Page 12 - MedigapFreedom Plan Information

MEDICARE SUPPLEMENT PLANS
Your MedigapFreedom Plan Choices
Service category
Primary Care Physician Visits
Specialist Visits Emergency Room Urgent Care Outpatient Surgery Inpatient Hospital
Part B Excess Charges†
Prescription Drugs (Part D)
Medicare pays:
80% of Medicare-approved amounts after
$233** annual Part B deductible is met
All charges except $1,556** (Part A deductible) and Part A coinsurance
Nothing Nothing
Plan B
You pay:
$233** Part B deductible (Plan pays 20% coinsurance)
$0
Plan A
You pay:
$233** Part B deductible (Plan pays 20% coinsurance)
$1,556 ** (Part A deductible)
100%
Prescription Drug coverage is not included
100%
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Benefits underwritten by QCC Insurance Company, a subsidiary of Independence Blue Cross — independent licensees of the Blue Cross and Blue Shield Association.
To join, you must be enrolled in Medicare Parts A and B.
You must continue to pay Medicare Part A (if applicable) and Part B premiums.