| 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: 881.18 I: Additional benefits included with Anthem Innovative plan rider
|
632.49 | 680.52 | ||
| Blue Shield eff 7/1/2024 | 967.00 | S: 787.00 Extra Rider
E: 819.00 |
653 | ||
| Blue Shield to 6/30/2024 | 892.00 | S: 726.00 Extra Rider
E: 756.00 |
603 | ||
| Continental (Aetna) | 983.94 | 184.09 | 720.97 | 513.11 | |
| Health Net | S: 746.00 Additional benefits included with Health Net Innovative plan rider
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322.00 | S: 597.00 Additional benefits included with Health Net Innovative plan rider
|
309.00 | 594.00 |
| Humana Achieve | 678.95 | 601.80 | 201.79 | 498.09 | |
| Physicians Mutual | 687.29 | 599.20 | 497.16 | ||
| United American to 4/30/2024 | 870.00 | 179.00 | 721.00 | 179.00 | 589.00 |
| United American eff 5/1/2024 | 926.00 | 197.00 | 775.00 | 197.00 | 647.00 |
| UHC to 5/31/2024 | 729.45 | 570.20 | 483.00 | ||
| UHC eff 6/1/2024 | 813.75 | 636.45 | 538.80 |
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Prepared for KENNETH & IRENE HIROSE
Zip code: 91302 Age: 81 Spouse: 79 |
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Anthem rates reflect 5%
Enrollees who reside with another Anthem Blue Cross Medicare Supplement for subscribermember may qualify for a household discount
Anthem spouse rates reflect 5%
Enrollees who reside with another Anthem Blue Cross Medicare Supplement member may qualify for a household discount for co-resident
UHC rates based on Part B effective 10 or more years UHC spousal rates based on Part B effective 10 or more years UHC rates reflect 7% You can take 7% off your monthly premiums if
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