| 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: 350.48 I: Additional benefits included with Anthem Innovative plan rider
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255.09 | 263.89 | ||
| Blue Shield eff 7/1/2024 Application | 378.00 | S: 318.00 Extra Rider
E: 334.00 |
299 | ||
| Blue Shield to 6/30/2024 Application | 346.00 | S: 291.00 Extra Rider
E: 306.00 |
274 | ||
| Continental (Aetna) | 355.11 | 66.39 | 260.40 | 193.17 | |
| Health Net Application | S: 334.00 Additional benefits included with Health Net Innovative plan rider
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144.00 | S: 298.00 Additional benefits included with Health Net Innovative plan rider
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129.00 | 256.00 |
| Humana Achieve | 256.68 | 226.57 | 77.83 | 185.21 | |
| Physicians Mutual | 281.06 | 245.42 | 204.12 | ||
| United American to 4/30/2024 Application | 309.00 | 61.00 | 256.00 | 61.00 | 208.00 |
| United American eff 5/1/2024 Application | 329.00 | 66.00 | 275.00 | 66.00 | 228.00 |
| UHC to 5/31/2024 Application | 313.75 | 245.25 | 207.75 | ||
| UHC eff 6/1/2024 Application | 350.00 | 273.75 | 231.75 |
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Prepared for ZETTA WILLIAMS
Zip code: 93536 Age: 77 |
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UHC rates based on Part B effective less than 10 years
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