

| Part A Hospital Services | G | G-ded | 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) |
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$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 |
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$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 |
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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 | ![]() |
$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 |
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| 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 |
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| Part B Services | G | G-ded | 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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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 | G | G-ded | N |
| 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 |
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| Foreign Travel Emergency | ![]() |
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| Monthly Rates & Brochures | G | G-ded | N |
| Anthem Application | 263.99 | 284.03 | |
| Choosing a Medigap Policy | |||
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Prepared for SHELBY
Zip code: 92691 Age: 74 |
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