| Part A Hospital Services | F | F-ded | 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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$2700 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2700 in a calendar year After that coverage is 100% after ded |
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$2700 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2700 in a calendar year After that coverage is 100% after ded |
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$2700 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2700 in a calendar year After that coverage is 100% after ded |
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$2700 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2700 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 | |
$2700 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2700 in a calendar year After that coverage is 100% after ded |
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$2700 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2700 in a calendar year After that coverage is 100% after ded |
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| 3 Pints of (unreplaced) blood | |
$2700 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2700 in a calendar year After that coverage is 100% after ded |
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$2700 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2700 in a calendar year After that coverage is 100% after ded |
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| Part B Services | F | F-ded | G | G-ded | 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 | F-ded | G | G-ded | N |
| Out of Pocket Limit | NA | NA | NA | NA | NA |
| Hospice coverage | |
$2700 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2700 in a calendar year After that coverage is 100% after ded |
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$2700 annual deductible applies You pay all Medicare deductibles, copays and coinsurance until you spend $2700 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 | F | F-ded | G | G-ded | N |
| Anthem | S: 610.73 I: Additional benefits included with Anthem Innovative plan rider
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438.38 | 471.65 | ||
| Blue Shield | 532.00 | S: 432.00 Extra Rider
E: 461.00 |
408 | ||
| Continental (Aetna) | 821.50 | 153.61 | 601.93 | 416.64 | |
| Health Net | S: 536.00 Additional benefits included with Health Net Innovative plan rider
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231.00 | S: 433.00 Additional benefits included with Health Net Innovative plan rider
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220.00 | 408.00 |
| Humana Achieve | 442.59 | 385.77 | 133.26 | 306.28 | |
| Physicians Mutual | 524.08 | 457.05 | 379.40 | ||
| United American to 4/30/2024 | 683.00 | 127.00 | 559.00 | 127.00 | 450.00 |
| United American eff 5/1/2024 | 727.00 | 139.00 | 601.00 | 139.00 | 495.00 |
| UHC to 5/31/2024 | 505.14 | 394.85 | 334.48 | ||
| UHC eff 6/1/2024 | 563.50 | 440.74 | 373.12 |
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Prepared for
Zip code: 90265 Age: 74 Spouse: 67 |
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Anthem rates reflect 10%
Enrollees who reside with another Anthem Blue Cross Medicare Supplement member may qualify for a household discount for subscriber
Humana Achieve rates 12% household discount UHC rates based on Part B effective less than 10 years UHC spousal rates based on Part B effective less than 10 years
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