| Part A Hospital Services | A | B | C | D | F | F-ded | G | G-ded | K | L | M | N |
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| The Part A deductible is $1632 per benefit period A benefit period starts when you are admitted to a facility and ends 60 days after you last received inpatient care at any facilityPart A Deductible ($1632) |
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$2800 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2800 in a calendar year After that coverage is 100% after ded |
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$2800 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2800 in a calendar year After that coverage is 100% after ded |
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$2800 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2800 in a calendar year After that coverage is 100% after ded |
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$2800 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2800 in a calendar year After that coverage is 100% after ded |
Plan covers 50% of your out of pocket expenses Your share is capped at $5120 per year50% |
Plan covers 75% of your out of pocket expenses Your share is capped at $2560 per year75% |
Plan covers 50% Part A deductible50% | |
| Covers 365 Additional inpatient days after lifetime reserve has been used up365 days extra Hospital coverage | |
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| Skilled nursing facility coinsurance | |
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$2800 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2800 in a calendar year After that coverage is 100% after ded |
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$2800 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2800 in a calendar year After that coverage is 100% after ded |
Plan covers 50% of your out of pocket expenses Your share is capped at $5120 per year50% |
Plan covers 75% of your out of pocket expenses Your share is capped at $2560 per year75% |
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| 3 Pints of (unreplaced) blood | |
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$2800 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2800 in a calendar year After that coverage is 100% after ded |
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$2800 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2800 in a calendar year After that coverage is 100% after ded |
Plan covers 50% of your out of pocket expenses Your share is capped at $5120 per year50% |
Plan covers 75% of your out of pocket expenses Your share is capped at $2560 per year75% |
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| Part B Services | A | B | C | D | F | F-ded | G | G-ded | K | L | M | N |
| Part B Annual Deductible ($240) | |
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| Medicare covers 80% of Part B claims, you are responsible for 20%Part B Coinsurance | |
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Plan covers 50% of your out of pocket expenses Your share is capped at $5120 per year50% |
Plan covers 75% of your out of pocket expenses Your share is capped at $2560 per year75% |
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You pay $20 for Dr. office visits You pay $50 for emergency room visits$20/$50 |
| Doctors who do not take Medicare Assignment can charge 15% above what medicare allows Some Medicare Supplement plans cover that extra 15%Part B Excess Charges |
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| Additional Features | A | B | C | D | F | F-ded | G | G-ded | K | L | M | N |
| Out of Pocket Limit | NA | NA | NA | NA | NA | NA | NA | NA | $5120 | $2560 | NA | NA |
| Hospice coverage | |
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$2800 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2800 in a calendar year After that coverage is 100% after ded |
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$2800 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2800 in a calendar year After that coverage is 100% after ded |
Plan covers 50% of your out of pocket expenses Your share is capped at $5120 per year50% |
Plan covers 75% of your out of pocket expenses Your share is capped at $2560 per year75% |
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| Foreign Travel Emergency | |
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| Monthly Rates & Brochures | A | B | C | D | F | F-ded | G | G-ded | K | L | M | N |
| Anthem | 189.09 | S: 327.28 I: Additional benefits included with Anthem Innovative plan rider
See page 21 or 22 in Anthem brochure for details |
234.93 | 252.76 | ||||||||
| Blue Shield | 167.00 | 293.00 | S: 245.00 Note: Silver Sneakers gym membership is included with all Blue Shield plans. Additonal benefits with Blue Shield Extra RiderForeign Travel - Not covered by Medicare
Physician Consultation by Phone or Video Through Teledoc
Over-the-Counter Items through CVS
Accupuncture and Chiropractic Services (provided by AHS provider network)
Vision Coverage (provided by Vision Service Plan)
Hearing Aid Services (provided by Epic Hearing Healthcare)
E: 262.00 |
223 | ||||||||
| Cigna | 228.28 | 301.98 | 70.81 | 245.97 | 175.07 | |||||||
| Continental (Aetna) | 208.25 | 263.73 | 369.44 | 68.89 | 270.64 | 196.50 | ||||||
| Health Net | 195.00 | 246.00 | S: 278.00 Additional benefits included with Health Net Innovative plan rider
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119.00 | S: 247.00 Additional benefits included with Health Net Innovative plan rider
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108.00 | 213.00 | |||||
| Humana Achieve | 218.53 | 266.65 | 231.20 | 76.16 | 170.07 | |||||||
| National Health Ins | 235.85 | 308.55 | 90.30 | 263.09 | 207.74 | |||||||
| Physicians Mutual | 232.45 | 289.20 | 252.52 | 209.98 | ||||||||
| United American | 197.00 | 269.00 | 365.00 | 329.00 | 379.00 | 69.00 | 313.00 | 69.00 | 168.00 | 237.00 | 258.00 | |
| UHC | 169.74 | 236.78 | 285.57 | 287.00 | 224.48 | 157.44 | 190.04 | |||||
| United World Life | 205.17 | 301.72 | 241.89 | 72.80 | 179.86 | |||||||
| Choosing a Medigap Policy | ||||||||||||
| Continental: Add $20 application fee. | ||||||||||||
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Prepared for
Zip code: 92804 Age: 71 |
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UHC rates based on Part B effective less than 10 years
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