Page 15 - Cover Letter and Evaluation for Raquelle Myers

Your estimated costs in each plan

Plan name Medigap Plan G Medigap Plan N Medigap Plan L

Toll-Free Number NA NA NA

Health plan premiums + medical deductible + Rx drug costs
lity ratings from
Medicare web site
2020 Part B premium
for 5 months ($144.60 a $723 $723 $723
month)*

Est. Medigap premiums
for 5 months $920 $730 $725

Part B deductible** $198 $198 $198

Est. Rx drug costs for
mail-order $4,671 $4,671 $4,671
prescriptions***

Total $6,512 $6,322 $6,317

Part A and Part B out-of-pocket costs

Part A: The amount you
will pay if you are No cost No cost $352
hospitalized

Part B: Amounts owed Below are cost-sharing
for most outpatient No cost after Part B amounts after Part B 5% of cost
deductible is paid
services deductible is paid

Cost-sharing for doctors' office visits
=
In-Network Primary
Care Co-Pays After Part B deductible is

In-Network Specialist No cost after Part B paid, $20 for doctors' 5% of cost after Part B
Co-Pays deductible has been paid office visits and $50 for deductible has been paid
visit to emergency room
Out-of-Network
Co-Pays

*This is 2020 Part B premium for new enrollees. Higher income people may pay more.
**Part B deductible in 2020 is $198. ***One-month's supply of medications will be left at end of year

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