Page 43 - Cover Letter & Evaluation for Patricia Letizia

10/12/2018 Your Medicare Health Plan Details
Plan Type: Local Preferred Provider Organization
Plan Status: Approved by Medicare
Area: Peoria Illinois area

View plan website 
Important Note:
This plan does not charge an annual deductible for all drugs. The $250.00 annual deductible only applies to drugs on certain tiers.

View Drug Benefit Summary

Provider Network: 10001-11000 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 2019.

Costs

Monthly Premiums

2
Part B premium $134.00
View Part B premiums based on income
Plan premium $97.00

Health plan premium $85.60

Drug plan premium $11.40
Estimated Costs

*Inpatient care $24.00

*Outpatient prescription drugs $39.53

*Dental services $27.00
*All other services
$71.00
Total monthly estimated costs
$392.53

3
TOTAL ESTIMATED ANNUAL COSTS [?] $4,710

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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