| Effective January 1, 2012 |
Bridge
Plan A |
Bridge
Plan C |
Bridge
Plan F |
Bridge
Plan K |
| Monthly Surepay Rate |
$136 |
$191 |
$192 |
$103 |
| 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 |
|
|
|
|
Discounts are reflected in the premiums listed above for all payment options other than Monthly Paper Bill; there is no discount for monthly paper billing
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