Page 9 - Cover Letter and Evaluation for Michael Boucher

Your estimated costs in each plan

Plan name Medigap Plan G
Medigap Plan G is the only option in this evaluation
Toll-Free Number NA

Health plan premiums + medical deductible + Rx drug costs
lity ratings from
Medicare web site
2021 Part B premium
($148.50 a month)* $1,782

Health plan annual
premiums (Medigap $1,680
premiums are estimates)
Plan medical/Part B
deductible** $203

Rx drug costs for 8

months at CVS $1,026

Total $4,691

Part A and Part B out-of-pocket costs

Part A: The amount you
will pay if you are No cost
hospitalized

Part A: Care in a skilled
nursing facility No cost

Part B: Emergency care No cost after $203
(not including ambulance) Part B deductible

Cost-sharing for doctors' office visits
=
In-Network Primary
Care Co-Pays
No cost after $203
In-Network Specialist Part B deductible is
Co-Pays paid
Out-of-Network

Co-Pays
*This is 2021 Part B premium for new enrollees. Higher income people may pay more.
**Part B deductible in 2021 is $203; medical deductibles for Advantage plans vary.

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