Page 13 - Cover letter and evaluation for Paulina Rosenstein

Comprehensive Benefits Comprehensive Benefits with Higher Cost-Sharing

CDF F N
G (High K L M

Deductible)

$3,680 $3,500 $3,700 $3,500 $1,675 $2,000 $2,525 $3,275 $2,775
99.7% 97.1% 100.0% 72.6% 84.2% 71.5%
97.3% 43.5% 53.5%

Co-Payments and Cost-Sharing

You pay You pay
nothing nothing

You pay You pay You pay You pay You pay You pay
nothing nothing $83.75 a $41.88 a nothing nothing

You pay You pay After you day day
$183 $183
have paid You pay You pay
You pay You pay
You pay nothing nothing the plan's 2.5% & 1.25% &
nothing
$2,240 $2.50 $1.25

You pay deductible, You pay You pay You pay $670
nothing you will $670 $335 You pay $183 You pay $183
have no
You pay You pay
further cost- $183 $183
sharing for

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

amount amount

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

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

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

2018 high-deductible amount = $2,240

2018 Out-of-Pocket Limit*** $5,240 $2,620

*** Out-of-pocket limits do not include plan premiums. Neither do they apply to services that are not covered. In Plans K and L, for
instance, the Part B deductible is not covered. Thus any money you spend for the deductible will not count toward the OOP limit.

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