Page 15 - Cover Letter and Evaluation for Paul Stelter

Comprehensive Benefits Comprehensive Benefits with Higher Cost-Sharing

F
C D F G (High K L M N
Deductible)

$2,075 $1,800 $2,100 $1,850 $1,000 $1,050 $1,450 $1,600 $1,450

99.7% 97.1% 100.0% 97.3% 43.5% 53.5% 72.6% 84.2% 71.5%
Co-Payments and Cost-Sharing

You pay You pay
nothing nothing

You pay $88 You pay $44 You pay
You pay You pay a day a day nothing You pay
nothing nothing After you nothing
have paid You pay 2.5% You pay
You pay the plan's & $2.50 1.25% &
nothing $2,340 $1.25
deductible, You pay
You pay you will You pay $704 You pay $352 $704
nothing have no
You pay $198 You pay further cost- You pay $198 You pay $198 You pay You pay
$198 sharing for $198 $198

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

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

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

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

2020 high-deductible amount = $2,340

2020 Out-of-Pocket Limit $5,880 $2,940

*** Out-of-pocket limits do not include plan premiums. Nor do they apply to services that are not covered. In Plans K and L, for example,
the Part B deductible is not covered. Thus any money you spend for the Part B deductible does not count toward the OOP limit.

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