| Part A Hospital Services | A | B | C | D | F | F-ded | G | G-ded | K | L | M | N |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 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) |
 |
|
|
|
$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 |
|
$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 |
|
|
|
|
|
|
|
|
|
|
|
$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 |
|
$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 | |
|
|
|
|
|
|
|
|
|
|
|
| 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 |
|
$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% |
|
|||
| 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 |
|
$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% |
|
|
| Part B Services | A | B | C | D | F | F-ded | G | G-ded | K | L | M | N |
| Part B Annual Deductible ($240) | |
|
||||||||||
| Medicare covers 80% of Part B claims, you are responsible for 20%Part B Coinsurance | |
|
|
|
|
|
|
|
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% |
|
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 |
|
|
|
|
||||||||
| 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 | |
|
|
|
|
$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 |
|
$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% |
|
|
| Foreign Travel Emergency | |
|
|
|
|
|
|
|
|
|||
| Monthly Rates & Brochures | A | B | C | D | F | F-ded | G | G-ded | K | L | M | N |
| Anthem | 0.00 | S: -20.00 I: Additional benefits included with Anthem Innovative plan rider
See page 21 or 22 in Anthem brochure for details |
0.00 | |||||||||
| Blue Shield | -25.00 | -25.00 | S: -25.00 Extra Rider
E: -25.00 |
0 | ||||||||
| Cigna | 0.00 | 0.00 | 0.00 | |||||||||
| Continental (Aetna) | 0.00 | 0.00 | 0.00 | 0.00 | ||||||||
| Health Net | -30.00 | -30.00 | S: -30.00 Additional benefits included with Health Net Innovative plan rider
|
-30.00 | S: -30.00 Additional benefits included with Health Net Innovative plan rider
|
-30.00 | -30.00 | |||||
| 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. | ||||||||||||
|
Prepared for
Zip code: 86301 Age: 65 |
|
Anthem Plan F rates reflect $20.00 Welcome to Medicare discount
Anthem Plan G rates reflect $25.00 Welcome to Medicare discount
Blue Shield Plan F rates reflect $25 Welcome to Medicare discount
Blue Shield Plan G rates reflect $25 Welcome to Medicare discount
Health Net rates reflect $30 Welcome to Medicare discount
UHC rates based on Part B effective less than 10 years UHC Plan G rates reflect $25 Welcome to Medicare discount
|