Page 13 - Cover Letter and Evaluation for Stephen Spero

Your estimated costs in each plan

Anthem MediBlue
Anthem MediBlue
Plan name Medigap Plan G Medigap Plan N Coordination Plus
Plus HMO Plan
HMO Plan
Toll-Free Number NA NA (844) 316-0357 (844) 799-9862

Health plan premiums + medical deductible + Rx drug costs
lity ratings from
Medicare web site
Part B premiums for 3
months ($144.60 a $434 $434 $434 $434

month)*
Health plan premiums

for 3 months (Medigap $425 $350 $0 $0
premiums are estimates)

Health plan/Part B
deductible** $198 $198 $0 $0
Rx drug costs for 3
months in lowest-cost $625 $625 $416 $797
option

Total $1,682 $1,607 $850 $1,231

Excellent.
Part A and Part B out-of-pocket costs
$3,399 limit
Part A: The amount you $1,408 deductible
will pay if you are No cost No cost $295 a day for days for days 1-60; $352
daily co-pay for
1-7; 0 for days 8-90
hospitalized days 61-90

Part B: Amounts owed Below are cost-

for most outpatient No cost after Part B sharing amounts Low co-pays for 20% co-insurance
for many services
after Part B
deductible is paid
most services
services deductible is paid
Cost-sharing for doctors' office visits
= Some dental and vision benef
In-Network Primary
Care Co-Pays After deductible is $10 20% co-insurance
paid, up to $20 for
In-Network Specialist No cost after Part B doctors' office visits $35 20% co-insurance
Co-Pays deductible is paid and $50 for visit to

Out-of-Network emergency room No coverage unless No coverage unless
Co-Pays emergency emergency
*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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