| Part A Hospital Services | F | F-ded | G |
|---|---|---|---|
| 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 |
|
| 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 |
|
| 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 |
|
| Part B Services | F | F-ded | G |
| Part B Annual Deductible ($240) | |
||
| Medicare covers 80% of Part B claims, you are responsible for 20%Part B Coinsurance | |
|
|
| 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 |
| Out of Pocket Limit | 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 |
|
| Foreign Travel Emergency | |
|
|
| Monthly Rates & Brochures | F | F-ded | G |
| Blue Shield eff 7/1/2024 | 286.00 | S: 239.00 Extra Rider
E: 256.00 |
|
| Blue Shield to 6/30/2024 | 269.00 | S: 224.00 Extra Rider
E: 240.00 |
|
Prepared for
Zip code: 90066 Age: 71 |
|