Page 13 - Cover Letter and Evaluation for Patti Messerschmitt

Your estimated costs for the last 4 months of 2020

Plan name Medigap Plan G Medigap Plan N

Toll-Free Number NA NA

Health plan premiums + medical deductible + Rx drug costs
lity ratings from
Medicare web site
Part B premiums for last

4 months of 2020* $578 $976

Est. Medigap premiums
for last 4 months of $540 $430
2020

Part B deductible** $198 $198

Rx drug costs for the
last 4 months of 2020 $55 $55

Total $1,371 $1,659

Part A and Part B out-of-pocket costs

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

Part B: Amounts owed Below are cost-sharing
for most outpatient No cost after Part B amounts after Part B
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'
Co-Pays deductible has been paid office visits and $50 for
Out-of-Network visit to emergency room
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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