Medi-Pak Plan G
Plan costs
Premium $165.80 monthly
Benefits
| Coverage Overview | |
|---|---|
| Rating Method | Community 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 copay | You pay $0 |
| Blood - first three pints each year | You pay $0 |
| Hospice - Part A coinsurance or copay | You pay $0 |
| Skilled Nursing Facility (SNF) coinsurance | You 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 Charges | You 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-MACRA | 2021 Medi-Pak Buck Slip Post-MACRA |
| 2021 Medi-Pak Buck Slip Pre-MACRA | 2021 Medi-Pak Buck Slip Pre-MACRA |
| Enrollment Application (PostMACRA) | Enrollment Application (PostMACRA) |
| Enrollment Application (PreMACRA) | Enrollment Application (PreMACRA) |
| Learn More about Applying Online | Learn More about Applying Online |
| Learn More About Medicare Supplement Plans | Learn More About Medicare Supplement Plans |
| Outlines Of Coverage (PostMACRA) | Outlines Of Coverage (PostMACRA) |
| Outlines Of Coverage (PreMACRA) | Outlines Of Coverage (PreMACRA) |
| Post-MACRA Brochure | Post-MACRA Brochure |
| Pre-MACRA Brochure | Pre-MACRA Brochure |
| Silver Sneakers Member Value Flyer | Silver 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.