| 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: 265.80 I: Additional benefits included with Anthem Innovative plan rider
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188.29 | 198.62 | ||
| Blue Shield eff 7/1/2024 | 269.00 | S: 213.00 Extra Rider
E: 230.00 |
204 | ||
| Blue Shield to 6/30/2024 | 248.00 | S: 196.00 Extra Rider
E: 212.00 |
188 | ||
| Health Net | 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 to 7/31/2024 | 195.76 | 170.31 | 58.61 | 133.55 | |
| Humana Achieve eff 8/1/2024 | 210.29 | 182.94 | 58.61 | 133.55 | |
| Physicians Mutual | 238.49 | 208.32 | 173.40 | ||
| United American to 4/30/2024 | 310.00 | 55.00 | 252.00 | 55.00 | 202.00 |
| United American eff 5/1/2024 | 330.00 | 60.00 | 270.00 | 60.00 | 222.00 |
| UHC to 5/31/2024 | 243.27 | 190.17 | 161.15 | ||
| UHC eff 6/1/2024 | 277.40 | 216.99 | 183.78 |
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Prepared for ALFRED BARCARSE
Zip code: 91320 Age: 68 |
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UHC rates based on Part B effective less than 10 years
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