Page 11 - Cover Letter and Evaluation for Paul Stelter

Your estimated costs in each plan

Aetna Medicare Humana Gold Plus
Plan name Medigap Plan F Medigap Plan N
Value PPO HMO Plan

Toll-Free Number NA NA (855) 275-6627 (800) 833-2364
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 $1,735

Health plan annual

premiums (Medigap $2,100 $1,450 $0 $0
premiums are estimates)
Plan or Part B

deductible** $0 $198 $0 $0

2021 Rx drug costs (mail
order) $245 $245 $0 $3

Total $4,080 $3,628 $1,735 $1,738

Part A and Part B out-of-pocket costs

Part A: The amount you $300 a day for days
$150 a day for days
1-7 in a network
will pay if you are No cost No cost hospital; $0 for days 1-7; $0 thereafter
hospitalized 8-90.

Part B: Amounts owed Below are cost- Fixed costs in Fixed costs in
for most outpatient No cost sharing amounts network; up to 50% network; no out-of-
after Part B
of cost out ot
services deductible is paid network network coverage
Cost-sharing for doctors' office visits
=
In-Network Primary

Care Co-Pays $20 for doctors' $0 $0
In-Network Specialist No cost office visits and $50 $35 $25
Co-Pays for visit to
Out-of-Network emergency room $25 primary care;
Co-Pays $50 specialist Not covered

*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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