| 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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$2800 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2800 in a calendar year After that coverage is 100% after ded |
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$2800 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2800 in a calendar year After that coverage is 100% after ded |
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$2800 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2800 in a calendar year After that coverage is 100% after ded |
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$2800 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2800 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 | |
$2800 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2800 in a calendar year After that coverage is 100% after ded |
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$2800 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2800 in a calendar year After that coverage is 100% after ded |
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| 3 Pints of (unreplaced) blood | |
$2800 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2800 in a calendar year After that coverage is 100% after ded |
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$2800 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2800 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 | |
$2800 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2800 in a calendar year After that coverage is 100% after ded |
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$2800 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2800 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: 836.11 I: Additional benefits included with Anthem Innovative plan rider
|
592.34 | 624.80 | ||
| Blue Shield eff 7/1/2024 | 1,098.00 | S: 907.00 Extra Rider
E: 940.00 |
746 | ||
| Blue Shield to 6/30/2024 | 1,012.00 | S: 836.00 Extra Rider
E: 867.00 |
688 | ||
| Health Net | S: 805.00 Additional benefits included with Health Net Innovative plan rider
|
348.00 | S: 634.00 Additional benefits included with Health Net Innovative plan rider
|
331.00 | 598.00 |
| Humana Achieve to 7/31/2024 | 615.39 | 546.94 | 181.26 | 456.20 | |
| Humana Achieve eff 8/1/2024 | 661.25 | 587.65 | 181.26 | 456.20 | |
| Physicians Mutual | 697.24 | 607.86 | 504.33 | ||
| United American to 4/30/2024 | 882.00 | 186.00 | 732.00 | 186.00 | 600.00 |
| United American eff 5/1/2024 | 940.00 | 204.00 | 786.00 | 204.00 | 658.00 |
| UHC to 5/31/2024 | 619.85 | 484.53 | 410.60 | ||
| UHC eff 6/1/2024 | 706.80 | 552.89 | 468.26 |
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Prepared for ANDREA CAPACHIETTI
Zip code: 91361 Age: 81 Spouse: 83 |
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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
Anthem spouse rates reflect 5%
Enrollees who reside with another Anthem Blue Cross Medicare Supplement member may qualify for a household discount for co-resident
UHC rates based on Part B effective less than 10 years UHC spousal rates based on Part B effective less than 10 years UHC rates reflect 7% You can take 7% off your monthly premiums if
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