Page 17 - Cover Letter and Mediicae Evaluation for Mr. Bruno V. Manno

Comprehensive Benefits Comprehensive Benefits with Higher Cost-Sharing

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

$2,350 $2,300 $2,400 $2,200 $825 $975 $1,750 $2,000 $1,800

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 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
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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