Medicare Supplement Washington

Asuris Northwest Health - Online Application

Rates effective June 1, 2010	Plan A	Plan C	Plan F	Plan K
Monthly Surepay Rate	$120	$169	$170	$91
Monthly Paper Bill Rate	$122	$171	$172	$93
Quarterly Rate	$362	$509	$512	$275
Semi-Annual Rate	$722	$1,016	$1,022	$548
Annual Rate	$1,442	$2,030	$2,042	$1,094
Benefits	Plan A	Plan C	Plan F	Plan K
Medicare Part A Coinsurance and Hospital Benefits
Medicare Part A Deductible				50%
Medicare Part B Coinsurance or Co-payment				50%
Medicare Part B Deductible
Medicare Part B Excess Charges
Blood (First Three Pints)				50%
Hospice Care Coinsurance or Co-payment				50%
Skilled Nursing Coinsurance				50%
Foreign Travel Emergency (Up to Plan Limits)3
Medicare Preventive Care Part B Coinsurance
2010 out-of-pocket limit4				$4,620

Discounts are reflected in the premiums listed above for all payment options other than Monthly Paper Vill; there is no discount for monthly paper billing

• Monthly Surepay from your bank account receives a discount of $2 - a $24 savings annually
• Paying your bill quarterly saves you $4 - a $16 savings annually
• Paying your bill semi-annually saves you $10 - a $20 savings annually
• Paying your bill quarterly saves you $22

Asuris EFT form