| Part A Hospital Services | F | G | 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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| 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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| 3 Pints of (unreplaced) blood | |
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| Part B Services | F | G | 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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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 | F | G | N |
| Out of Pocket Limit | NA | NA | NA |
| Hospice coverage | |
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| Foreign Travel Emergency | |
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| Monthly Rates & Brochures | F | G | N |
| Anthem | S: 677.06 I: Additional benefits included with Anthem Innovative plan rider
|
485.97 | 522.86 |
| Blue Shield | 581.00 | S: 472.00 Extra Rider
E: 503.00 |
441 |
| UHC to 5/31/2024 | 611.81 | 478.24 | 405.11 |
| UHC eff 6/1/2024 | 682.50 | 533.81 | 451.91 |
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Prepared for
Zip code: 90505 Age: 67 Spouse: 76 |
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UHC rates based on Part B effective less than 10 years UHC spousal rates based on Part B effective 10 or more years
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