Page 61 - Cover Letter and Evaluation for Debbie Workman
P. 61
12/13/2017 Your Medicare Health Plan Details
Plan Type: HMO
Plan Status: Approved by Medicare
Area: Spokane County
Previous Plan Name
View plan website
Important Note:
This plan does not charge an annual deductible for all drugs. The $180.00 annual deductible only applies to drugs on certain tiers.
View Drug Benefit Summary
Provider Network: 3501-4000 physicians and providers.
View provider and physician network website
View a chart on how an independent sales agent or broker would be compensated if they were to enroll you in a plan
for 2018
Costs
Monthly Premiums
2
Part B premium $134.00
View Part B premiums based on income
Plan premium $0.00
Health plan premium $0.00
Drug plan premium $0.00
Estimated Costs
*Inpatient care $33.00
*Outpatient prescription drugs $18.50
*Dental services $40.00
*All other services
$94.00
Total monthly estimated costs
$319.50
3
TOTAL ESTIMATED ANNUAL COSTS [?] $3,830
How are Out-of-Pocket costs calculated?
View estimated monthly Out-of-Pocket Costs (OOPC) for people with High-Cost Conditions (chronic care and unexpected illnesses)
1 An out-of-pocket cost maximum applies for some services covered by this plan.
2 Medicare costs at a glance
3 Estimated Annual Costs are rounded to the nearest $10. They don't include any Medicare Part D (prescription drug) late enrollment
penalty amounts that may apply to you. Also, if you have limited income and resources, your expenses may be lower.
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