| Part A Hospital Services | A | B | D | G | K | L | M | 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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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 | |
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| Skilled nursing facility coinsurance | |
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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% |
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| 3 Pints of (unreplaced) blood | |
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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% |
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| Part B Services | A | B | D | G | K | L | M | N |
| Part B Annual Deductible ($240) | ||||||||
| 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% |
Plan covers 75% of your out of pocket expenses Your share is capped at $2560 per year75% |
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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 | A | B | D | G | K | L | M | N |
| Out of Pocket Limit | NA | NA | NA | NA | $5120 | $2560 | NA | NA |
| Hospice coverage | |
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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% |
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| Foreign Travel Emergency | |
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| Monthly Rates & Brochures | A | B | D | G | K | L | M | N |
| Anthem | 0.00 | 0.00 | ||||||
| Blue Shield eff 7/1/2024 | -25.00 | S: -25.00 Extra Rider
E: -25.00 |
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| Blue Shield to 6/30/2024 | -25.00 | S: -25.00 Extra Rider
E: -25.00 |
0 | |||||
| Continental (Aetna) | 0.00 | 0.00 | 0.00 | |||||
| Humana Achieve eff 8/1/2024 | 0.00 | 0.00 | 0.00 | |||||
| UHC to 5/31/2024 | 0.00 | 0.00 | ||||||
| UHC eff 6/1/2024 | 0.00 | 0.00 |
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Prepared for Kelly Lotti
Zip code: 92928 Age: 65 |
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Anthem Plan G rates reflect $25.00 Welcome to Medicare discount
Blue Shield Plan G rates reflect $25 Welcome to Medicare discount
UHC rates based on Part B effective less than 10 years UHC Plan G rates reflect $25 Welcome to Medicare discount
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