| Part A Hospital Services | F | G | 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) |
 |
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| 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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| 3 Pints of (unreplaced) blood | |
|
|
| Part B Services | F | G | N |
| Part B Annual Deductible ($240) | |
||
| Medicare covers 80% of Part B claims, you are responsible for 20%Part B Coinsurance | |
|
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 | F | G | N |
| Out of Pocket Limit | NA | NA | NA |
| Hospice coverage | |
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| Foreign Travel Emergency | |
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| Monthly Rates & Brochures | F | G | N |
| Anthem | S: 377.45 I: Additional benefits included with Anthem Innovative plan rider
|
270.92 | 291.50 |
| Blue Shield eff 7/1/2024 | 380.00 | S: 318.00 Extra Rider
E: 335.00 |
292 |
| Blue Shield to 6/30/2024 | 353.00 | S: 296.00 Extra Rider
E: 312.00 |
272 |
| Health Net | S: 320.00 Additional benefits included with Health Net Innovative plan rider
|
S: 286.00 Additional benefits included with Health Net Innovative plan rider
|
250.00 |
| UHC to 5/31/2024 | 304.34 | 237.89 | 201.52 |
| UHC eff 6/1/2024 | 339.50 | 265.54 | 224.80 |
|
Prepared for
Zip code: 90210 Age: 76 |
|
Anthem rates reflect 5%
Enrollees who reside with another Anthem Blue Cross Medicare Supplement for subscribermember may qualify for a household discount
UHC rates based on Part B effective less than 10 years
|