| Part A Hospital Services | F | F-ded | G | G-ded | 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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$2700 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2700 in a calendar year After that coverage is 100% after ded |
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$2700 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2700 in a calendar year After that coverage is 100% after ded |
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$2700 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2700 in a calendar year After that coverage is 100% after ded |
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$2700 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2700 in a calendar year After that coverage is 100% after ded |
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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 | |
$2700 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2700 in a calendar year After that coverage is 100% after ded |
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$2700 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2700 in a calendar year After that coverage is 100% after ded |
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| 3 Pints of (unreplaced) blood | |
$2700 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2700 in a calendar year After that coverage is 100% after ded |
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$2700 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2700 in a calendar year After that coverage is 100% after ded |
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| Part B Services | F | F-ded | G | G-ded | 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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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 | F | F-ded | G | G-ded | N |
| Out of Pocket Limit | NA | NA | NA | NA | NA |
| Hospice coverage | |
$2700 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2700 in a calendar year After that coverage is 100% after ded |
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$2700 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2700 in a calendar year After that coverage is 100% after ded |
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| Foreign Travel Emergency | |
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| Monthly Rates & Brochures | F | F-ded | G | G-ded | N |
| Anthem | S: 524.13 I: Additional benefits included with Anthem Innovative plan rider
|
376.23 | 404.78 | ||
| Blue Shield | 475.00 | S: 374.00 Extra Rider
E: 405.00 |
353 | ||
| Continental (Aetna) | 739.95 | 138.45 | 542.28 | 371.62 | |
| Health Net | S: 494.00 Additional benefits included with Health Net Innovative plan rider
|
214.00 | S: 395.00 Additional benefits included with Health Net Innovative plan rider
|
200.00 | 370.00 |
| Humana Achieve | 412.46 | 356.44 | 122.64 | 280.13 | |
| Physicians Mutual | 481.31 | 419.78 | 348.52 | ||
| United American to 4/30/2024 | 622.00 | 111.00 | 505.00 | 111.00 | 405.00 |
| United American eff 5/1/2024 | 662.00 | 122.00 | 543.00 | 122.00 | 445.00 |
| UHC to 5/31/2024 | 458.08 | 358.07 | 303.32 | ||
| UHC eff 6/1/2024 | 511.00 | 399.68 | 338.36 |
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Prepared for
Zip code: 90291 Age: 69 Spouse: 67 |
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Anthem rates reflect 10%
Enrollees who reside with another Anthem Blue Cross Medicare Supplement member may qualify for a household discount for subscriber
Anthem spouse rates reflect 10%
Enrollees who reside with another Anthem Blue Cross Medicare Supplement member may qualify for a household discount for co-resident
Humana Achieve rates 12% household discount 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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