| 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 | 0.00 | S: 0.00 I: Additional benefits included with Anthem Innovative plan rider
See page 21 or 22 in Anthem brochure for details |
0 | 0.00 | ||||||||
| Blue Shield | 0.00 | 0.00 | S: 0.00 Extra Rider
E: 0.00 |
0 | ||||||||
| Cigna | 0.00 | 0.00 | 0.00 | |||||||||
| Continental (Aetna) | 0.00 | 0.00 | 0.00 | 0.00 | ||||||||
| Health Net | 0.00 | 0.00 | 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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0.00 | 0.00 | |||||
| Humana Achieve | 0.00 | 0.00 | 0.00 | 0.00 | 0.00 | |||||||
| UHC | 0.00 | 0.00 | 0.00 | 0.00 | ||||||||
| Choosing a Medigap Policy | ||||||||||||
| Continental: Add $20 application fee. | ||||||||||||
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Prepared for Zip code: 86301 Age: 65 |
| Select all that apply |
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If you are new to Medicare the following monthly discounts
are available for your first year of coverage
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Enrollees who live with another Anthem Medicare Supplement
member may qualify for a household discount.
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Blue ShieldYou are eligible for a 7% household premium discount
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Cigna Cigna
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Continental LifeContinental Life offers a 5% household premium discount
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Humana AchieveHumana Achieve offers a 12% household premium discount
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UHC/AARPYou can take 7% off your monthly premiums if
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| Contact us |
| (800) 464-4941 |
| [email protected] |
| CA Ins Lic 0765088 |