Services

What Medicare Pays

What Plan G Pays

What you Pay

Hospitalization

• First 60 Days

All But $1556

$1556

$0

• Days 61-90

All but $389 a Day

$389 a Day

$0

• Days 91 and After (60 Reserve Days)

All but $778 a Day

$778 a Day

$0

• After Reserve (Additional 365 Days)

$0

100% of Eligible Expenses

$0

• Beyond lifetime reserve days

$0

$0

All Costs

Skilled Nursing Facility Care

• Days 1-20

All Approved Amounts

$0

$0

• Days 21-100

All but $194.50 a Day

Up to $194.50 a Day

$0

• Days 101 and beyond

$0

$0

All Costs

Blood

• First Three Pints

$0

100%

$0

• Additional Amounts

100%

$0

$0

Hospice Care

• You must meet Medicare’s requirements, including a doctor’s certification of terminal illness

All but very limited copayment/coinsurance for outpatient drugs and inpatient respite care

Medicare copayment/coinsurance

$0

Services

What Medicare Pays

What Plan G Pays

What you Pay

Medical Expenses

• First $233 of Approved Amounts

$0

$0

$233

• Remainder of Approved Amounts

Generally 80%

20%

$0

• Part B Excess Charge

$0

100%

$0

Blood

• First Three Pints

$0

100%

$0

Foreign Travel

• 1st $250 day 1-60

$0

$0

$250

• Remainder of charges up to a lifetime max of $50,000

$0

80%

20%