Page 55 - Memo to Randy & Nancy

Comprehensive Benefits Comprehensive Benefits with Higher Cost-Sharing

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

$1,780 $1,590 $2,100 $1,600 $825 $975 $1,500 $1,750 $1,500

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
nothing nothing

You pay You pay You pay
You pay You pay $85.25 a day $42.63 a day nothing You pay
nothing nothing After you nothing
have paid You pay 2.5% You pay
You pay the plan's & $2.50 1.25% &
nothing $2,300 $1.25
deductible, You pay
You pay you will You pay $682 You pay $341 $682
nothing have no
You pay $185 You pay further cost- You pay $185 You pay $185 You pay You pay
$185 sharing for $185 $185

Medicare- You pay 10% You pay 5% of Only costs are
You pay covered of Medicare- Medicare- You pay $20 for doctor's
nothing services. approved approved nothing office visits; $50
amount amount for an ER visit
You pay
nothing

Not covered Not covered Not covered Not covered Not covered Not covered

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

You pay You pay You pay You pay You pay You pay 10% You pay 5% You pay You pay
nothing nothing nothing nothing nothing of cost of cost nothing nothing

2019 high-deductible amount = $2,300

2019 Out-of-Pocket Limit*** $5,560 $2,780

*** Out-of-pocket limits do not include plan premiums. Nor do they apply to services that are not covered. In Plans K and L, for example,
the Part B deductible is not covered. Thus any money you spend for the Part B deductible does not count toward the OOP limit.