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Medicare Plans
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Your plan benefits coverage for what Medicare does not pay

A B C D F G J
Monthly Premium $89.10 $114.80 $130.90 $128.30 $173.80 $125.40 $126.30
Inpatient hospital deductible each benefit period
Copayment for days 61-90 in hospital
Copayment for days 91-150 in hospital
Additional 365 hospital days after Medicare hospital benefits end
Calendar year blood deductible
Copayment for days 21-100 in skilled nursing facility
Part B Deductible
20% of Part B coinsurance after deductible is met
Excess charges 100% 80% 100%
At home recovery
Emergency care in a foreign country
Additional preventive care benefits
Vision care
SilverSneakers®

Medicare Plans
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The benefit information provided above is a brief summary, but not a comprehensive description of available benefits. Additional information about benefits is available to assist you in making a decision about your coverage. This is an advertisement; for more information, contact a benefits specialist.



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