Part A Hospital Services F F-ded G G-ded K 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)		 $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
 $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
  • The inpatient deductible is $1632 for each benefit period
  • Days 1-60: Medicare covers 100%
  • Days 61-90: You are responsible for $408 per day
  • Days 91 until 60 day lifetime reserve is used up: Your responsibility is $826 per day
  • Beyond lifetime reserve: You are responsible for all costs incurred
Hospital 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
 $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
 Plan covers 50% of your out of pocket expenses
Your share is capped at $5120 per year50%
Covers 365 Additional inpatient days after lifetime reserve has been used up365 days extra Hospital coverage
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
 $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
 Plan covers 50% of your out of pocket expenses
Your share is capped at $5120 per year50%
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
 $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
 Plan covers 50% of your out of pocket expenses
Your share is capped at $5120 per year50%
Part B Services F F-ded G G-ded K N
Part B Annual Deductible ($240)




Medicare covers 80% of Part B claims, you are responsible for 20%Part B Coinsurance Plan covers 50% of your out of pocket expenses
Your share is capped at $5120 per year50%		 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

Additional Features F F-ded G G-ded K N
Out of Pocket Limit NA NA NA NA $5120 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
 $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
 Plan covers 50% of your out of pocket expenses
Your share is capped at $5120 per year50%
Foreign Travel Emergency
Monthly Rates & Brochures F F-ded G G-ded K N
Anthem
S: 239.22
I: Additional benefits included with Anthem Innovative plan rider
  • Vision Benefits
  • Routine eye exam In network: No Charge Out of network: $35 Allowance
  • Eyeglass Frames In network: $100 allowance Out of network: $45 Allowance
  • Eyeglass Lenses
    • Single vision - In network:100% coverage after $25 copay Out of network:$25 benefit after $25 copay
    • Bifocal - In network:100% coverage after $25 copay Out of network:$40 benefit after $25 copay
    • Trifocal or Lenticular - In network:100% coverage after $25 copay Out of network:$55 benefit after $25 copay
  • Contact Lenses In network: $100 allowance Out of network: $80 Allowance
  • Hearing Benefits Coverage through Hearing Care Solutions
  • Hearing exam: 100% coverage
  • Hearing aids: Coverage allowance up to $750 per year
  • Other Innovative Plan Benefits
  • Nurse help line: Speak with a Registered nurse about health related questions
  • Other Benefits (included with both Standard and Innovative Plans)
  • SilverSneakers gym membership
    • See page 21 or 22 in Anthem brochure for details
223.02
169.46

178.76
Blue Shield eff 7/1/2024 269.00
S: 213.00
Extra Rider
  • Basic gym access through sliver sneakers fitness program (silversneakers.com)
  • Personal emergency response system
  • Physician consultation by phone or video through Teladoc
  • Over the counter items through CVS (Up to $100 one time use per quarter allowance)
  • The vision benefit includes coverage for exams, frames and lenses ($100 frame allowance)
  • Hearing aid benefit includes an annual hearing aid test and coverage for Vista brand mid-level and premium-level hearing aids for a low copay
  • Acupuncture and chiropractic, up to 20 combined visits per calendar year
  • Identity theft protection
E: 230.00

204
Health Net
S: 231.00
Additional benefits included with Health Net Innovative plan rider
  • Vision Benefits
  • Routine Eye Exam (In network) - One vision exam every 12 months - $10 Copayment
  • Routine Eye Exam (Out of network) - One vision exam every 12 months - $45 Allowance
  • Frame & Lens Package - available from provider only (Once every 24 Months) - Up to $250 allowance
  • Contact Lenses (includes materials only - once every 24 months) - Up to $250 allowance
  • Medically necessary contact Lenses - Up to $250 allowance
  • Hearing Benefits
  • Routine Hearing Exam - One hearing exam every 12 months
  • Hearing Aid(s) - all sizes and styles offered by Hearing Care Solutions
    • Level 4 - You pay $1580
    • Level 3 - You pay $1125
    • Level 2 - You pay $700
    • Level 1 - You pay $0
See page 44 in Health Net brochure for detailsI: 237.00
 100.00
S: 206.00
Additional benefits included with Health Net Innovative plan rider
  • Vision Benefits
  • Routine Eye Exam (In network) - One vision exam every 12 months - $10 Copayment
  • Routine Eye Exam (Out of network) - One vision exam every 12 months - $45 Allowance
  • Frame & Lens Package - available from provider only (Once every 24 Months) - Up to $250 allowance
  • Contact Lenses (includes materials only - once every 24 months) - Up to $250 allowance
  • Medically necessary contact Lenses - Up to $250 allowance
  • Hearing Benefits
  • Routine Hearing Exam - One hearing exam every 12 months
  • Hearing Aid(s) - all sizes and styles offered by Hearing Care Solutions
    • Level 4 - You pay $1580
    • Level 3 - You pay $1125
    • Level 2 - You pay $700
    • Level 1 - You pay $0
See page 44 in Health Net brochure for detailsI: 196.00
 85.00
167.00
Humana Achieve 210.29
182.94 58.61
133.55
Physicians Mutual 193.59
169.22

141.02
United American eff 5/1/2024 247.00 45.00 203.00 45.00 111.00 167.00
UHC 277.40
216.99

183.78
Choosing a Medigap Policy
Prepared for DORENE BLAIR
Zip code: 93012
Age: 68

Anthem rates reflect 10%
Enrollees who reside with another Anthem Blue Cross Medicare Supplement member may qualify for a household discount
  • For members with an original Anthem Blue Cross effective date after 2/28/2023 the discount is 10%
  • For those with original effective dates between 6/1/2010 and 2/28/2023 the discount is 5%
  • The household discount is not available to persons enrolled before 6/1/2010
household discount
for subscriber
UHC rates based on Part B effective less than 10 years
Contact us
(818) 888-0880
[email protected]
CA Ins Lic OA2225