Page 16 - Evaluation for Jeanne Huybrechts

Comprehensive Benefits Comprehensive Benefits with Higher Cost-Sharing

F
C D F G (High K L M N
Deductible)

$2,200 $2,350 $2,250 $2,050 $825 $1,000 $1,700 $2,025 $1,775

99.7% 97.1% 100.0% 97.3% 43.5% 53.5% 72.6% 84.2% 71.5%
Co-Payments and Cost-Sharing

You pay You pay You pay You pay
nothing nothing nothing nothing

You pay You pay You pay You pay

You pay You pay $82.25 a $41.13 a nothing nothing
nothing nothing day day
After you You pay You pay
have paid 2.5% & 1.25% & You pay You pay
You pay the $2,200 nothing nothing
nothing plan $2.50 $1.25
deductible, You pay You pay You pay $658 You pay
You pay you have no $658 $329 nothing
nothing
You pay You pay further cost- You pay You pay You pay $183 You pay $183
$183 $183 sharing for $183 $183
Medicare-
covered You pay 10% You pay 5% Only costs are
You pay services of Medicare- of Medicare- You pay $20 for doctor's
nothing approved approved nothing office visits; $50
amount amount for an ER visit
You pay
nothing
Not
Not covered Not covered Not covered Not covered Not covered
covered

Some Some Some Some Some Not Some Some
coverage* coverage* coverage* coverage* coverage* covered Not covered coverage* coverage*

You pay You pay You pay You pay You pay You pay You pay 5% You pay You pay
nothing nothing nothing nothing nothing 10% of cost of cost nothing nothing
2017 high-deductible amount = $2,200

2017 Out-of-Pocket Limit*** $5,120 $2,560

*** Out-of-pocket limits do not include plan premiums. Neither do they apply to services that are not covered. In Plans K and L, for
instance, the Part B deductible is not covered. Thus any money you spend for the deductible will not count toward the OOP limit.

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