Page 27 - Cover letter and evaluation for Peter Smith

11/27/2017 Your Medicare Health Plan Details
Plan Type: HMO
Plan Status: Approved by Medicare
Area: Clark County
Previous Plan Name
View plan website 
Important Note:
View Drug Benefit Summary

Provider Network: 251-500 physicians and providers.
View provider and physician network website 

View a chart on how an independent sales agent or broker would be compensated if they were to enroll you in a plan
for 2018

Costs

Monthly Premiums

2
Part B premium $134.00
View Part B premiums based on income
Plan premium $0.00

Health plan premium $0.00

Drug plan premium $0.00
Estimated Costs

*Inpatient care $8.00

*Outpatient prescription drugs $250.78

*Dental services $40.00

*All other services
$18.00
Total monthly estimated costs
$450.78

3
TOTAL ESTIMATED ANNUAL COSTS [?] $5,410
How are Out-of-Pocket costs calculated?

View estimated monthly Out-of-Pocket Costs (OOPC) for people with High-Cost Conditions (chronic care and unexpected illnesses)

1 An out-of-pocket cost maximum applies for some services covered by this plan.
2 Medicare costs at a glance
3 Estimated Annual Costs are rounded to the nearest $10. They don't include any Medicare Part D (prescription drug) late enrollment
penalty amounts that may apply to you. Also, if you have limited income and resources, your expenses may be lower.

Return to previous page

https://www.medicare.gov/find-a-plan/results/planresults/plan-details.aspx?cntrctid=H4346&plnid=001&sgmntid=0 2/2