Medicare Supplement Washington

Plan choices (PDF) | Plan Rates | Enrollment Application | Medicare and You | Choose Medigap

Rates

Rates effective June 1, 2010	Plan A	Plan F	High Ded. Plan F	Plan N
Monthly AFT Rate	$107	$134	$55	$105
Monthly Paper Bill Rate	$112	$139	$60	$110
Benefits	Plan A	Plan F	Plan F	Plan N
Medicare Part A Coinsurance and Hospital Benefits
Medicare Part A Deductible
Medicare Part B Coinsurance or Co-payment				2
Medicare Part B Deductible
Medicare Part B Excess Charges
Blood (First Three Pints)
Hospice Care Coinsurance or Co-payment
Skilled Nursing Coinsurance
Foreign Travel Emergency (Up to Plan Limits)3
Medicare Preventive Care Part B Coinsurance
2010 out-of-pocket limit4			$2,000

¹Plan F also has an option called High Deductible Plan F. This high deductible plan pays the same benefits as plan F after one has paid a calendar year $2,000 deductible. Benefits from High Deductible Plan F will not begin until the out-of-pocket expenses exceed $2,000. Out-of-pocket expenses for this deductible are expenses that would ordinarily be paid by the contract. These expenses include the Medicare deductibles for Part A and Part B, but do not include the plan’s separate foreign travel emergency deductible.

²100% part B coinsurance except up to $20 copayment for office visits and up to $50 copayment for ER.

Payment Mode Options

• Monthly payment by Automatic Funds Transfer (AFT)
  OR
• If you prefer us to bill you, Premera Blue Cross will send you a bill in the mail each month.

Rates and a summary of benefits (PDF) are available in a single document.