| 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: 457.64 I: Additional benefits included with Anthem Innovative plan rider
|
328.49 | 353.43 | ||
| Blue Shield eff 7/1/2024 | 509.00 | S: 413.00 Extra Rider
E: 429.00 |
337 | ||
| Blue Shield to 6/30/2024 | 469.00 | S: 381.00 Extra Rider
E: 396.00 |
311 | ||
| Continental (Aetna) | 501.72 | 93.88 | 367.69 | 276.06 | |
| Health Net | S: 387.00 Additional benefits included with Health Net Innovative plan rider
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167.00 | S: 345.00 Additional benefits included with Health Net Innovative plan rider
|
154.00 | 306.00 |
| Humana Achieve | 352.08 | 312.47 | 104.06 | 259.60 | |
| Physicians Mutual | 356.23 | 310.88 | 258.35 | ||
| United American to 4/30/2024 | 441.00 | 93.00 | 366.00 | 93.00 | 300.00 |
| United American eff 5/1/2024 | 470.00 | 102.00 | 393.00 | 102.00 | 329.00 |
| UHC to 5/31/2024 | 364.73 | 285.10 | 241.50 | ||
| UHC eff 6/1/2024 | 406.88 | 318.23 | 269.40 |
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Prepared for KENNETH & IRENE HIROSE
Zip code: 91302 Age: 81 |
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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
UHC 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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