Page 17 - Cover letter & Medicare evaluation for Mr. Carl Zambon

Comprehensive Benefits Comprehensive Benefits with Higher Cost-Sharing

High
C D F G Deductible K L M N
Plan F or G*

$2,250 $2,250 $2,300 $2,100 $1,050 $1,100 $1,675 $1,900 $1,650

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 You pay You pay
You pay You pay $92.75 a day $46.37 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 $2,370 $1.25
deductible, You pay
You pay you will You pay $742 You pay $371 $742
nothing have no
You pay $203 You pay further cost- You pay $203 You pay $203 You pay You pay
$203 sharing for $203 $203
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 Some Some
coverage* coverage* coverage* coverage* coverage* Not covered Not covered 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
* High 2021 high-deductible amount = $2,370
Deductible F
and G are 2021 Out-of-Pocket Limit $6,220 $3,110
identical
*** 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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