| $20 & $50 Copay Plan | 50% Cost Sharing Plan | 75% Cost Sharing Plan | Basic Plan | Extended Basic Plan | High Deductible Plan | |
|---|---|---|---|---|---|---|
| Monthly Cost (Premium) | (See policies) | Medigap 50% Cost Sharing Plan | Medigap 75% Cost Sharing Plan | (See policies) | (See policies) | (See policies) |
| Hospital (Part A) Deductible | $0 | $816 | $408 | $1,632 | $0 | $0 |
| Medical (Part B) Deductible | $240 | $240 | $240 | $240 | $240 | $240 |
| Part B Copays/Coinsurance | $0 with some $20 and $50 copays | 10% up to $7,060 | 5% up to $3,530 | $0 | $0 | $0 after $2,800 deductible |
| Hospital Stays | $0 for Days 1-150, All costs after | $816 for Days 1-60, $0 for Days 61-150, All costs after | $408 for Days 1-60, $0 for Days 61-150, All costs after | $1,632 for Days 1-60, $0 for Days 61-150, All costs after | $0 for Days 1-150, All costs after | $0 for Days 1-150, All costs after |
| Skilled Nursing Facility | $0 for Days 1-100, All costs after | $0 for Days 1-20, $102 for Days 21-100, All costs after | $0 for Days 1-20, $51 for Days 21-100, All costs after | $0 for Days 1-100, All costs after | $0 for Days 1-120, All costs after | $0 for Days 1-100, All costs after |
| Blood (during a hospital stay) | $0 | 50% of cost for first 3 pints, $0 after | 25% of cost for first 3 pints, $0 after | $0 | $0 | $0 |
| Hospice Care | $0 | 50% of Medicare copay/coinsurance | 25% of Medicare copay/coinsurance | $0 | $0 | $0 |
| Home Health Care | $0 | $0 | $0 | $0 | $0 | $0 |
| Durable Medical Equipment | $240 (Part B deductible), $0 after | $240 (Part B deductible), 10% of cost after | $240 (Part B deductible), 5% of cost after | $240 (Part B deductible), $0 after | $240 (Part B deductible), $0 after | $240 (Part B deductible), $0 after |
| Covered Part B Services | $240 (Part B deductible), $0 after | $240 (Part B deductible), 10% up to $7,060, $0 after | $240 (Part B deductible), 5% up to $3,530, $0 after | $240 (Part B deductible), $0 after | $240 (Part B deductible), $0 after | $240 (Part B deductible), $0 after |
| Preventive Services (covered by Medicare) | $0 | $0 | $0 | $0 | $0 | $0 |
| Preventive Services (not covered by Medicare) | All costs | All costs | All costs | Generally all costs | Balance after Medigap policy pays $120 | Balance after Medigap policy pays $120 |
| Part B Excess Charges | All costs | All costs | All costs | All costs | $0 | All costs |
| Blood (outside a hospital stay) | $240 (Part B deductible), $0 after | 50% of cost for first 3 pints, $240 (Part B deductible), 10% after | 25% of cost for first 3 pints, $240 (Part B deductible), 5% after | $240 (Part B deductible), $0 after | $240 (Part B deductible), $0 after | $240 (Part B deductible), $0 after |
| Tests for Diagnostic Services | $0 | $0 | $0 | $0 | $0 | $0 |
| Physical Therapy (when covered by Medicare) | $0 | $0 | $0 | $0 | $0 | $0 |
| Outpatient Mental Health Services (when covered by Medicare) | $0 | $0 | $0 | $0 | $0 | $0 |
| Foreign Travel Emergency | $250 then 20% | All costs | All costs | 20% | 20% | $0 |
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