Page 9 - Cover Letter and Evaluation for Dr. Maury Rosenstein

Your estimated costs in each plan

Plan name Medigap Plan F Medigap Plan G Medigap Plan N Medigap Plan L

Toll-Free Number NA NA NA NA

Minimum costs (health plan premiums + Rx drug costs)
lity ratings from
Medicare web site
2019 standard Part B

premium of $135.50 a $1,626 $1,626 $1,626 $1,626
month*

Health plan annual
premiums (Medigap $1,750 $1,550 $1,350 $1,275
premiums are estimates)

Rx drug costs (Rx
premiums + deductible + NA NA NA NA
copayments)

Total $3,376 $3,176 $2,976 $2,901

Part A and Part B out-of-pocket costs

Part A: The amount you No cost for No cost for No cost for You pay $341 (25%

will pay if you are Medicare-covered Medicare-covered Medicare-covered of the $1,364 Part A
hospitalized hospitalization hospitalization hospitalization deductible)

Part B: The amount you See below for cost- After paying the
will pay for most sharing amounts $185 Part B
deductible, you will
Medicare-covered $0 $185 after $185 pay 5% of most Part
outpatient services deductible is paid B costs

Cost-sharing for doctors' office visits
=
In-Network Primary

Care Co-Pays up to $20 for
No co-pays for
Medicare-approved
No co-pays for
In-Network Specialist Medicare-covered Medicare-covered doctor's office visit; 5% of Medicare-
Co-Pays services services $50 for emergency approved cost
Out-of-Network room visit

Co-Pays

*This is 2019 Part B premium for new enrollees. Higher income people may pay more.
**Part B deductible in 2019 is $185.

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