Page 13 - Cover Letter & Evaluation for Carol Evans

Plans that appear to meet your criteria (cont'd)

Plan name Medigap Plan F Medigap Plan G Medigap Plan N Medigap High
Deductible Plan F
Toll-Free Number NA NA NA NA

Estimated annual premiums for medical coverage
lity ratings from Medicare web site (best rating = 5 stars)
2018 standard Part B

premium of $134 a $1,608 $1,608 $1,608 $1,608
month*

Health plan annual
premiums (Medigap $1,700 $1,500 $1,300 $600
premiums are estimates)

Total $3,308 $3,108 $2,908 $2,208

Premiums, health deductibles, and est. Rx drug costs

Total medical premiums
(from above) $3,308 $3,108 $2,908 $2,208

Plan health deductible

(includes Part B deductible if $0 $183 $183 $1,640***
not covered by plan**)

Annual Rx costs (Plan HDF
includes est. $600 a year in Part $152 $152 $152 $752
B costs for Prolia)

Estimated total (includes cost-
sharing for the Rx drugs you $3,460 $3,443 $3,243 $4,600***
now take)

Cost-sharing for doctors office visits
=
In-Network Primary
Care Co-Pays Up to $20 for
No co-pays for
No co-pays for
No co-pays for
In-Network Specialist Medicare-covered Medicare-covered Medicare-approved Medicare-covered
doctor's visit; $50
Co-Pays services services for emergency services
Out-of-Network room visit
Co-Pays
*This is 2018 Part B premium for new enrollees. Higher income people may pay more. **Part B deductible in
2018 is $183. ***The 2018 deductible for Plan HDF is $2,240. If Prolia is covered by Part B and your co-insurance
payments are $600 a year, the remaining deductible amt. is $1,640.

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