Page 11 - Cover letter and evaluation for Janet Clayton

Your estimated costs in each plan

Plan name Medigap Plan G Medigap Plan N Medigap Plan L Medigap Plan High
Deductible G
Toll-Free Number NA NA NA NA

Health plan premiums + medical deductible + Rx drug costs
lity ratings from
Medicare web site
2020 Part B premium

($144.60 a month)* $1,735 $1,735 $1,735 $1,735

Health plan annual

premiums (Medigap $1,800 $1,400 $1,300 $800
premiums are estimates)

Part B deductible** $198 $198 $198 $198

2020 Rx drug costs for
mail-order refills $1,787 $1,787 $1,787 $1,787
(premiums and co-pays)

Total $5,520 $5,120 $5,020 $4,520
Part A and Part B out-of-pocket costs

Part A: The amount you $1,408 if you have
will pay if you are No cost No cost $352 not satisfied the
hospitalized plan's deductible

Part B: Amounts owed Below are cost-
for most outpatient No cost after Part B sharing amounts 5% of cost 100% of cost until
deductible is paid
after Part B
deductible is met
services deductible is paid
Cost-sharing for doctors' office visits
=
In-Network Primary
Care Co-Pays $20 for doctors'

In-Network Specialist No cost office visits and $50 5% of cost 100% of cost until
Co-Pays for visit to deductible is met
Out-of-Network emergency room
Co-Pays

*This is 2020 Part B premium for new enrollees. Higher income people may pay more.
**Part B deductible in 2020 is $198.

3