0074 UMS1129 01 L

0000001 0000013 0026 0074 UMS1129 01 L

Your Guide to AARP Medicare Supplement
Insurance Portfolio of Plans
How to Use Your Guide
This Guide contains detailed information about the AARP Medicare Supplement Insurance Plans.
The AARP Medicare Supplement Insurance Portfolio of Plans, insured by UnitedHealthcare Insurance Company,
provides a choice of benefits to AARP members, so you can choose the plan that best fits your individual
supplemental health insurance needs.
To help you choose the AARP Medicare Supplement Plan to meet your needs and budget:
• Look at the Cover Page which shows the benefits of each Medicare supplement plan and indicates any
specific provisions that may apply in your state. Also be sure to review the Monthly Premium information.
Benefits and cost vary depending upon the plan selected.
• For more information on a specific plan, look at the chart(s) which outline(s) the benefits of that plan. The
detailed chart(s) show(s) the expenses Medicare pays, the benefits the plan pays and the specific costs you
would have to pay yourself.
If you have any questions, call toll free, 1-800-523-5800, any weekday from 7 a.m. to 11 p.m. or Saturday from
9 a.m. to 5 p.m., Eastern Time. For members with speech or hearing impairments who have access to TTY, call
711 weekdays from 9 a.m. to 5 p.m., Eastern Time. Hablamos español — llame al 1-800-822-0246, de lunes a viernes,
de las 8 a.m. a las 5 p.m. y sábado de las 9 a.m. a las 5 p.m., hora del este.
Eligibility to Apply
To be eligible to apply, you must be an AARP member or spouse of a member, age 50 or over, enrolled in both
Part A and Part B of Medicare, and not duplicating any Medicare supplement coverage. (If you are not yet age 65,
you are only eligible if you enrolled in Medicare Part B within the last 6 months, unless you are an “Eligible Person”
entitled to Guaranteed Acceptance as shown under the following “Guaranteed Acceptance” section.)
Guaranteed Acceptance
• Your acceptance in any plan is guaranteed during your Medicare supplement open enrollment period which
lasts for 6 months beginning with the first day of the month in which you are both age 65 or older and
enrolled in Medicare Part B.
• If you lose health insurance coverage and are an eligible AARP member, you may be considered an “Eligible
Person” entitled to guaranteed acceptance and you may have a guaranteed right to enroll in certain AARP
Medicare Supplement Plans under specific circumstances. You are required to:
1. Apply within the required time period following the termination of your prior health insurance plan.
2. Provide a copy of the termination notice you received from your prior insurer with your application.
This notice must verify the circumstances of your prior plan’s termination and describe your right to
guaranteed issue of Medicare supplement insurance.
If you have any questions on your guaranteed right to insurance, you may wish to contact the administrator of
your prior health insurance plan, your local state department on aging, or your state insurance department.
Glossary of Terms
Medicare Eligible Expenses are the health care expenses of the kinds covered under Medicare Parts A and B that
Medicare recognizes as reasonable and medically necessary. Physicians under Medicare can agree to accept
Medicare’s eligible expense as their fee amount. Your physician or surgeon may charge you more.
Excess Charge is the difference between the actual Medicare Part B charge as billed, not to exceed any charge
limitation established by the Medicare program or state law, and the Medicare-approved Part B charge.
Hospital or Skilled Nursing Facility — A hospital is an institution that provides care for which Medicare pays
hospital benefits. A skilled nursing facility is a facility that provides skilled nursing care and is approved for payment
by Medicare. The skilled nursing facility stay must begin within 30 days after a hospital stay of 3 or more days in a
row or a prior covered skilled nursing facility stay. Both the hospital stay and the skilled nursing facility stay must
start while you are covered under this plan. Custodial care does not qualify as an eligible expense.
Lifetime Reserve Days are limited by Medicare to 60 days during your lifetime. Once these are used, Medicare
provides no hospital coverage after 90 days of a benefit period.
Hospice Care means care for those who are terminally ill. Hospice Care typically focuses on comfort (controlling
symptoms and managing pain) rather than seeking a cure.
General Information
AARP endorses the AARP Medicare Supplement Insurance Plans, insured by UnitedHealthcare Insurance
Company. UnitedHealthcare Insurance Company pays royalty fees to AARP for the use of its intellectual property.
These fees are used for the general purposes of AARP. AARP and its affiliates are not insurers.
BA25014CO (07-12)
0000001 0000014 0027 0074 UMS1129 01 L

This package describes the AARP Medicare Supplement Plans available in your state, but is not a contract,
policy, or insurance certificate. Please read your Certificate of Insurance, upon receipt, for plan benefits, definitions,
exclusions, and limitations. AARP Medicare Supplement Plans have been developed in line with federal standards.
However, these plans are not connected with, or endorsed by, the U.S. Government or the federal Medicare
program. The Policy Form No. GRP79171 GPS-1 (G-36000-4) is issued in the District of Columbia to the Trustees of the
AARP Insurance Plan. By enrolling, you are agreeing to the release of Medicare claim information to UnitedHealthcare
Insurance Company so your AARP Medicare Supplement Plan claims can be processed automatically.
AARP does not employ or endorse agents, brokers or producers.
This is a solicitation of insurance. An agent may contact you.
Colorado law requires carriers to make available a Colorado Health Plan Description Form (“Outline of Medicare
Supplement Coverage – Cover Page”), which is intended to facilitate comparison of health plans. This form must
be provided automatically within three (3) business days to a potential policyholder who has expressed interest
in a particular plan and who has selected the plan as a finalist from which the ultimate selection will be made. The
carrier also must provide the form, upon oral or written request, within three (3) business days, to any person who is
interested in coverage under or who is covered by a health benefit plan of the carrier.
Exclusions
• Benefits provided under Medicare.
• Care not meeting Medicare’s standards.
• Stays beginning, or care or supplies received, before your plan’s effective date.
• Injury or sickness payable by Workers’ Compensation or similar laws.
• Stays or treatment provided by a government-owned or -operated hospital or facility unless payment of
charges is required by law.
• Stays, care, or visits for which no charge would be made to you in the absence of insurance.
• Any stay which begins, or medical expenses you incur, during the first 3 months after your effective date will
not be considered if due to a pre-existing condition. A pre-existing condition is a condition for which medical
advice was given or treatment was recommended by or received from a physician within 3 months prior to
your plan’s effective date.
The following individuals are entitled to a waiver of this pre-existing condition exclusion:
1. Individuals who are replacing prior creditable coverage within 63 days after termination, or
2. Individuals who are turning age 65 and whose application form is received within six (6) months after
they turn 65 AND are enrolled in Medicare Part B, OR
3. Individuals who are “Eligible Persons” entitled to Guaranteed Acceptance, or
4. Individuals who have been covered under other health insurance coverage within the last 63 days and
have enrolled in Medicare Part B within the last 6 months.
Other exclusions may apply; however, in no event will your plan contain coverage limitations or exclusions for
the Medicare Eligible Expenses that are more restrictive than those of Medicare. Benefits and exclusions paid by
your plan will automatically change when Medicare’s requirements change.
You Cannot Be Singled Out for Cancellation
Your Medicare supplement plan can never be canceled because of your age, your health, or the number of
claims you make. Your Medicare supplement plan may be canceled due to nonpayment of premium or material
misrepresentation. If the group policy terminates and is not replaced by another group policy providing the same type
of coverage, you may convert your AARP Medicare Supplement Plan to an individual Medicare supplement policy
issued by UnitedHealthcare Insurance Company. Of course, you may cancel your AARP Medicare Supplement Plan
any time you wish. All transactions go into effect on the first of the month following receipt of the request.
The AARP Insurance Trust
AARP established the AARP Insurance Plan, a trust, to hold the master group insurance policies. The AARP
Medicare Supplement Insurance Plan is insured by UnitedHealthcare Insurance Company, not by AARP or its
affiliates. Please contact UnitedHealthcare Insurance Company if you have questions about your policy, including
any limitations and exclusions.
Premiums are collected from you by the Trust. These premiums are paid to the insurance company for your
insurance coverage, a percentage is used to pay expenses, benefitting the insureds, and incurred by the Trust in
connection with the insurance programs. At the direction of UnitedHealthcare Insurance Company, a portion of
the premium is paid as a royalty to AARP and used for the general purposes of AARP. Income earned from the
investment of premiums while on deposit with the Trust is paid to AARP and used for the general purposes of AARP.
Participants are issued certificates of insurance by UnitedHealthcare Insurance Company under the master
group insurance policy. The benefits of participating in an insurance program carrying the AARP name are solely
the right to receive the insurance coverage and ancillary services provided by the program.
AARP Medicare Supplement Plans insured by: UnitedHealthcare Insurance Company
1-800-523-5800
For information about the family of health products and services
www.aarphealthcare.com
0000001 0000014 0028 0074 UMS1129 01 L

Outline of Coverage | UnitedHealthcare Insurance Company
Plan Benefit Tables: Plan A
Medicare Part A: Hospital Services per Benefit Period 1
Service Medicare Pays Plan A Pays You Pay
Hospitalization 1
Semiprivate room and board,
general nursing and miscellaneous
services and supplies.
Skilled Nursing Facility Care 1
You must meet Medicare’s
requirements, including having
been in a hospital for at least
3 days and entered a Medicareapproved
facility within 30 days
after leaving the hospital.
First 60 days All but $1,184 $0 $1,184
(Part A
deductible)
Days 61–90 All but $296 per day $296 per day $0
Days 91 and later
while using 60 lifetime
reserve days
After lifetime reserve
days are used, an
additional 365 days
Beyond the additional
365 days
All but $592 per day $592 per day $0
$0 100% of Medicare
eligible expenses
$0 2
$0 $0 All costs
First 20 days All approved amounts $0 $0
Days 21–100 All but $148
per day
$0 Up to $148
per day
Days 101 and later $0 $0 All costs
Blood First 3 pints $0 3 pints $0
Additional amounts 100% $0 $0
Hospice Care
Available as long as you meet
Medicare’s requirements, your doctor
certifies you are terminally ill and
you elect to receive these services.
All but very limited
co-payment/
co-insurance for
outpatient drugs and
inpatient respite care
Medicare
co-payment/
co-insurance
$0
Notes
1 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.
Continued on next page
2 NOTICE: When your Medicare Part A hospital benefits
are exhausted, the insurer stands in 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.
▲
BT25 1/13
0000001 0000015 0029 0074 UMS1129 01 L

Outline of Coverage | UnitedHealthcare Insurance Company
Plan Benefit Tables: Plan A (continued)
Medicare Part B: Medical Services per Calendar Year
Service Medicare Pays Plan A Pays You Pay
Medical Expenses
INCLUDES TREATMENT 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.
Part B Excess Charges
Above Medicare-approved amounts
First $147 of $0 $0 $147
amounts 3 deductible)
Medicare-approved
(Part B
Remainder of
Medicare-approved
amounts
Generally 80% Generally 20% $0
$0 $0 All costs
Blood First 3 pints $0 All costs $0
Clinical Laboratory Services
Next $147 of $0 $0 $147
amounts 3 deductible)
Medicare-approved
(Part B
Remainder of
Medicare-approved
amounts
Tests for diagnostic
services
80% 20% $0
100% $0 $0
Parts A and B
Service Medicare Pays Plan A Pays You Pay
Home Health Care
Medicare-approved services
Durable medical equipment
Medicare-approved services
Medically necessary
skilled care services
and medical supplies
Notes
3 Once you have been billed $147 of Medicareapproved
amounts for covered services, your Part B
deductible will have been met for the calendar year.
100% $0 $0
First $147 of $0 $0 $147
amounts 3 deductible)
Medicare-approved
(Part B
Remainder of
Medicare-approved
amounts
80% 20% $0
0000001 0000015 0030 0074 UMS1129 01 L

Outline of Coverage | UnitedHealthcare Insurance Company
Plan Benefit Tables: Plan B
Medicare Part A: Hospital Services per Benefit Period 1
Service Medicare Pays Plan B Pays You Pay
Hospitalization 1
Semiprivate room and board,
general nursing and miscellaneous
services and supplies.
First 60 days All but $1,184 $1,184 (Part A
deductible)
Days 61–90 All but $296 per day $296 per day $0
Days 91 and later
while using 60 lifetime
reserve days
$0
All but $592 per day $592 per day $0
After lifetime reserve
days are used, an
additional 365 days
$0 100% of Medicare
eligible expenses
$0 2
Beyond the additional
365 days
$0 $0 All costs
Skilled Nursing Facility Care 1
You must meet Medicare’s
requirements, including having
been in a hospital for at least
3 days and entered a Medicareapproved
facility within 30 days
after leaving the hospital.
First 20 days All approved amounts $0 $0
Days 21–100 All but $148
per day
$0 Up to $148
per day
Days 101 and later $0 $0 All costs
Blood First 3 pints $0 3 pints $0
Additional amounts 100% $0 $0
Hospice Care
Available as long as you meet
Medicare’s requirements, your doctor
certifies you are terminally ill and
you elect to receive these services.
All but very limited
co-payment/
co-insurance for
outpatient drugs and
inpatient respite care
Medicare
co-payment/
co-insurance
$0
Notes
1 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.
Continued on next page
2 NOTICE: When your Medicare Part A hospital benefits
are exhausted, the insurer stands in 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.
▲
BT26 1/13
0000001 0000016 0031 0074 UMS1129 01 L

Outline of Coverage | UnitedHealthcare Insurance Company
Plan Benefit Tables: Plan B (continued)
Medicare Part B: Medical Services per Calendar Year
Service Medicare Pays Plan B Pays You Pay
Medical Expenses
INCLUDES TREATMENT 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.
Part B Excess Charges
Above Medicare-approved amounts
First $147 of $0 $0 $147
amounts 3 deductible)
Medicare-approved
(Part B
Remainder of
Medicare-approved
amounts
Generally 80% Generally 20% $0
$0 $0 All Costs
Blood First 3 pints $0 All costs $0
Clinical Laboratory Services
Next $147 of $0 $0 $147
amounts 3 deductible)
Medicare-approved
(Part B
Remainder of
Medicare-approved
amounts
Tests for diagnostic
services
80% 20% $0
100% $0 $0
Parts A and B
Service Medicare Pays Plan B Pays You Pay
Home Health Care
Medicare-approved services
Durable medical equipment
Medicare-approved services
Medically necessary
skilled care services
and medical supplies
Notes
3 Once you have been billed $147 of Medicareapproved
amounts for covered services, your Part B
deductible will have been met for the calendar year.
100% $0 $0
First $147 of $0 $0 $147
amounts 3 deductible)
Medicare-approved
(Part B
Remainder of
Medicare-approved
amounts
80% 20% $0
0000001 0000016 0032 0074 UMS1129 01 L

Outline of Coverage | UnitedHealthcare Insurance Company
Plan Benefit Tables: Plan C
Medicare Part A: Hospital Services per Benefit Period 1
Service Medicare Pays Plan C Pays You Pay
Hospitalization 1
Semiprivate room and board,
general nursing and miscellaneous
services and supplies.
First 60 days All but $1,184 $1,184 (Part A
deductible)
Days 61–90 All but $296 per day $296 per day $0
Days 91 and later
while using 60 lifetime
reserve days
After lifetime reserve
days are used, an
additional 365 days
Beyond the additional
365 days
$0
All but $592 per day $592 per day $0
$0 100% of Medicare
eligible expenses
$0 2
$0 $0 All costs
Skilled Nursing Facility Care 1
You must meet Medicare’s
requirements, including having
been in a hospital for at least
3 days and entered a Medicareapproved
facility within 30 days
after leaving the hospital.
First 20 days All approved amounts $0 $0
Days 21–100 All but $148
per day
Up to $148
per day
Days 101 and later $0 $0 All costs
$0
Blood First 3 pints $0 3 pints $0
Additional amounts 100% $0 $0
Hospice Care
Available as long as you meet
Medicare’s requirements, your doctor
certifies you are terminally ill and
you elect to receive these services.
All but very limited
co-payment/
co-insurance for
outpatient drugs and
inpatient respite care
Medicare
co-payment/
co-insurance
$0
Notes
1 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.
Continued on next page
2 NOTICE: When your Medicare Part A hospital benefits
are exhausted, the insurer stands in 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.
▲
BT27 1/13
0000001 0000017 0033 0074 UMS1129 01 L

Outline of Coverage | UnitedHealthcare Insurance Company
Plan Benefit Tables: Plan C (continued)
Medicare Part B: Medical Services per Calendar Year
Service Medicare Pays Plan C Pays You Pay
Medical Expenses
INCLUDES TREATMENT 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.
Part B Excess Charges
Above Medicare-approved amounts
Parts A and B
First $147 of
$0
Medicare-approved
amounts 3 $0 $147 (Part B
deductible)
Remainder of
Medicare-approved
amounts
Generally 80% Generally 20% $0
$0 $0 All costs
Blood First 3 pints $0 All costs $0
Next $147 of
Medicare-approved
amounts 3 $0 $147 (Part B
deductible)
$0
Clinical Laboratory Services
Remainder of
Medicare-approved
amounts
Tests for diagnostic
services
80% 20% $0
100% $0 $0
Service Medicare Pays Plan C Pays You Pay
Home Health Care
Medicare-approved services
Durable medical equipment
Medicare-approved services
Other Benefits not covered by Medicare
Medically necessary
skilled care services
and medical supplies
100% $0 $0
First $147 of $0 $147 (Part B $0
amounts 3
Medicare-approved
deductible)
Remainder of 80% 20% $0
Medicare-approved
amounts
Service Medicare Pays Plan C Pays You Pay
Foreign Travel
NOT COVERED BY MEDICARE—
Medically necessary emergency
care services beginning during the
first 60 days of each trip outside
the USA.
First $250 each
calendar year
Remainder of
charges
$0 $0 $250
$0 80% to a lifetime
maximum benefit
of $50,000
20% and
amounts
over the
$50,000
lifetime
maximum
Notes
3 Once you have been billed $147 of Medicare-approved amounts for covered services, your Part B deductible will
have been met for the calendar year.
0000001 0000017 0034 0074 UMS1129 01 L

Outline of Coverage | UnitedHealthcare Insurance Company
Plan Benefit Tables: Plan F
Medicare Part A: Hospital Services per Benefit Period 1
Service Medicare Pays Plan F Pays You Pay
Hospitalization 1
Semiprivate room and board,
general nursing and miscellaneous
services and supplies.
First 60 days All but $1,184 $1,184 (Part A
deductible)
Days 61–90 All but $296 per day $296 per day $0
Days 91 and later
while using 60 lifetime
reserve days
After lifetime reserve
days are used, an
additional 365 days
Beyond the additional
365 days
$0
All but $592 per day $592 per day $0
$0 100% of Medicare
eligible expenses
$0 2
$0 $0 All costs
Skilled Nursing Facility Care 1
You must meet Medicare’s
requirements, including having
been in a hospital for at least
3 days and entered a Medicareapproved
facility within 30 days
after leaving the hospital.
First 20 days All approved amounts $0 $0
Days 21–100 All but $148
per day
Up to $148
per day
Days 101 and later $0 $0 All costs
$0
Blood First 3 pints $0 3 pints $0
Additional amounts 100% $0 $0
Hospice Care
Available as long as you meet
Medicare’s requirements, your doctor
certifies you are terminally ill and
you elect to receive these services.
All but very limited
co-payment/
co-insurance for
outpatient drugs and
inpatient respite care
Medicare
co-payment/
co-insurance
$0
Notes
1 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.
Continued on next page
2 NOTICE: When your Medicare Part A hospital benefits
are exhausted, the insurer stands in 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.
▲
BT28 1/13
0000001 0000018 0035 0074 UMS1129 01 L

Outline of Coverage | UnitedHealthcare Insurance Company
Plan Benefit Tables: Plan F (continued)
Medicare Part B: Medical Services per Calendar Year
Service Medicare Pays Plan F Pays You Pay
Medical Expenses
INCLUDES TREATMENT 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.
Part B Excess Charges
Above Medicare-approved amounts
Parts A and B
First $147 of
$0
Medicare-approved
amounts 3 $0 $147 (Part B
deductible)
Remainder of
Medicare-approved
amounts
Generally 80% Generally 20% $0
$0 100% $0
Blood First 3 pints $0 All costs $0
Next $147 of
Medicare-approved
amounts 3 $0 $147 (Part B
deductible)
$0
Clinical Laboratory Services
Remainder of
Medicare-approved
amounts
Tests for diagnostic
services
80% 20% $0
100% $0 $0
Service Medicare Pays Plan F Pays You Pay
Home Health Care
Medicare-approved services
Durable medical equipment
Medicare-approved services
Medically necessary
skilled care services
and medical supplies
100% $0 $0
First $147 of $0 $147 (Part B $0
amounts 3
Medicare-approved
deductible)
Remainder of 80% 20% $0
Medicare-approved
amounts
Other Benefits not covered by Medicare
Service Medicare Pays Plan F Pays You Pay
Foreign Travel
NOT COVERED BY MEDICARE—
Medically necessary emergency
care services beginning during the
first 60 days of each trip outside
the USA.
First $250 each
calendar year
Remainder of
charges
$0 $0 $250
$0 80% to a lifetime
maximum benefit
of $50,000
20% and
amounts
over the
$50,000
lifetime
maximum
Notes
3 Once you have been billed $147 of Medicare-approved amounts for covered services, your Part B deductible will
have been met for the calendar year.
0000001 0000018 0036 0074 UMS1129 01 L

Outline of Coverage | UnitedHealthcare Insurance Company
Plan Benefit Tables: Plan K
Medicare Part A: Hospital Services per Benefit Period 1
Service Medicare Pays Plan K Pays You Pay 3
Hospitalization 1
Semiprivate room and board,
general nursing and miscellaneous
services and supplies.
First 60 days All but $1,184 $592 (50% of
Part A deductible)
Days 61–90 All but $296 per day $296 per day $0
$592
(50% of
Part A
deductible)
Skilled Nursing Facility Care 1
You must meet Medicare’s
requirements, including having
been in a hospital for at least
3 days and entered a Medicareapproved
facility within 30 days
after leaving the hospital.
Days 91 and later
while using 60
lifetime reserve days
After lifetime reserve
days are used, an
additional 365 days
All but $592 per day $592 per day $0
$0 100% of Medicare
eligible expenses
Beyond the additional
365 days
$0 $0 All costs
First 20 days All approved amounts $0 $0
Days 21–100 All but $148
per day
Up to $74
per day
$0 2
Up to $74
per day
Days 101 and later $0 $0 All costs
Blood First 3 pints $0 50% 50%
Additional amounts 100% $0 $0
Hospice Care
Available as long as you meet
Medicare’s requirements, your doctor
certifies you are terminally ill and
you elect to receive these services.
All but very limited
co-payment/
co-insurance for
outpatient drugs and
inpatient respite care
50% of
co-payment/
co-insurance
50% of
Medicare
co-payment/
coinsurance
Notes
1 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.
2 NOTICE: When your Medicare Part A hospital benefits
are exhausted, the insurer stands in 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.
Continued on next page
▲
3 You will pay half of the cost-sharing of some covered
services until you reach the annual out-of-pocket limit of
$4800 each calendar year. The amounts that count
toward your annual limit are noted with diamonds () in
the chart above. Once you reach the annual limit, the
plan pays 100% of the Medicare co-payment and
coinsurance for the rest of the calendar year. However,
this limit does NOT include charges from your provider
that exceed Medicare-approved amounts (these are
called “Excess Charges”) and you will be responsible for
paying this difference in the amount charged by your
provider and the amount paid by Medicare for the item or
service.
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Outline of Coverage | UnitedHealthcare Insurance Company
Plan Benefit Tables: Plan K (continued)
Medicare Part B: Medical Services per Calendar Year
Service Medicare Pays Plan K Pays You Pay 4
Medical Expenses
INCLUDES TREATMENT 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.
Parts A and B
First $147 of $0 $0 $147
Medicare-approved
(Part B
amounts 5 deductible)
5
Preventive Benefits
for Medicare Covered
Services
Remainder of
Medicare-approved
amounts
Generally 75%
or more of Medicareapproved
amounts
Remainder of
Medicareapproved
amounts
Generally 80% Generally 10% Generally
10%
All costs
above
Medicareapproved
amounts
Part B Excess Charges
Above Medicare-approved
amounts
$0 $0 All Costs
(and they do
not count
toward
annual
out-of-pocket
limit of
$4800) 4
Blood First 3 pints $0 50% 50%
Next $147 of $0 $0 $147
Medicare-approved
(Part B
amounts
deductible)
5
Clinical Laboratory Services
Remainder of
Medicare-approved
amounts
Tests for diagnostic
services
Generally
80%
Generally
10%
100% $0 $0
Generally
10%
Service Medicare Pays Plan K Pays You Pay 4
Home Health Care
Medicare-approved services
Medically necessary
skilled care services
and medical supplies
Notes
4 This plan limits your annual out-of-pocket payments for
Medicare-approved amounts to $4800 per calendar year.
However, this limit does NOT include charges from your
provider that exceed Medicare-approved amounts (these
are called “Excess Charges”) and you will be responsible
for paying this difference in the amount charged by your
provider and the amount paid by Medicare for the item or
service.
100% $0 $0
Continued on next page
▲
5 Once you have been billed $147 of Medicare-approved
amounts for covered services, your Part B deductible will
have been met for the calendar year.
0000001 0000019 0038 0074 UMS1129 01 L

Outline of Coverage | UnitedHealthcare Insurance Company
Plan Benefit Tables: Plan K (continued)
Parts A and B
Service Medicare Pays Plan K Pays You Pay 4
Durable medical equipment
Medicare-approved services
First $147 of $0 $0 $147
Medicare-approved
(Part B
amounts 6 deductible)
Remainder of
Medicare-approved
amounts
80% 10% 10%
Notes
6 Medicare benefits are subject to change.
Please consult the latest Guide to Health
Insurance for People with Medicare.
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Outline of Coverage | UnitedHealthcare Insurance Company
Plan Benefit Tables: Plan L
Medicare Part A: Hospital Services per Benefit Period 1
Service Medicare Pays Plan L Pays You Pay 3
Hospitalization 1
Semiprivate room and board,
general nursing and miscellaneous
services and supplies.
First 60 days All but $1,184 $888 (75% of
Part A deductible)
Days 61–90 All but $296 per day $296 per day $0
Days 91 and later
while using 60
lifetime reserve days
After lifetime reserve
days are used, an
additional 365 days
Beyond the additional
365 days
All but $592 per day $592 per day $0
$0 100% of Medicare
eligible expenses
$296
(25% of
Part A
deductible)
$0 2
$0 $0 All costs
Skilled Nursing Facility Care 1
You must meet Medicare’s
requirements, including having
been in a hospital for at least
3 days and entered a Medicareapproved
facility within 30 days
after leaving the hospital.
First 20 days All approved amounts $0 $0
Days 21–100 All but $148
per day
Up to $111
per day
Up to $37
per day
Days 101 and later $0 $0 All costs
Blood First 3 pints $0 75% 25%
Hospice Care
Available as long as you meet
Medicare’s requirements, your doctor
certifies you are terminally ill and
you elect to receive these services.
Additional amounts 100% $0 $0
All but very limited
co-payment/
co-insurance for
outpatient drugs and
inpatient respite care
75% of
co-payment/
co-insurance
25% of
Medicare
co-payment/
coinsurance
Notes
1 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.
2 NOTICE: When your Medicare Part A hospital benefits
are exhausted, the insurer stands in 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.
Continued on next page
3 You will pay one-fourth of the cost-sharing of some
covered services until you reach the annual out-ofpocket
limit of $2400 each calendar year. The amounts
that count toward your annual limit are noted with
diamonds () in the chart above. Once you reach the
annual limit, the plan pays 100% of the Medicare copayment
and coinsurance for the rest of the calendar
year. However, this limit does NOT include charges from
your provider that exceed Medicare-approved amounts
(these are called “Excess Charges”) and you will be
responsible for paying this difference in the amount
charged by your provider and the amount paid by
Medicare for the item or service.
▲
BT30 1/13
0000001 0000021 0041 0074 UMS1129 01 L

Outline of Coverage | UnitedHealthcare Insurance Company
Plan Benefit Tables: Plan L (continued)
Medicare Part B: Medical Services per Calendar Year
Service Medicare Pays Plan L Pays You Pay 4
Medical Expenses
INCLUDES TREATMENT 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.
Part B Excess Charges
Above Medicare-approved
amounts
Parts A and B
Preventive Benefits
for Medicare Covered
Services
Remainder of
Medicare-approved
amounts
Generally 75%
or more of Medicareapproved
amounts
Remainder of
Medicareapproved
amounts
First $147 of $0 $0 $147
amounts 5 deduct-
Medicare-approved
(Part B
ible) 5
All costs
above
Medicareapproved
amounts
Generally 80% Generally 15% Generally
5%
$0 $0 All Costs
(and they do
not count
toward
annual
out-of-pocket
limit of
$2400) 4
Blood First 3 pints $0 75% 25%
Next $147 of $0 $0 $147
Medicare-approved
(Part B
amounts 5 deductible)
5
Remainder of
Medicare-approved
Generally
80%
Generally
15%
Generally
5%
amounts
Clinical Laboratory Services Tests for diagnostic
services
100% $0 $0
Service Medicare Pays Plan L Pays You Pay 4
Home Health Care
Medicare-approved services
Medically necessary
skilled care services
and medical supplies
Notes
4 This plan limits your annual out-of-pocket payments for
Medicare-approved amounts to $2400 per calendar year.
However, this limit does NOT include charges from your
provider that exceed Medicare-approved amounts (these
are called “Excess Charges”) and you will be responsible
for paying this difference in the amount charged by your
provider and the amount paid by Medicare for the item or
service.
100% $0 $0
Continued on next page
5 Once you have been billed $147 of Medicare-approved
amounts for covered services, your Part B deductible will
have been met for the calendar year.
▲
0000001 0000021 0042 0074 UMS1129 01 L

Outline of Coverage | UnitedHealthcare Insurance Company
Plan Benefit Tables: Plan L (continued)
Parts A and B
Service Medicare Pays Plan L Pays You Pay 4
Durable medical equipment
Medicare-approved services
First $147 of
Medicare-approved
amounts 6 $0 $0 $147
(Part B
deductible)
Remainder of
Medicare-approved
amounts
80% 15% 5%
Notes
6 Medicare benefits are subject to change.
Please consult the latest Guide to Health
Insurance for People with Medicare.
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0000001 0000022 0043 0074 UMS1129 01 L

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Outline of Coverage | UnitedHealthcare Insurance Company
Plan Benefit Tables: Plan N
Medicare Part A: Hospital Services per Benefit Period 1
Service Medicare Pays Plan N Pays You Pay
Hospitalization 1
Semiprivate room and board,
general nursing and miscellaneous
services and supplies.
First 60 days All but $1,184 $1,184 (Part A
deductible)
Days 61–90 All but $296 per day $296 per day $0
Days 91 and later
while using 60 lifetime
reserve days
After lifetime reserve
days are used, an
additional 365 days
Beyond the additional
365 days
$0
All but $592 per day $592 per day $0
$0 100% of Medicare
eligible expenses
$0 2
$0 $0 All costs
Skilled Nursing Facility Care 1
You must meet Medicare’s
requirements, including having
been in a hospital for at least
3 days and entered a Medicareapproved
facility within 30 days
after leaving the hospital.
First 20 days All approved amounts $0 $0
Days 21–100 All but $148
per day
Up to $148
per day
Days 101 and later $0 $0 All costs
$0
Blood First 3 pints $0 3 pints $0
Additional amounts 100% $0 $0
Hospice Care
Available as long as you meet
Medicare’s requirements, your doctor
certifies you are terminally ill and
you elect to receive these services.
All but very limited
co-payment/
co-insurance for
outpatient drugs and
inpatient respite care
Medicare
co-payment/
co-insurance
$0
Continued on next page
▲
Notes
1 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.
2 NOTICE: When your Medicare Part A hospital benefits
are exhausted, the insurer stands in 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.
BT31 1/13
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Outline of Coverage | UnitedHealthcare Insurance Company
Plan Benefit Tables: Plan N (continued)
Medicare Part B: Medical Services per Calendar Year
Service Medicare Pays Plan N Pays You Pay
Medical Expenses
INCLUDES TREATMENT 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.
Parts A and B
Service Medicare Pays Plan N Pays You Pay
Notes
3 Once you have been billed $147 of Medicareapproved
amounts for covered services, your Part B
deductible will have been met for the calendar year.
First $147 of $0 $0 $147
amounts 3 deductible)
Medicare-approved
(Part B
Remainder of
Medicare-approved
amounts
Generally 80%
Balance, other
than up to $20
per office visit
and up to $50
per emergency
room visit. The
co-payment of
up to $50 is
waived if you
are admitted to
any hospital and
the emergency
visit is covered
as a Medicare
Part A expense.
Up to $20
per office
visit and up
to $50 per
emergency
room visit.
The copayment
of
up to $50 is
waived if
you are
admitted to
any hospital
and the
emergency
visit is
covered as
a Medicare
Part A
expense.
Part B Excess Charges
$0 $0 All costs
Above Medicare-approved amounts
Blood First 3 pints $0 All costs $0
Next $147 of
Medicare-approved
amounts 3 $0 $0 $147
(Part B
deductible)
Remainder of 80% 20% $0
Medicare-approved
amounts
Clinical Laboratory Services Tests for diagnostic
services
100% $0 $0
Home Health Care
Medicare-approved services
Medically necessary
skilled care services
and medical supplies
100% $0 $0
Continued on next page
▲
0000001 0000023 0046 0074 UMS1129 01 L

Outline of Coverage | UnitedHealthcare Insurance Company
Plan Benefit Tables: Plan N (continued)
Parts A and B, continued
Service Medicare Pays Plan N Pays You Pay
Durable Medical Equipment
Medicare-approved services
Remainder of
Medicare-approved
amounts
Other Benefits not covered by Medicare
Foreign Travel
NOT COVERED BY MEDICARE -
Medically necessary emergency
care services beginning during the
first 60 days of each trip outside
the USA.
First $147 of $0 $0 $147
amounts 3 deductible)
Medicare-approved
(Part B
First $250 each
calendar year
Remainder of
charges
80% 20% $0
$0 $0 $250
$0 80% to a lifetime
maximum benefit
of $50,000
20% and
amounts
over the
$50,000
lifetime
maximum
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Outline of Coverage | UnitedHealthcare Insurance Company
Rules and Disclosures about this Insurance
This page explains important rules governing your Medicare supplement coverage. These rules affect you.
Please read them carefully and make sure you understand them before you buy or change any Medicare
supplement insurance.
Premium information
You may keep your Medicare supplement plan in
force by paying the required monthly premium
when due. Monthly rates shown reflect current
premium levels and all rates are subject to change.
Any change will apply to all members of the same
class insured under your plan who reside in your
state. Your premium can only be changed with the
approval of AARP and/or your state insurance
department.
Disclosures
Use the Overview of Available Plans, the Plan
Benefit Tables and Cover Page - Rates to compare
benefits and premiums among plans.
Read your certificate very carefully
This is only an outline describing your certificate’s
most important features. The certificate is your
insurance contract. You must read the certificate
itself to understand all of the rights and duties of
both you and your insurance company.
Your right to return the certificate
If you find that you are not satisfied with your
coverage, you may return the certificate to:
UnitedHealthcare
P.O. Box 1000
Montgomeryville, PA 18936-1000
If you send the certificate back to us within
30 days after you receive it, we will treat the
certificate as if it had never been issued and
return all of your premium payments. However,
UnitedHealthcare has the right to recover any
claims paid during that period. Any premium
refund otherwise due to you will be reduced by the
amount of any claims paid during this period. If
you have received claims payment in excess of the
amount of your premium, no refund of premium
will be made.
Policy replacement
If you are replacing another health insurance
policy, do NOT cancel it until you have actually
received your new certificate and are sure you want
to keep it.
Notice
The certificate may not fully cover all of your
medical costs. Neither UnitedHealthcare Insurance
Company nor its agents are connected with
Medicare. This outline of coverage does not give
all the details of Medicare coverage. Contact your
local Social Security office or consult the Centers
for Medicare & Medicaid Services (CMS)
publication Medicare & You for more details.
Complete answers are very important
When you fill out the enrollment application for
the new certificate, be sure to answer all questions
about your medical and health history truthfully
and completely. The company may cancel your
certificate and refuse to pay any claims if you
leave out or falsify important medical information.
Review the enrollment application carefully before
you sign it. Be certain that all information has been
properly recorded.
RD4 6/10
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0000001 0000025 0050 0074 UMS1129 01 L

Your Exclusive Member Services.
Get answers. Save money. Live healthy.
SILVERSNEAKERS ® FITNESS PROGRAM provided by Healthways
Live healthier with free access to fitness centers
and classes.
Get access to thousands of participating fitness
centers, with amenities like exercise equipment and
fitness classes included in their basic membership.
Take signature classes from certified instructors,
specifically designed for older adults. Additional
options (YogaStretch, SilverSplash ® , CardioFit, and
Weight Circuit) may be available at select health
centers as your fitness levels progress. Designated
Senior Advisors SM
will also help you all along the way.
SilverSneakers ® Steps is also available to members
living 15+ miles from a participating fitness center.
This self-directed physical activity program provides
the equipment and motivation for you to manage
your activities and achieve a healthier lifestyle.
Visit www.silversneakers.com to find a health
center location near you.
AARP ® VISION DISCOUNTS provided by EyeMed Vision Care
Save on every eyewear purchase and on routine
eye exams.
Save 30% on eyewear, including bifocals, lenses,
and frames.* Contact lens wearers save 10% on
disposables and 20% on all other contact lenses.
Plus, receive a 90-day guarantee on every eyewear
purchase.
Pay only $40 for routine eye exams
including an Eye Health Exam Report that details
your results, and receive $10 off contact lens exams.
Simply show your AARP ® Medicare Supplement
card when you visit any participating LensCrafters ® ,
Pearle Vision ® , Sears Optical ® , Target Optical ® , and
JCPenney Optical ® location, or one of many private
practice locations.**
NURSE HEALTHLINE
Get your health issues assessed, then get the help
you need to make the right choices.
Speak directly with registered nurses, toll-free,
24 hours a day.
Make informed decisions on how to get proper care.
Nurses will review your symptoms and recommended
treatment options, and refer you to providers that
meet high standards of quality and efficiency.
Start healthy lifestyle changes with personal
coaching and guidance.
Spanish is available, as well as translation
assistance in 140+ languages.
These are additional insured member services apart from the AARP Medicare Supplement Insurance Plan benefits, are
not insurance programs, may be subject to geographic availability and may be discontinued at any time.
*30% discount only available when a complete pair of glasses (frames, lenses, and lens options) is purchased in the same transaction.
Items purchased separately will be discounted at 15% off the retail price.
**Eye exams available by Independent Doctors of Optometry at or next to LensCrafters, Pearle Vision, Sears Optical and Target Optical in
most states. Doctors in some states are employed by the location. In California, optometrists are not employed by LensCrafters, Sears
Optical and Target Optical, which do not provide eye exams. For LensCrafters, eye exams are available from optometrists employed by
EYEXAM of California, a licensed vision health care service plan. ForSears Optical and Target Optical, eye exams are available from selfemployed
doctors who lease space inside the store. Eye exam discount applies only to comprehensive eye exams and does not include
contact lens exams or fitting. Contact lens purchase requires valid contact lens prescription. At LensCrafters locations, contact lenses are
available by participating Independent Doctors of Optometry or at LensCrafters locations.
The AARP Medicare Supplement Insurance Plans carry the AARP name and UnitedHealthcare Insurance Company pays a
royalty fee to AARP for use of the AARP intellectual property. Amounts paid are used for the general purposes of AARP and its
members. NeitherAARP nor its affiliate is the insurer.
SA25025ST (8-11) AGT BW
0000001 0000026 0051 0074 UMS1129 01 L

The SilverSneakers program is made available as a value added service to AARP members insured by
UnitedHealthcare. Neither AARP nor UnitedHealthcare endorse or are responsible for the services or information
provided by this program. Consult a health care professional before beginning any exercise program. EyeMed
Vision Care (EyeMed) is the network administrator of AARP Vision Discounts. These discounts cannot be
combined with any other discounts, promotions, coupons, or vision care plans. Products or services that are
reimbursable by federal programs including Medicare and Medicaid are not available on a discounted or
complimentary basis. EyeMed pays a royalty fee to AARP for use of the AARP intellectual property. Amounts paid
are used for the general purposes of AARP and its members. Cannot be combined with any other offer, previous
purchases, or vision and insurance plans. Some restrictions apply. Some brands excluded. See store for details.
Void where prohibited. Valid at participating locations. The Sears trademark is registered and used under license
from Sears Brands LLC. Target Optical ® is a registered mark of Target Brands, Inc. used under license. OptumHealth
is the provider of Nurse HealthLine. OptumHealth nurses cannot diagnose problems or recommend specific
treatment and are not a substitute for your doctor’s care. All decisions about medications, vision care, and health
and wellness care are between you and your health care provider.
AARP doesn’t make individual recommendations for health-related products, services, insurance or programs. You
are encouraged to evaluate your needs and compare products.
AARP Medicare Supplement Insurance Plans are insured by UnitedHealthcare Insurance Company, Horsham, PA.
Policy Form No. GRP 79171 GPS-1 (G-36000-4). In some states, plans may be available to persons eligible for
Medicare by reason of disability. All plans may not be available in your state/area.
Not connected with or endorsed by the U.S. Government or the federal Medicare program.
This is a solicitation of insurance. An agent may contact you.
AARP and its affiliate are not insurance agencies or carriers and do not employ or endorse insurance agents,
producers, brokers, representatives or advisors.
See the enclosed brochure for complete information including benefits, costs, eligibility requirements, exclusions
and limitations.
0000001 0000026 0052 0074 UMS1129 01 L

Enrollment Checklist
In the following section, you will find the forms you need to complete when applying for coverage.
Please be sure to complete and submit all the necessary forms to ensure your enrollment is
processed quickly and accurately.
Here is an overview of the different forms and some helpful tips:
Application Form
• Be sure to review and complete each applicable section.
• Please only write comments where indicated on the application. Written comments in other
areas of the form will slow down processing of the application.
• Be sure to sign and date the application in all the places indicated. The agent must also sign
and date the application and include his or her agent identification number.
AARP Membership Form
AARP membership is required to enroll in an AARP Medicare Supplement Plan. If you are not
currently an AARP member, simply complete the membership form and submit with the plan
application, along with a separate check for $16.00 payable to AARP.
Automatic Payments Authorization Form
Automatic payments are available by submitting the completed form (signed and dated) and a
voided check. If requesting automatic payments, you can deduct $2 from the first month’s
premium check.
Notice to Applicants Regarding Replacement of Coverage
If you are replacing current coverage as indicated on the form, complete both copies of the
form, submit one copy with the enrollment application, and keep the other copy for your records.
The agent must also sign and date both copies of the form.
SA25124ST (10-10)
0000001 0000027 0053 0074 UMS1129 01 L

0000001 0000027 0054 0074 UMS1129 01 L

Application Form
AARP ® Medicare Supplement Insurance Plans
Insured by UnitedHealthcare Insurance Company
Horsham, PA 19044
AARP Membership Number (If you are already a member)
_
First Name MI Last Name
Address Line 1
Address Line 2
City ST Zip
Note: Plans and rates described in this package
are good only for residents of Colorado
Instructions
1. Fill in all requested information on this form
and be sure to sign where indicated.
2. Print clearly. Use CAPITAL letters.
3. Fill in the circles with black or blue ink.
Not pencil.
Example:
Y N
If you are not already an AARP Member,
please include your AARP Membership
Application and a check or money order
for your annual Membership dues with
this application.
If reply envelope is missing,
please mail to: UnitedHealthcare
Insurance Company, P.O. Box 105331,
Atlanta, GA 30348-5331.
1 Tell us about yourself
Birthdate
M M D D Y Y Y Y
Gender
M F
Phone
Area Code and Phone Number
E-mail address (optional)
Please supply the following information, found on your Medicare card.
MEDICARE
HEALTH INSURANCE
NAME
First / Middle Initial / Last
MEDICARE CLAIM #
HOSPITAL (PART A) EFFECTIVE DATE: 0 1
M M D D Y Y Y Y
MEDICAL (PART B) EFFECTIVE DATE: 0 1
M M D D Y Y Y Y
ARE BOTH MEDICARE PARTS A & B COVERAGE ACTIVE?
Y
N
By providing your email address, you are agreeing to receive important account information and product offers.
Be sure to write all necessary periods (.) and symbols (@) in their space.
2460720307
Continued on next page
M78243AGMMCO01 02B Page 1 of 8
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0000001 0000028 0055 0074 UMS1129 01 L

2 Tell us about your tobacco usage
If you have smoked cigarettes or used any tobacco product at any time within the past twelve months, darken this circle:
3 Choose your plan and effective date
Please indicate your plan choice below:
A B C F K L N
You are eligible to enroll if all of these are true:
• you are an AARP member,
• you are age 50 or older,
• you are enrolled in Medicare Parts A&B,
• you are not duplicating Medicare supplement coverage.
• If you are not yet age 65, you are eligible only if you
enrolled in Medicare Part B within the last 6 months,
unless you are an “Eligible Person” entitled to guaranteed
acceptance as shown in the enclosed “Your Guide”.
Coverage Effective Date
Your coverage will become effective on the first day
of the month following receipt and approval of this
application and first month's premium. You will receive a
Certificate of Insurance confirming your effective date.
If you would like your coverage to begin on a later date
(the 1st day of a future month), please indicate below.
Requested Effective Date
0 1
M M D D Y Y Y Y
4 Answer these questions to determine if your acceptance is guaranteed
4A. Did you turn age 65 in the last 6 months?
Y N If YES, skip to Section 7.
4D. Have you lost other health insurance coverage and,
if so, are you an “eligible person” as defined within the
termination notice you received from your prior insurer?
4B. Did you enroll in Medicare Part B within the last
6 months?
Y N If YES, skip to Section 7.
4C. Will your plan effective date be within 6 months after
turning age 65 and enrolling in Medicare Part B?
Y N If YES, skip to Section 7.
• If you answered YES to 4A, 4B, or 4C, your acceptance
is guaranteed.
• If you answered NO to 4A, 4B, and 4C, continue to
question 4D.
Y
N
If YES, skip to Section 7.
• If you answered YES to 4D, you may be guaranteed
acceptance in certain AARP Medicare Supplement Plans.
Include a copy of the termination notice with
your application.
If you answered NO to all questions in this section and:
• You are age 65 or over: Go to Section 5.
• You are age 50 to 64: You are NOT eligible to apply for
these plans.
Continued on next page
M78243AGMMCO01 02B Page 2 of 8
▲
0000001 0000028 0056 0074 UMS1129 01 L

5 Answer these health questions to determine if you are eligible for this coverage
5A. Do any of these apply to you?
If you answered YES to either question in
• have end stage renal (kidney) disease
STOP
this section, you are NOT eligible for these
• currently receiving dialysis
plans at this time.
• diagnosed with kidney disease that may require dialysis
If your health status changes in the future, allowing you
• admitted to a hospital as an inpatient within the past
to answer NO to all of the questions in this section,
90 days
please submit an application at that time.
Y
N
5B. Within the past two years, has a medical professional
recommended or discussed as a treatment option, any
of the following that has NOT been completed:
• hospital admittance as an inpatient
• organ transplant
• back or spine surgery
• joint replacement
• surgery for cancer
• heart surgery
• vascular surgery
For information regarding plans that may be available,
contact your local state department on aging.
If you answered NO to both questions in this section,
please continue to Section 6.
Y
N
6 Tell us if you have any of these medical conditions to determine your rate
Complete this section only if you enrolled in Medicare Part B three or more years ago. All others go to Section 7.
Read the conditions listed below carefully. If within the past two years, you have been diagnosed, treated, or had
(as determined by a member of the medical profession) any of the following conditions, darken the circle next
to it. If you are unsure how to respond, please consult your physician.
6A. Heart or Vascular Conditions
Aneurysm
Arteriosclerosis or Atherosclerosis
Artery or Vein Blockage
Atrial Fibrillation or Atrial Flutter
Cardiomyopathy
Carotid Artery Disease
Congestive Heart Failure (CHF)
Coronary Artery Disease (CAD)
Heart Attack
Peripheral Vascular Disease or Claudication
Stroke, Transient Ischemic Attack (TIA), or mini-stroke
Ventricular Tachycardia
6B. Diabetes
With any of the following complications:
Circulatory problems, Kidney problems, or Retinopathy
6C. Lung/Respiratory Conditions
Chronic Obstructive Pulmonary Disease (COPD)
Emphysema
6D. Cancer or Tumors
Cancer (other than skin cancer)
Leukemia or Lymphoma
Melanoma
Continued on next page
M78243AGMMCO01 02B Page 3 of 8
▲
0000001 0000029 0057 0074 UMS1129 01 L

6 Tell us if you have any of these medical conditions to determine your rate – continued
Complete this section only if you enrolled in Medicare Part B three or more years ago. All others go to Section 7.
Read the conditions listed below carefully. If within the past two years, you have been diagnosed, treated, or had
(as determined by a member of the medical profession) any of the following conditions, darken the circle next
to it. If you are unsure how to respond, please consult your physician.
6E. Kidney Conditions
Chronic Renal Failure or Insufficiency
Polycystic Kidney Disease
Renal Artery Stenosis
6F. Liver
Cirrhosis of the Liver
6G. Transplants
Bone marrow or organ transplant
6H. Gastrointestinal Conditions
Chronic Pancreatitis
Esophageal Varices
6I. Musculoskeletal Conditions
Amputation due to disease
Rheumatoid Arthritis
Spinal Stenosis
6J. Substance Abuse
Alcohol Abuse or Alcoholism
Drug Abuse or use of illegal drugs
6K. Brain or Spinal Cord Conditions
Paraplegia, Quadriplegia or Hemiplegia
6L. Psychological/Mental Conditions
Bipolar or Manic Depressive
Schizophrenia
6M. Eye Condition
Macular Degeneration
6N. Nervous System Conditions
Amyotrophic Lateral Sclerosis (ALS)
Alzheimer’s Disease or Dementia
Multiple Sclerosis (MS)
Parkinson’s Disease
Systemic Lupus Erythematosus (SLE)
6O. Immune System Conditions
AIDS
HIV positive
If you darkened a circle for any of the medical
conditions in this Section (6), your rate will be
the level 2 rate. Please see the enclosed
“Cover Page – Rates”.
Continued on next page
M78243AGMMCO01 02B Page 4 of 8
▲
0000001 0000029 0058 0074 UMS1129 01 L

7 Tell us about your past and current coverage
Please review the statements below, then answer all
questions to the best of your knowledge.
• You do not need more than one Medicare Supplement
insurance policy.
• You may want to evaluate your existing health coverage
and decide if you need multiple coverage.
• You may be eligible for benefits under Medicaid and may
not need a Medicare supplement policy.
• If, after purchasing this policy, you become eligible for
Medicaid, the benefits and premiums under your Medicare
Supplement policy can be suspended, if requested, during
your entitlement to benefits under Medicaid for 24 months.
You must request this suspension within 90 days of
becoming eligible for Medicaid. If you are no longer
entitled to Medicaid, your suspended Medicare
supplement policy (or, if that is no longer available, a
substantially equivalent policy) will be reinstituted if
requested within 90 days of losing Medicaid eligibility. If
the Medicare supplement policy provided coverage for
outpatient prescription drugs and you enrolled in Medicare
Part D while your policy was suspended, the reinstituted
policy will not have outpatient prescription drug coverage,
but will otherwise be substantially equivalent to your
coverage before the date of the suspension.
• If you are eligible for, and have enrolled in a Medicare
supplement policy by reason of disability, and you later
become covered by an employer or union-based group
health plan, the benefits and premiums under your
Medicare supplement policy can be suspended, if
requested,while you are covered under the employer or
union-based group health plan. If you suspend your
Medicare supplement policy under these circumstances,
and later lose your employer or union-based group health
plan, your suspended Medicare supplement policy (or, if
that is no longer available, a substantially equivalent
policy) will be reinstituted if requested within 90 days of
losing your employer or union-based group health plan. If
the Medicare supplement policy provided coverage for
outpatient prescription drugs, and you enrolled in Medicare
Part D while your policy was suspended, the reinstituted
policy will not have outpatient prescription drug
coverage,but will otherwise be substantially equivalent to
your coverage before the date of the suspension.
• Counseling services may be available in your state to
provide advice concerning your purchase of Medicare
supplement insurance and concerning medical assistance
through the state Medicaid program, including benefits as
a Qualified Medicare Beneficiary (QMB) and a Specified
Low-Income Medicare Beneficiary (SLMB).
For your protection, you are required to answer
all the questions below (7A through 7N) and sign in
the signature box on the next page.
7A. Are you covered for medical assistance through the state
Medicaid program? (Medicaid is a state-run health care
program that helps with medical costs for people with low or
limited income. It is not the Federal Medicare Program.)
Note to applicant: If you are participating in a
“Spend-down Program” and have not met your “Share
of Cost,” please answer NO to this question.
Y
If NO, skip to question 7D.
If YES, please continue to 7B and 7C.
7B. Will Medicaid pay your premiums for this Medicare
supplement policy?
Y
N
N
7C. Do you receive any benefits from Medicaid other than
payments toward your Medicare Part B premium?
Y
7D. Have you had coverage from any Medicare plan
other than original Medicare within the past 6 months
(for example, a Medicare Advantage plan, a Medicare
HMO, or PPO)?
Y
N
N
If NO, skip to question 7I.
If YES, fill in your start and end dates and continue to
question 7E. If you are still covered under this plan, leave
the end date blank.
Start Date
End Date
0 1 0 1
M M D D Y Y Y Y M M D D Y Y Y Y
Continued on next page
▲
M78243AGMMCO01 02B Page 5 of 8
0000001 0000030 0059 0074 UMS1129 01 L

7 Tell us about your past and current coverage – continued
7E. If you are still covered under the Medicare plan, do you
intend to replace your current coverage with this new
Medicare Supplement policy?
Y
7F. Was this your first time in this type of Medicare plan?
Y
7G. Did you drop a Medicare Supplement policy to enroll in
the Medicare plan?
Y
7H. Has your coverage under the previous plan been
involuntarily terminated for reasons other than
nonpayment of premiums or for fraud?
Y
7I. Do you have another Medicare Supplement policy
in force?
Y
If NO, skip to question 7K.
If YES, please continue.
7J. If YES, do you intend to replace your current Medicare
Supplement policy with this policy?
Y
N
N
N
N
N
N
7K. Have you had coverage under any other health
insurance within the past 6 months (for example, an
employer, union, or individual plan)?
Y
N
If NO, please sign below, then continue to Section 8.
If YES, please list with what company and what type
of policy in the space provided below. Then continue to
question 7L.
Company Name
Policy Type
HMO/PPO Major Medical Employer Plan
Union Plan Other_______________________
7L. What are your dates of coverage under the policy you
listed in 7K? Leave the end date blank if you are still
covered under the other policy.
Start Date
End Date
M M D D Y Y Y Y M M D D Y Y Y Y
7M. Are you replacing this health insurance?
Y
N
7N. Has your coverage under the previous plan been
involuntarily terminated for reasons other than
nonpayment of premiums or for fraud?
Y
N
✗
Your Signature – 1 (required)
______________________________________
Continued on next page
M78243AGMMCO01 02B Page 6 of 8
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0000001 0000030 0060 0074 UMS1129 01 L

8 Authorization and Verification of Information
Please read carefully, and sign and date in the highlighted area below.
• My signature indicates I have read and understand the
contents of this application form.
• I declare the answers on this application form are
complete and true to the best of my knowledge
and belief and are the basis for issuing coverage.
I understand that this application form becomes a part
of the insurance contract and that if the answers are
incomplete, incorrect or untrue, UnitedHealthcare
Insurance Company may have the right to rescind my
coverage, adjust my premium, or reduce my benefits.
• It is unlawful to knowingly provide false, incomplete, or
misleading facts or information to an insurance company
for the purpose of defrauding or attempting to defraud
the company. Penalties may include imprisonment, fines,
denial of insurance, and civil damages. Any insurance
company or agent of an insurance company who
knowingly provides false, incomplete, or misleading
facts or information to a policyholder or claimant for the
purpose of defrauding or attempting to defraud the
policyholder or claimant with regard to a settlement or
award payable from insurance proceeds shall be
reported to the Colorado Division of Insurance within
the Department of Regulatory Agencies.
• I understand the agent or broker cannot grant approval.
This application and payment of the initial premium does
not guarantee coverage will be provided. I understand
coverage, if provided, will not take effect until issued by
UnitedHealthcare Insurance Company, and actual rates
are not determined until coverage is issued.
• I understand the agent or broker may not change or waive any
terms or requirements related to this application and its
contents, underwriting, premium, or coverage.
• I acknowledge receipt of the Guide to Health Insurance
for People with Medicare and the Outline of Coverage.
• I understand the person discussing plan options with
me is either employed by or contracted with
UnitedHealthcare Insurance Company. This person may
be compensated based on my enrollment in a plan.
Authorization for the Release of Medical Information
I authorize any health care provider, licensed physician,
medical practitioner, hospital, pharmacy, clinic or other
medical facility, health care clearinghouse, pharmacy
benefit manager, insurance company, or other organization,
institution, or person to give UnitedHealthcare Insurance
Company and its affiliates (“The Company”) any data or
records about me or my mental or physical health. I
understand the purpose of this disclosure and use of my
information is to allow The Company to determine my
eligibility for coverage and rate. I understand this
authorization is voluntary and I may refuse to sign the
authorization. My refusal may, however, affect my
eligibility to enroll in the health plan or to receive benefits,
if permitted by law. I understand the information I
authorize The Company to obtain and use may be
re-disclosed to a third party only as permitted under
applicable law, and once re-disclosed, the information
may no longer be protected by Federal privacy laws. I
understand I may end this authorization if I notify The
Company, in writing, prior to the issuance of coverage.
After coverage is issued, this authorization is not
revocable. This authorization is valid for 24 months from
the date of my signature.
Please see “Your Guide” to determine if the following
pre-existing condition waiting period applies to you.
I understand the plan will not pay benefits for stays
beginning or medical expenses incurred during the
first 3 months of coverage if they are due to conditions
for which medical advice was given or treatment
recommended by or received from a physician within
3 months prior to the insurance effective date.
I have read all information and have answered all questions to the best of my ability.
Your Signature – 2 (required)
Today’s Date (required)
✗
_______________________________________________________________
M M D D Y Y Y Y
Note: If you are signing as the legal representative for the applicant, please enclose a copy of the appropriate legal documentation.
Continued on next page
M78243AGMMCO01 02B Page 7 of 8
▲
0000001 0000031 0061 0074 UMS1129 01 L

8 Authorization and Verification of Information
Please read carefully, and sign and date in the highlighted area below.
I authorize any health care provider, licensed physician, medical use of my information is to allow The Company to determine
practitioner, hospital, pharmacy, clinic or other medical facility, the eligibility of and/or amount payable for my claims and for
health care clearinghouse, pharmacy benefit manager, analytic studies. I understand I may end this authorization if I
insurance company, or other organization, institution, or person notify The Company, in writing, except to the extent that The
to give UnitedHealthcare Insurance Company and its affiliates Company has already acted on my authorization. If not revoked,
(“The Company”) any data or records about me or my mental or this authorization is valid for the term of the coverage.
physical health. I understand the purpose of this disclosure and
✗
Your Signature – 3
Today’s Date
_______________________________________________________________
M M D D Y Y Y Y
Note: If you are signing as the legal representative for the applicant, please enclose a copy of the appropriate legal documentation.
Plan Rates
Please refer to the "Cover Page - Rates" for the monthly cost of
the plan you have selected. If you answered YES to any medical
conditions in Section 6, your rate will be the level 2 rate.
Once your application is processed, you'll be notified of your
acceptance, rate and insurance start date.
Please submit your first month's payment with this application.
Make your check or money order payable to: UnitedHealthcare
Insurance Company. If you are currently insured under an AARP
Medicare Supplement Plan, Send No Money Now. You will
receive updated payment instructions later.
9 For Agent Use Only
If application is being made through an Agent, he or she must complete the following; and if appropriate, the notice of
replacement coverage included with this application. All information must be completed or the application will be returned.
1. List any other medical or health insurance policies sold to the applicant:
2. List any policies that are still in force:
3. List policies sold in the past five years that are no longer in force:
Agent Name (PLEASE PRINT)
First Name MI Last Name
✗
Agent Phone Number
Agent Signature (required)
Agent ID (required)
M M D D Y Y Y Y
M78243AGMMCO01 02B Page 8 of 8
0000001 0000031 0062 0074 UMS1129 01 L

AARP membership
offers so much for so little.
What Each Member Receives:
Membership - For individual member (12 months) $16
Price
Membership - For member's spouse or partner (at any age) Included
Discounts (nationwide) - Vision: exams, frames, lenses Included
- Pharmacy: prescriptions and over-the-counter items
- Plus, look to AARPdiscounts.com for easy access to savings
on trusted brands, all in one place. Enjoy one-stop deals from
shopping and dining to rental cars, hotels and cruises – and
so much more!
Trusted Information - AARP The Magazine: the largest magazine circulation in the world Included
- AARP Bulletin Newspaper (10 issues per year)
Access to Health Products - AARP-endorsed health insurance for you and your dependents Included
- AARP-endorsed dental and long-term care insurance
Advocacy - Representation of your interests in Washington and your state Included
- Confronting age discrimination by employers
- Strengthening Social Security
- Protecting pension and retirement benefits
- Fighting predatory home loan lending
Access to Financial Programs - AARP-endorsed auto, homeowners, life, mobile home and
Included
motorcycle insurance
- Earn rewards with a no-annual-fee AARP-endorsed credit card
Local Opportunities - Safe driving courses (also available online) Included
- Over 2,200 local AARP chapters
- Social activities, volunteer opportunities, classes and workshops
BA25233
Yes, I'd like to join AARP today!
It's simple ... just follow these instructions.
If you're already a member, give this to someone
you know or complete it to renew your membership.
___________________________________________________________
My Name (please print: Mr./Mrs./Ms./Dr./First, Middle Initial, Last)
___________________________________________________________
Address
Apt.
___________________________________________________________
City State Zip
_______ /________ /__________
Date of Birth: Month / Day / Year
___________________________________________________________
Spouse’s/Partner’s Name (for FREE membership – at any age)
I agree to pay for the term I select:
1 year/$16 3 years/$43 5 years/$63
Check or money order enclosed, payable
to AARP. Do not send cash.
Please keep in touch by e-mail about AARP
activities, events and member benefits:
__________________________________________
E-mail Address
V7FYUHG
Dues are not deductible for income tax purposes. One membership includes spouse/partner. Annual dues include $4.03 for a subscription to AARP The
Magazine and $3.09 for the AARP Bulletin. Dues outside U.S. domestic mail limits: $17/one year for Canada and Mexico, $28/one year for all other countries.
We may steward your resources by converting your check into an electronic deposit. Please allow up to six weeks for delivery of your membership kit. When
you join, AARP shares your membership information with the companies we have selected to provide AARP member benefits, companies that support AARP
operations, and select non-profit organizations. If you don’t want us to share your information with providers of AARP member benefits or non-profit
organizations, please let us know by calling 1-800-516-1993 or e-mailing us at AARPmember@aarp.org.
AA25001
✁
Choose from 3 easy ways to join:
1.) Log on to www.AGNTU.aarpenrollment.com
2.) Call toll-free: 1-866-331-1964
3.) Send completed form in the envelope
provided
AGT
0000001 0000032 0063 0074 UMS1129 01 L

BENEFITS & SERVICES
AARP members have access to:
Travel Discounts
Using AARP’s exclusive travel savings just once could
pay for your membership several times over!
• Savings on hotels, motels and resorts worldwide
• Discounted rates on airfares, cruises and auto
rentals
• Special pricing on vacation packages
Health-Related Benefits
With today’s high health care costs, AARP membership
is more valuable than ever.
• Supplemental and custom-designed health plans
for AARP members and their dependents
• Vision and prescription discounts nationwide
• Dental and long-term care insurance
Local Opportunities
AARP offers many ways to get
active in your community.
• Over 2,200 local AARP
chapters
• Social activities
• Volunteer opportunities
• Safe driving courses
• Classes and workshops
Protection of Your Rights
Your job. Your health. Your future. AARP will stand up
for you by ...
• Representing your interests in Washington and
your state
• Confronting age discrimination by employers
• Strengthening Social Security
• Protecting pension and retirement benefits
• Fighting predatory home loan lending
Dependable
Financial Programs
Designed specifically for
AARP members. With
the high level of service
you expect.
• Earn rewards with
a no-annual-fee
credit card
• Auto, homeowners and
life insurance
Valuable Information
Accurate and authoritative, direct from
your reliable source – AARP.
• AARP The Magazine
• AARP Bulletin
• FREE financial and health guides
• Our web site, www.aarp.org
Specially Priced Products & Services
AARP helps you save in ways and places you never
imagined.
• Discounts on groceries, home security, restaurants
and more!
• Reduced-fee legal services*
• Roadside assistance and emergency towing
NOTE: The benefits listed are only a partial list. Your
Membership Kit will supply you with a full list of approved
service providers that offer exclusive services and discounts
to AARP members only.
* Legal Services Network reduced-fee benefits are not
available in HI, NV and OH.
Value our members appreciate.
Members often tell us their AARP membership paid for itself with the first
service they used. They’re surprised at how many ways and places their
membership proves valuable. And it’s an even better value because your
spouse/partner is included free (at any age)!
0000001 0000032 0064 0074 UMS1129 01 L

Save $24 a year with the
Electronic Funds Transfer (EFT) service
The easiest way to pay.
More than 2.5 million AARP members nationwide enjoy the convenience of the automatic payments
option. With EFT, your monthly payment will automatically be deducted from your checking or
savings account. Also, you’ll save $2.00 off the total monthly rate for your household.
In addition to saving up to $24.00 a year:
• You’ll save on the cost of checks and rising postal rates.
• You don’t have to take time to write a check each month.
• You don’t have to worry about mailing a payment if you travel or become ill, because your
payment is always deducted on or about the fifth day of each month.
Sign Up in Two Easy Steps
1. Complete both sides of the Automatic Payment Authorization Form below. Return it with
the application and be sure to keep a copy for your records.
2. Include a voided check for the checking account from which you want your payments
withdrawn. The information on your check is needed to process your request for EFT.
Do not send a deposit slip or cancelled check.
Your Automatic Payments Effective Date
If you are submitting this EFT form with your enrollment application, your automatic payments start
date will be equal to your plan effective date. A letter will be sent to confirm this and will include the
amount of your withdrawal. Please note that if your coverage is effective in the future or your account
is paid in advance, EFT withdrawals will begin for the next payment due. If your account is effective in
the past or is past due, a letter will be sent that explains how to make the payment that is due.
BA9957A (10-12)
Cut along the dotted line.
AUTOMATIC PAYMENT AUTHORIZATION FORM
I allow UnitedHealthcare Insurance Company
(UnitedHealthcare Insurance Company of New York,
for New York residents), hereafter named UnitedHealthcare,
to take monthly withdrawals, for the then-current
monthly rate, from the account named on this form.
I also allow the named banking facility (BANK) to
charge such withdrawals to this account.
Member Name __________________________
Member Address_________________________
City ___________________________________
State ________________ Zip Code __________
Bank Name _____________________________
Bank Routing No. ________________________
Bank Account No. ________________________
Account Type: Checking
Savings (statement savings only)
The reverse side of this form must also be completed.
0000001 0000033 0065 0074 UMS1129 01 L

IMPORTANT
• Please refer to the diagram below to obtain your bank routing information.
• Be sure to attach a voided check from the checking account you wish to use.
VOID
We look forward to continuing to serve you.
Monthly withdrawal amounts will be for the total household payment due each month.
This will include premiums for a spouse or other member(s) of the household on the same
membership account. This authority is active until UnitedHealthcare and the BANK receive
notice from me to end withdrawals in enough time to give UnitedHealthcare and the BANK
a reasonable opportunity to act on it. I have the right to stop payment of a withdrawal by
giving notice to the BANK in such time as to give the BANK a reasonable opportunity to
act upon it. I understand such action may make the health care insurance coverage past
due and subject to cancellation.
Member Name________________________________________ Member # _____________
Bank Acct Holder’s Name (if different) ___________________________________________
Bank Acct Holder’s Signature ________________________________ Date _____________
Please do not write in the space below. For company use only.
0000001 0000033 0066 0074 UMS1129 01 L

Save $24 a year with the
Electronic Funds Transfer (EFT) service
The easiest way to pay.
More than 2.5 million AARP members nationwide enjoy the convenience of the automatic payments
option. With EFT, your monthly payment will automatically be deducted from your checking or
savings account. Also, you’ll save $2.00 off the total monthly rate for your household.
In addition to saving up to $24.00 a year:
• You’ll save on the cost of checks and rising postal rates.
• You don’t have to take time to write a check each month.
• You don’t have to worry about mailing a payment if you travel or become ill, because your
payment is always deducted on or about the fifth day of each month.
Sign Up in Two Easy Steps
1. Complete both sides of the Automatic Payment Authorization Form below. Return it with
the application and be sure to keep a copy for your records.
2. Include a voided check for the checking account from which you want your payments
withdrawn. The information on your check is needed to process your request for EFT.
Do not send a deposit slip or cancelled check.
Your Automatic Payments Effective Date
If you are submitting this EFT form with your enrollment application, your automatic payments start
date will be equal to your plan effective date. A letter will be sent to confirm this and will include the
amount of your withdrawal. Please note that if your coverage is effective in the future or your account
is paid in advance, EFT withdrawals will begin for the next payment due. If your account is effective in
the past or is past due, a letter will be sent that explains how to make the payment that is due.
BA9957A (10-12)
Cut along the dotted line.
AUTOMATIC PAYMENT AUTHORIZATION FORM
I allow UnitedHealthcare Insurance Company
(UnitedHealthcare Insurance Company of New York,
for New York residents), hereafter named UnitedHealthcare,
to take monthly withdrawals, for the then-current
monthly rate, from the account named on this form.
I also allow the named banking facility (BANK) to
charge such withdrawals to this account.
Member Name __________________________
Member Address_________________________
City ___________________________________
State ________________ Zip Code __________
Bank Name _____________________________
Bank Routing No. ________________________
Bank Account No. ________________________
Account Type: Checking
Savings (statement savings only)
The reverse side of this form must also be completed.
0000001 0000034 0067 0074 UMS1129 01 L

IMPORTANT
• Please refer to the diagram below to obtain your bank routing information.
• Be sure to attach a voided check from the checking account you wish to use.
VOID
We look forward to continuing to serve you.
Monthly withdrawal amounts will be for the total household payment due each month.
This will include premiums for a spouse or other member(s) of the household on the same
membership account. This authority is active until UnitedHealthcare and the BANK receive
notice from me to end withdrawals in enough time to give UnitedHealthcare and the BANK
a reasonable opportunity to act on it. I have the right to stop payment of a withdrawal by
giving notice to the BANK in such time as to give the BANK a reasonable opportunity to
act upon it. I understand such action may make the health care insurance coverage past
due and subject to cancellation.
Member Name________________________________________ Member # _____________
Bank Acct Holder’s Name (if different) ___________________________________________
Bank Acct Holder’s Signature ________________________________ Date _____________
Please do not write in the space below. For company use only.
0000001 0000034 0068 0074 UMS1129 01 L

NOTICE TO APPLICANT REGARDING REPLACEMENT OF
MEDICARE SUPPLEMENT INSURANCE OR MEDICARE ADVANTAGE
UNITEDHEALTHCARE INSURANCE COMPANY
Horsham, Pennsylvania
Save this notice! It may be important to you in the future
According to the information you furnished, you intend to terminate existing Medicare supplement or Medicare
Advantage insurance and replace it with a policy to be issued by UnitedHealthcare Insurance Company. Your new
policy will provide thirty (30) days within which you may decide without cost whether you desire to keep the policy.
You should review this new coverage carefully. Compare it with all accident and sickness coverage you now have. If,
after due consideration, you find that purchase of this Medicare supplement coverage is a wise decision, you should
terminate your present Medicare supplement or Medicare Advantage coverage. You should evaluate the need for other
accident and sickness coverage you have that may duplicate this policy.
Statement To Appplicant By Issuer, Agent, Broker Or Other Representative:
I have reviewed your current medical or health insurance coverage. To the best of my knowledge, this Medicare
supplement policy will not duplicate your existing Medicare supplement or, if applicable, Medicare Advantage coverage
because you intend to terminate your existing Medicare supplement policy or leave your Medicare Advantage plan.
The replacement policy is being purchased for one of the following reasons (check one):
Additional benefits.
No change in benefits, but lower premiums.
Fewer benefits and lower premiums
My plan has outpatient prescription drug
coverage and I am enrolling in Part D.
1. Health conditions which you may presently have
(Pre-existing conditions) may not be immediately or
fully covered under the new policy. This could result
in denial or delay of a claim for benefits under the
new policy, whereas a similar claim might have been
payable under your present policy.
2. State law provides that your replacement policy or
certificate may not contain new pre-existing
conditions, waiting periods, elimination periods, or
probationary periods. The insurer will waive any time
periods applicable to pre-existing conditions, waiting
periods, elimination periods, or probationary periods
in the new policy (or coverage) for similar benefits to
Disenrollment from a Medicare Advantage
plan. Please explain reason for Disenrollment.
Other (Please Specify)
the extent such time was spent (depleted) under the
original policy.
3. If you still wish to terminate your present policy and
replace it with new coverage, be certain to truthfully
and completely answer all questions on the
application concerning your medical and health
history. Failure to include all material medical
information on an application may provide a basis for
the company to deny any future claims and to refund
your premium as though your policy had never been
in force. After the application has been completed
and before you sign it, review it carefully to be certain
that all information has been properly recorded.
Do not cancel your present policy until you have received your new policy and are sure that you want to keep it.
(Signature of Agent, Broker or Other Representative)
(Date)
(Applicant’s Signature)
(Date)
(Applicant’s Printed Name & Address)
RN033 Complete and submit this copy with the application
7/09
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Thank You for Applying for an AARP ®
Medicare Supplement Insurance Plan.
For your records:
• You selected Plan __________
• The effective date you requested is (1st day of a future month): _____ / _____
Month
• Based on the information you provided, your monthly premium for the plan
you selected is $ __________
• You will be notified when review of your application has been completed
Please Note: Your final monthly premium will be determined once your
application is approved.
Year
What’s Next
Once Your Application Is Approved, You Will Receive:
• Your insured member identification card
• A Welcome Kit, including your certificate of insurance and coverage details
• Ongoing educational materials about how to make the most of your health
plan benefits
• Help and answers to any questions you may have from courteous Customer
Service Representatives
A continuing relationship with your agent/producer
SA25235ST (05-12)
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