Page 13 - Cover Letter and Evaluation for Sarah Spero

Your estimated costs in each plan

Scripps Classic
Blue Shield 65 Plus
Plan name Medigap Plan G Medigap Plan N offered by SCAN (an
HMO Plan
HMO)
Toll-Free Number NA NA (888) 534-4263 (888) 315-7226

Health plan premiums + medical deductible + Rx drug costs
lity ratings from
Medicare web site
Part B premiums for 3
months ($144.60 a $434 $434 $434 $434

month)*
Health plan premiums

for 3 months (Medigap $475 $400 $0 $0
premiums are estimates)

Health plan/Part B
deductible** $198 $198 $0 $0
Rx drug costs for 3
months at plan's $146 $146 $15 $45
preferred pharmacy

Total $1,253 $1,178 $449 $479

Excellent.
Part A and Part B out-of-pocket costs
$3,399 limit Excellent. $3,400
Part A: The amount you $295 a day for days $295 a day for days
1-7 in a network
1-7 in a network
will pay if you are No cost No cost hospital; $0 per day hospital; $0 per day
hospitalized for days 8-90 for days 8-90

Part B: Amounts owed Below are cost-

for most outpatient No cost after Part B sharing amounts Varies Varies
deductible is paid
after Part B
services deductible is paid
Cost-sharing for doctors' office visits

=
In-Network Primary
Care Co-Pays After deductible is $15 $10
paid, up to $20 for
In-Network Specialist No cost after Part B doctors' office visits
Co-Pays deductible is paid and $50 for visit to $35 $35

Out-of-Network emergency room
Co-Pays No coverage No coverage
*This is 2020 Part B premium for new enrollees. Higher income people may pay more.
**Part B deductible in 2020 is $198.

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