Page 13 - Cover Letter and Evaluation for Maria Elena Yajarano

Your estimated costs in each plan

Plan Name Medigap Plan F Medigap Plan G 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

($144.60 a month)* $1,735 $1,735 $1,735

Health plan annual

premiums (Medigap $2,000 $1,800 $1,650
premiums are estimates)
2020 Part B
deductible** NA $198 $198

2021 Rx drug costs (mail-
order) $229 $229 $229

Total $3,964 $3,962 $3,812

Part A and Part B out-of-pocket costs

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

Part B: Amounts owed
for most outpatient No cost No cost after Part B You pay 5% of Medicare-
deductible is paid
approved amount
services
Cost-sharing for doctors' office visits
=
In-Network Primary
Care Co-Pays

In-Network Specialist No cost No cost after Part B You pay 5% of Medicare-
Co-Pays deductible is paid approved amount
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.

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