Page 11 - Cover letter and evaluation for Jerry Sicherman

Comprehensive Benefits Comprehensive Benefits with Higher Cost-Sharing

F
C D F G (High K L M N
Deductible)

$3,380 $3,200 $3,400 $3,200 $1,300 $1,825 $2,000 $3,000 $3,000
99.7% 97.1% 100.0% 97.3% 43.5% 53.5% 72.6% 84.2% 71.5%
Co-Payments and Cost-Sharing

You pay You pay
nothing nothing

You pay You pay You pay
$85.25 a $42.63 a
You pay You pay nothing You pay
nothing nothing After you day day nothing
have paid You pay You pay
the plan's 2.5% & 1.25% &
You pay
$2,300 $2.50 $1.25
nothing
deductible, You pay You pay
You pay you will $682 $341 You pay $682
nothing have no
You pay You pay You pay You pay
further cost- You pay $185 You pay $185
$185 $185 $185 $185
sharing for
Medicare- You pay 10% You pay 5% Only costs are
You pay covered of Medicare- of Medicare- You pay $20 for doctor's
nothing services. approved approved nothing office visits; $50
amount amount for an ER visit
You pay
nothing
Not
Not covered Not covered Not covered Not covered Not covered
covered

Some Some Some Some Some Not Some Some
Not covered
coverage* coverage* coverage* coverage* coverage* covered coverage* coverage*

You pay You pay You pay You pay You pay You pay You pay 5% You pay You pay
nothing nothing nothing nothing nothing 10% of cost of cost nothing nothing

2019 high-deductible amount = $2,300

2019 Out-of-Pocket Limit*** $5,560 $2,780

*** Out-of-pocket limits do not include plan premiums. Neither do they apply to services that are not covered. In Plans K and L, for
instance, the Part B deductible is not covered. Thus any money you spend for the deductible will not count toward the OOP limit.

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