TN 2 (09-11)

NL 00720.225 MPD Medicare Prescription Drug Plan

MPD346 (HC3)

(Requested/Generated)

Caption: Information About The Prescription Drug Coverage (IRMAA)

Based on the information we have  (1)   (2)  due a refund for prescription drug coverage income-related monthly adjustment amounts.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: (Name)

Choice 2: you

Fill-in (2) - Systems Generated

Choice 1: is

Choice 2: are

MPD347 (HC4)

(Requested/Generated)

Caption: Information About The Prescription Drug Coverage (IRMAA)

This payment includes a refund of  (1)  prescription drug coverage income-related monthly adjustment amount.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Name possessive

Choice 2: your

MPD348 (HC5)

(Requested/Generated)

Caption: Information About The Prescription Drug Coverage (IRMAA)

We deducted  (1)  for  (2)  prescription drug coverage income-related monthly adjustment amount from the check  (3)  will receive for  (4)  on or about  (5)  .

Fill-in values:

Fill-in (1) - Requested As A Money Amount In Format $$$$$.¢¢

Choice 1: Amount

Fill-in (2) - Systems Generated

Choice 1: Name possessive

Choice 2: your

Fill-in (3) - Systems Generated

Choice 1: he

Choice 2: she

Choice 3: you

Fill-in (4) - Requested As A Date In Format Shown

Choice 1: MM/CCYY

Fill-in (5) - Requested As A Date In Format Shown

Choice 1: MM/DD/CCYY

MPD349 (HC6)

(Requested/Generated)

Caption: Information About The Prescription Drug Coverage (IRMAA)

The monthly deduction for  (1)  prescription drug coverage income-related monthly adjustment amount is  (2)  .

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Name possessive

Choice 2: your

Fill-in (2) - Requested As A Money Amount In Format $$$$$.¢¢

Choice 1: Amount

MPD350 (HC7)

(Requested/Generated)

Caption: Information About The Prescription Drug Coverage (IRMAA)

We deducted  (1)  for  (2)  prescription drug coverage income-related monthly adjustment amount from the check you will receive on or about  (3)  .

Fill-in values:

Fill-in (1) - Requested As A Money Amount In Format $$$$$.¢¢

Choice 1: Amount

Fill-in (2) - Systems Generated

Choice 1: Name possessive

Choice 2: your

Fill-in (3) - Requested As A Date In Format Shown

Choice 1: MM/DD/CCYY

MPD351 (HC8)

(Requested/Generated)

Caption: Information About The Prescription Drug Coverage (IRMAA)

We will no longer deduct  (1)  prescription drug coverage income-related monthly adjustment amount from  (2)  monthly benefits.

Fill-in values:

Fill-in (1) - Systems Generated

Choice 1: Name possessive

Choice 2: your

Fill-in (2) - Systems Generated

Choice 1: his

Choice 2: her

Choice 3: your

MPD352 (HC9)

(Requested/Generated)

Caption: Information About The Prescription