Page 13 - Cover letter & Medicare evaluation for Mr. Carl Zambon

Your estimated costs in each plan

Plan name Medigap Plan F Medigap Plan G Medigap Plan N Medigap Plan L

Toll-Free Number NA NA NA NA

Health plan premiums + medical deductible + Rx drug costs
lity ratings from
Medicare web site
2021 Part B premium

($148.50 a month)* $1,782 $1,782 $1,782 $1,782

Health plan annual

premiums (Medigap $2,300 $2,100 $1,650 $1,675
premiums are estimates)

Part B deductible** NA $203 $203 $203

2021 Rx drug costs for
mail-order refills $1,928 $1,928 $1,928 $1,928
(premiums and co-pays)

Total $6,010 $6,013 $5,563 $5,588

Part A and Part B out-of-pocket costs

Part A: The amount you
will pay if you are No cost No cost No cost You will pay $371
hospitalized

Part B: Amounts owed No cost after the Below are the cost- 5% of Medicare-
for most outpatient No cost Part B deductible is sharing amounts approved cost after
Part B deductible is
after Part B
services paid deductible is paid paid
Cost-sharing for doctors' office visits
=
In-Network Primary
Care Co-Pays $20 for doctor's 5% of Medicare-
No cost after the
In-Network Specialist No cost Part B deductible is office visits and $50 approved cost after
Co-Pays paid for emergency Part B deductible is
Out-of-Network room visits paid
Co-Pays

*This is 2021 Part B premium for new enrollees. Higher income people may pay more.
**Part B deductible in 2021 is $203.

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