| Part A Hospital Services | F | F-ded | G | K |
|---|---|---|---|---|
| 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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Plan covers 50% of your out of pocket expenses Your share is capped at $5120 per year50% |
| Covers 365 Additional inpatient days after lifetime reserve has been used up365 days extra Hospital coverage | |
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| Skilled nursing facility coinsurance | |
$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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Plan covers 50% of your out of pocket expenses Your share is capped at $5120 per year50% |
| 3 Pints of (unreplaced) blood | |
$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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Plan covers 50% of your out of pocket expenses Your share is capped at $5120 per year50% |
| Part B Services | F | F-ded | G | K |
| 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% |
| 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 | F | F-ded | G | K |
| Out of Pocket Limit | NA | NA | NA | $5120 |
| Hospice coverage | |
$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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Plan covers 50% of your out of pocket expenses Your share is capped at $5120 per year50% |
| Foreign Travel Emergency | |
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| Monthly Rates & Brochures | F | F-ded | G | K |
| Anthem | S: 0.00 I: Additional benefits included with Anthem Innovative plan rider
See page 21 or 22 in Anthem brochure for details |
0 | ||
| Blue Shield | 0.00 | S: 0.00 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: 0.00 |
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| Cigna | 618.92 | 145.14 | 504.14 | |
| Continental (Aetna) | 730.38 | 136.62 | 535.28 | |
| Health Net | S: 0.00 Additional benefits included with Health Net Innovative plan rider
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0.00 | S: 0.00 Additional benefits included with Health Net Innovative plan rider
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| Humana Achieve | 0.00 | 0.00 | ||
| National Health Ins | 606.26 | 177.49 | 516.90 | |
| Physicians Mutual | 536.72 | 469.68 | ||
| United American | 784.00 | 158.00 | 654.00 | 324.00 |
| UHC | 613.00 | 479.50 | ||
| United World Life | 611.10 | 490.62 | ||
| Choosing a Medigap Policy | ||||
| Continental: Add $20 application fee. | ||||
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Prepared for
Zip code: 94025 Age: 78 Spouse: 78 |
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UHC rates based on Part B effective less than 10 years UHC spousal rates based on Part B effective less than 10 years
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