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)
  • The inpatient deductible is $1632 for each benefit period
  • Days 1-60: Medicare covers 100%
  • Days 61-90: You are responsible for $408 per day
  • Days 91 until 60 day lifetime reserve is used up: Your responsibility is $826 per day
  • Beyond lifetime reserve: You are responsible for all costs incurred
Hospital Coinsurance
Covers 365 Additional inpatient days after lifetime reserve has been used up365 days extra Hospital coverage
Skilled nursing facility coinsurance
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
Foreign Travel Emergency
Monthly Rates & Brochures F G N
Blue Shield eff 7/1/2024 349.00
S: 294.00
Extra Rider
  • Basic gym access through sliver sneakers fitness program (silversneakers.com)
  • Personal emergency response system
  • Physician consultation by phone or video through Teladoc
  • Over the counter items through CVS (Up to $100 one time use per quarter allowance)
  • The vision benefit includes coverage for exams, frames and lenses ($100 frame allowance)
  • Hearing aid benefit includes an annual hearing aid test and coverage for Vista brand mid-level and premium-level hearing aids for a low copay
  • Acupuncture and chiropractic, up to 20 combined visits per calendar year
  • Identity theft protection
E: 310.00
 273
Blue Shield to 6/30/2024 329.00
S: 277.00
Extra Rider
  • Basic gym access through sliver sneakers fitness program (silversneakers.com)
  • Personal emergency response system
  • Physician consultation by phone or video through Teladoc
  • Over the counter items through CVS (Up to $100 one time use per quarter allowance)
  • The vision benefit includes coverage for exams, frames and lenses ($100 frame allowance)
  • Hearing aid benefit includes an annual hearing aid test and coverage for Vista brand mid-level and premium-level hearing aids for a low copay
  • Acupuncture and chiropractic, up to 20 combined visits per calendar year
  • Identity theft protection
E: 292.00
 257
Humana Achieve 283.23 248.52 200.76
Prepared for
Zip code: 90211
Age: 75

Contact us
(714) 921-9214
[email protected]
CA Ins Lic 0D57926