Part A Hospital Services A B C D G G-ded K L M 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
  • 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
 Plan covers 50% of your out of pocket expenses
Your share is capped at $5120 per year50%		 Plan covers 75% of your out of pocket expenses
Your share is capped at $2560 per year75%		 Plan covers 50% Part A deductible50%
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
 Plan covers 50% of your out of pocket expenses
Your share is capped at $5120 per year50%		 Plan covers 75% of your out of pocket expenses
Your share is capped at $2560 per year75%
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
 Plan covers 50% of your out of pocket expenses
Your share is capped at $5120 per year50%		 Plan covers 75% of your out of pocket expenses
Your share is capped at $2560 per year75%
Part B Services A B C D G G-ded K L M 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%		 Plan covers 75% of your out of pocket expenses
Your share is capped at $2560 per year75%		 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 A B C D G G-ded K L M N
Out of Pocket Limit NA NA NA NA NA NA $5120 $2560 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
 Plan covers 50% of your out of pocket expenses
Your share is capped at $5120 per year50%		 Plan covers 75% of your out of pocket expenses
Your share is capped at $2560 per year75%
Foreign Travel Emergency


Monthly Rates & Brochures A B C D G G-ded K L M N
Anthem 165.25


195.86



206.60
Blue Shield eff 7/1/2024 142.00


S: 199.00
Note: Silver Sneakers gym membership is included with all Blue Shield plans.
Additonal benefits with Blue Shield Extra Rider
Foreign Travel - Not covered by Medicare
  • $250 annual deductible, 80% coverage, $50,000 lifetime max (Click the Brochure link, see page 20)
Physician Consultation by Phone or Video Through Teledoc
  • No charge (see brochure page 20)
Over-the-Counter Items through CVS
  • Up to $100 allowance per quarter (see brochure page 20)
Accupuncture and Chiropractic Services (provided by AHS provider network)
  • Up to 20 visits per year, plan pays 100%, see page 21 in brochure for details
Vision Coverage (provided by Vision Service Plan)
  • Exam every 12 months, eyeglasses every 24 months, click the brochure link for details (see page 21)
Hearing Aid Services (provided by Epic Hearing Healthcare)
  • Routine hearing exams, copayments for hearing aids, see page 23 of brochure for details
E: 215.00



192
UHC 157.32 219.45 264.67
208.05

145.92
176.13
Choosing a Medigap Policy

Prepared for Lee Chen
Zip code: 91765
Age: 69
Select all that apply
  • Anthem $2 per month
  • Blue Shield $3 per month
  • United Healthcare $2 per month
Automatic Checking Withdrawal Discount
If you are new to Medicare the following monthly discounts
are available for your first year of coverage
  • Anthem Plan F: $20 Plans G: $25 per month
  • Blue Shield Plans A. F and G: $25 per month
  • United Healthcare Plan G: $25 per month
Welcome to Medicare discount 2 party
Enrollees who live with another Anthem 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
Anthem household discount
Blue ShieldYou are eligible for a 7% household premium discount
  • if you reside with another person who is on the same Blue Shield Medicare Supplement plan
  • including same Dental plan.
Only one policy will be issued, the second party will be covered as a dependent. household discount (7%)
UHC/AARPYou can take 7% off your monthly premiums if
  • two or more members are enrolled under the same AARP membership number
  • and each is insured under an eligible AARP-branded supplemental insurance
    policy insured by UnitedHealthcare Insurance Company.
 household discount (7%)
Contact us
(800) 564-0614
Apochet@adhealthinsurance.com
CA Ins Lic 749983