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Medi-Pak Plan G

Plan costs

Premium $147.60 monthly


Coverage Overview
Rating MethodCommunity Rated
Basic Benefit Amount You Pay
Hospitalization - Medicare Part A coinsurance (up to an additional 365 days after Medicare benefits are used)You pay $0
Medical Expenses - Part B coinsurance or copayYou pay $0
Blood - first three pints each yearYou pay $0
Hospice - Part A coinsurance or copayYou pay $0
Skilled Nursing Facility (SNF) coinsuranceYou pay $0
Medicare Part A Deductible ($1,556 in 2022)You pay $0
Medicare Part B Deductible ($233 in 2022)Not Covered
Part B Excess ChargesYou pay $0
Foreign travel emergency (up to plan limits)$250 deductible, then you pay 20%
Out-of-Pocket Limit (2022)n/a
Plan Deductible (2022)n/a
Plan Documents
2021 Medi-Pak Buck Slip Post-MACRA2021 Medi-Pak Buck Slip Post-MACRA
2021 Medi-Pak Buck Slip Pre-MACRA2021 Medi-Pak Buck Slip Pre-MACRA
Enrollment Application (PostMACRA)Enrollment Application (PostMACRA
Enrollment Application (PreMACRA)Enrollment Application (PreMACRA
Learn More about Applying OnlineLearn More about Applying Online
Learn More About Medicare Supplement PlansLearn More About Medicare Supplement Plans
Outlines Of Coverage (PostMACRA)Outlines Of Coverage (PostMACRA
Outlines Of Coverage (PreMACRA)Outlines Of Coverage (PreMACRA
Post-MACRA BrochurePost-MACRA Brochure
Pre-MACRA BrochurePre-MACRA Brochure
Silver Sneakers Member Value FlyerSilver Sneakers Member Value Flyer

Limitations, copayments, and restrictions may apply. See above or contact the plan for more details.

*Enrollee must continue to pay the Medicare Part B premium.

You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for extra help, call:

  • 800-MEDICARE (800-633-4227). TTY users should call 877-486-2048. 24 hours a day, 7 days a week.
  • The Social Security Office at 800-772-1213. TTY users should call 1-800-325-0778. Monday through Friday, 7 a.m. to 7 p.m.
  • Your State Medicaid Office.