| 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) |
 |
$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 |
|
$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 |
|
|
|
$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 |
|
$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 |
|
| Covers 365 Additional inpatient days after lifetime reserve has been used up365 days extra Hospital coverage | |
|
|
|
|
| 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 |
|
$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 |
|
| 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 |
|
$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 |
|
| Part B Services | F | F-ded | G | G-ded | N |
| Part B Annual Deductible ($240) | |
||||
| Medicare covers 80% of Part B claims, you are responsible for 20%Part B Coinsurance | |
|
|
|
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 | 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 |
|
$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 |
|
| Foreign Travel Emergency | |
|
|
|
|
| Monthly Rates & Brochures | F | F-ded | G | G-ded | N |
| Anthem | S: 715.18 I: Additional benefits included with Anthem Innovative plan rider
|
513.32 | 552.31 | ||
| Blue Shield | 706.00 | S: 592.00 Extra Rider
E: 624.00 |
544 | ||
| Continental (Aetna) | 886.82 | 165.94 | 650.08 | 456.29 | |
| Health Net | S: 640.00 Additional benefits included with Health Net Innovative plan rider
|
276.00 | S: 511.00 Additional benefits included with Health Net Innovative plan rider
|
246.00 | 428.00 |
| Humana Achieve | 520.47 | 458.64 | 158.21 | 373.07 | |
| Physicians Mutual | 610.96 | 532.74 | 442.12 | ||
| United American to 4/30/2024 | 808.00 | 158.00 | 668.00 | 158.00 | 542.00 |
| United American eff 5/1/2024 | 862.00 | 174.00 | 718.00 | 174.00 | 594.00 |
| UHC to 5/31/2024 | 564.75 | 441.45 | 373.95 | ||
| UHC eff 6/1/2024 | 630.00 | 492.75 | 417.15 |
|
Prepared for
Zip code: 91355 Age: 76 Spouse: 76 |
|
Anthem rates reflect 10%
Enrollees who reside with another Anthem Blue Cross Medicare Supplement member may qualify for a household discount for subscriber
Anthem spouse rates reflect 10%
Enrollees who reside with another Anthem Blue Cross Medicare Supplement member may qualify for a household discount for co-resident
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 UHC rates reflect 7% You can take 7% off your monthly premiums if
|