Page 13 - Cover Letter & Evaluation for Mr. Henry Stiepel

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
2021 Part B premium

($148.50 a month)* $1,782 $1,782 $1,782

Health plan annual

premiums (Medigap $1,900 $1,600 $1,600
premiums are estimates)

Part B deductible** $203 $203 $203

2021 Rx drug costs for
monthly refills at Sav- $1,166 $1,166 $1,166
On

Total $5,051 $4,751 $4,751

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
Out-of-Network visit to emergency room
Co-Pays

*This is 2021 Part B premium for new enrollees. Higher income people may pay more.
**Part B deductible in 2021 is $203

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