Page 111 - Cover Letter & Evaluation for Carol Evans

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Plan L
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$76.96 Benefits Benefit Table

100%
Part A Coinsurance:
Lowest Estimated Monthly Rate* Part B Coinsurance: 75%
The rate is for a non-tobacco user and is
based on the information you entered. Your Blood Coinsurance: 75%
actual monthly rate will be determined when
you apply. Part A Hospice Care Coinsurance: 75%
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Part A Deductible: 75%
Part B Deductible: --

Part B Excess Charges: --
Skilled Nursing Facility Coinsurance: 75%
Foreign Travel Emergency Care
(up to plan limits)** : --

Out-of-pocket limit -- $2,620 (2018)^^

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*Rates shown are based on the information entered and are for the current month. All rates are subject to change. Any rate
change will apply to all members of the same class insured under your plan who reside in your state/area.

Plan N (10 of 10 Plans)