| Part A Hospital Services | F | F-ded | G | G-ded | N |
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| 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: 412.87 I: Additional benefits included with Anthem Innovative plan rider
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296.37 | 318.86 | ||
| Blue Shield eff 7/1/2024 | 407.00 | S: 341.00 Extra Rider
E: 358.00 |
309 | ||
| Blue Shield to 6/30/2024 | 373.00 | S: 312.00 Extra Rider
E: 328.00 |
283 | ||
| Continental (Aetna) | 512.05 | 95.71 | 375.43 | 278.56 | |
| Health Net | S: 341.00 Additional benefits included with Health Net Innovative plan rider
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148.00 | S: 303.00 Additional benefits included with Health Net Innovative plan rider
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137.00 | 270.00 |
| Humana Achieve | 305.65 | 269.75 | 92.41 | 220.44 | |
| Physicians Mutual | 317.07 | 276.78 | 230.10 | ||
| United American to 4/30/2024 | 309.00 | 61.00 | 256.00 | 61.00 | 208.00 |
| United American eff 5/1/2024 | 329.00 | 66.00 | 275.00 | 66.00 | 228.00 |
| UHC to 5/31/2024 | 392.18 | 306.56 | 259.68 | ||
| UHC eff 6/1/2024 | 437.50 | 342.18 | 289.68 |
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Prepared for JOSEPH PONTENZA
Zip code: 91606 Age: 77 |
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UHC rates based on Part B effective 10 or more years
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