| 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: 712.53 I: Additional benefits included with Anthem Innovative plan rider
|
511.45 | 550.28 | ||
| Blue Shield eff 7/1/2024 | 685.00 | S: 577.00 Extra Rider
E: 608.00 |
537 | ||
| Blue Shield to 6/30/2024 | 633.00 | S: 533.00 Extra Rider
E: 562.00 |
496 | ||
| Health Net | S: 619.00 Additional benefits included with Health Net Innovative plan rider
|
267.00 | S: 495.00 Additional benefits included with Health Net Innovative plan rider
|
243.00 | 437.00 |
| Humana Achieve | 554.60 | 485.98 | 171.30 | 391.65 | |
| Physicians Mutual | 584.74 | 509.92 | 423.18 | ||
| United American to 4/30/2024 | 784.00 | 152.00 | 646.00 | 152.00 | 523.00 |
| United American eff 5/1/2024 | 834.00 | 166.00 | 695.00 | 166.00 | 575.00 |
| UHC to 5/31/2024 | 536.51 | 419.38 | 355.25 | ||
| UHC eff 6/1/2024 | 598.50 | 468.11 | 396.29 |
|
Prepared for VALERIE FUKUCHI & WAYNE
Zip code: 90275 Age: 75 Spouse: 74 |
|
Anthem rates reflect 5%
Enrollees who reside with another Anthem Blue Cross Medicare Supplement for subscribermember may qualify for a household discount
Anthem spouse rates reflect 5%
Enrollees who reside with another Anthem Blue Cross Medicare Supplement member may qualify for a household discount for co-resident
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
|