Page 11 - Cover Letter and Evaluation for Fred Heald

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
2020 Part B premium

($144.60 a month)* $1,735 $1,735 $1,735

Health plan annual

premiums (Medigap $2,200 $1,750 $1,750
premiums are estimates)

Part B deductible** $198 $198 $198

2020 Rx drug costs at
Walgreens beginning $1,306 $1,306 $1,306
March 1

Total $5,439 $4,989 $4,989

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 2020 Part B premium for new enrollees. Higher income people may pay more.
**Part B deductible in 2020 is $198.

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