Page 13 - Cover letter and evaluation for John Johnson

Your estimated costs in each plan

Aetna Medicare
Plan name Medigap Plan F Medigap Plan G Medigap Plan N
Choice PPO Plan
Toll-Free Number NA NA NA (855) 275-6627

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 $1,800 $1,600 $1,300 $0
premiums are estimates)
Rx drug costs (Rx
premiums + deductible + $125 $125 $125 $261

copayments)

Total $3,426 $3,226 $2,926 $1,626
Part A and Part B out-of-pocket costs

Part A: The amount you No cost for No cost for No cost for $300 a day for days
1-6 in network
will pay if you are Medicare-covered Medicare-covered Medicare-covered hospital; no co-pays
hospitalized hospitalization hospitalization hospitalization for days 7-90

Part B: The amount you See below for cost-
will pay for most $185 a year (Part B sharing amounts Various co-pays for
Medicare-covered $0 deductible) after $185 covered services
outpatient services deductible is paid

Cost-sharing for doctors' office visits
=
In-Network Primary
Care Co-Pays No co-pays for up to $20 for No co-pay required
Medicare-covered Medicare-approved
No co-pays for
In-Network Specialist Medicare-covered services after $185 doctor's office visit;
Co-Pays services Part B deductible is $50 for emergency $40
Out-of-Network paid room visit
Co-Pays 50% of cost

*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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