| 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 Application | S: 247.00 I: Additional benefits included with Anthem Innovative plan rider
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179.75 | 185.97 | ||
| Blue Shield eff 7/1/2024 Application | 238.00 | S: 188.00 Extra Rider
E: 205.00 |
186 | ||
| Blue Shield to 6/30/2024 Application | 219.00 | S: 173.00 Extra Rider
E: 189.00 |
171 | ||
| Continental (Aetna) | 256.31 | 47.90 | 187.84 | 135.61 | |
| Health Net Application | S: 231.00 Additional benefits included with Health Net Innovative plan rider
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100.00 | S: 206.00 Additional benefits included with Health Net Innovative plan rider
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85.00 | 167.00 |
| Humana Achieve | 195.76 | 170.31 | 58.61 | 133.55 | |
| Physicians Mutual | 211.54 | 184.86 | 153.97 | ||
| United American to 4/30/2024 Application | 232.00 | 42.00 | 189.00 | 42.00 | 152.00 |
| United American eff 5/1/2024 Application | 247.00 | 45.00 | 203.00 | 45.00 | 167.00 |
| UHC to 5/31/2024 Application | 229.04 | 179.03 | 151.66 | ||
| UHC eff 6/1/2024 Application | 255.50 | 199.84 | 169.18 |
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Prepared for ZETTA WILLIAMS
Zip code: 93536 Age: 68 |
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UHC rates based on Part B effective less than 10 years
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