| Part A Hospital Services | A | C | F-ded | G | G-ded | K | 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 |
Plan covers 50% of your out of pocket expenses Your share is capped at $5120 per year50% |
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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 |
Plan covers 50% of your out of pocket expenses Your share is capped at $5120 per year50% |
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| 3 Pints of (unreplaced) blood | |
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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 |
Plan covers 50% of your out of pocket expenses Your share is capped at $5120 per year50% |
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| Part B Services | A | C | F-ded | G | G-ded | K | 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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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 |
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| Additional Features | A | C | F-ded | G | G-ded | K | N |
| Out of Pocket Limit | NA | NA | NA | NA | NA | $5120 | NA |
| Hospice coverage | |
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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 |
Plan covers 50% of your out of pocket expenses Your share is capped at $5120 per year50% |
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| Foreign Travel Emergency | |
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| Monthly Rates & Brochures | A | C | F-ded | G | G-ded | K | N |
| Anthem | 181.84 | 225.92 | 243.07 | ||||
| Continental (Aetna) | 200.50 | 66.56 | 260.40 | 188.51 | |||
| Health Net | 180.00 | 112.00 | S: 229.00 Additional benefits included with Health Net Innovative plan rider
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98.00 | 194.00 | ||
| Humana Achieve | 197.51 | 207.79 | 73.65 | 163.14 | |||
| ManhattanLife | 202.75 | 203.83 | 172.42 | ||||
| National Health Ins | 226.71 | 86.85 | 252.99 | 199.80 | |||
| United American | 185.00 | 335.00 | 61.00 | 279.00 | 61.00 | 163.00 | 225.00 |
| UHC | 146.55 | 246.68 | 193.75 | 164.12 |
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Prepared for
Zip code: 92804 Age: 70 |
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UHC rates based on Part B effective less than 10 years
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