| 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: 423.54 I: Additional benefits included with Anthem Innovative plan rider
|
304 | 327.09 | ||
| Blue Shield eff 7/1/2024 | 458.00 | S: 374.00 Extra Rider
E: 390.00 |
316 | ||
| Blue Shield to 6/30/2024 | 423.00 | S: 345.00 Extra Rider
E: 360.00 |
292 | ||
| Continental (Aetna) | 482.22 | 90.21 | 353.28 | 264.06 | |
| Health Net | S: 359.00 Additional benefits included with Health Net Innovative plan rider
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155.00 | S: 320.00 Additional benefits included with Health Net Innovative plan rider
|
146.00 | 288.00 |
| Humana Achieve | 326.87 | 289.33 | 97.73 | 238.49 | |
| Physicians Mutual | 336.06 | 293.32 | 243.81 | ||
| United American to 4/30/2024 | 429.00 | 86.00 | 355.00 | 86.00 | 289.00 |
| United American eff 5/1/2024 | 456.00 | 95.00 | 382.00 | 95.00 | 318.00 |
| 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: 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
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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