COVERAGE

PLAN A

PLAN B

PLAN C

PLAN D

PLAN F

PLAN HDF

PLAN G

PLAN K

PLAN L

PLAN M

PLAN N

BASIC COVERAGE

Basic, including 100% Part B coinsurance

Basic, including 100% Part B coinsurance

Basic, including 100% Part B coinsurance

Basic, including 100% Part B coinsurance

Basic, including 100% Part B coinsurance

Basic, including 100% Part B coinsurance

Basic, including 100% Part B coinsurance

Hospitalization and prevention care paid 100%, other basic benefits paid at 50%

Hospitalization and prevention care paid 100%, other basic benefits paid at 75%

Basic, including 100% Part B coinsurance

Basic, including 100% Part B coinsurance, except up to $20 copay for office visit & up to 50 copay for ER

NO

NO

100%

100%

100%

100%

100%

50%

75%

100%

100%

Part A Deductible

NO

100%

100%

100%

100%

100%

100%

50%

75%

50%

100%

Part B Deductible

NO

NO

100%

NO

100%

100%

NO

NO

NO

NO

NO

Part B Excess

NO

NO

NO

NO

100%

100%

100%

NO

NO

NO

NO

Foreign Travel
Emergency

NO

NO

YES

YES

YES

YES

YES

NO

NO

YES

YES

YOUR OUT OF POCKET

$2,200.00

$5,120.00

$2,560.00