LifeWise Health Plan of Oregon

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Medicare Supplement Rates

Rates effective 6/1/2010	Plan A	Plan F	High Ded. Plan F	Plan N
Ages 65-69	$129	$171	$64	$127
Ages 70-74	$165	$218	$82	$162
Age 75+	$194	$257	$97	$192
Benefits	Plan A	Plan F	High Ded. Plan F	Plan N
Medicare Part A Coinsurance and Hospital Benefits
Medicare Part A Deductible
Medicare Part B Coinsurance or Co-payment				3
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

¹Medigap Plan F offers a high deductible option. You must pay for Medicare-covered costs up to the high-deductible amount ($2,000 in 2010) before your Medigap policy pays anything
³You must also pay a separate deductible for foreign travel emergency ($250 per year).

Rates are for Automatic Funds Transfer (AFT). Paper billing is $5 per month extra.