| Rates effective 10/1/2011 |
Plan A |
Plan B |
Plan C |
Plan D |
Plan F |
High
Plan F |
Plan G |
Plan M |
Plan N |
| Male / 65yr / Non-tobacco / zip codes 970-972 |
$82.33 |
$96.08 |
$115.08 |
$100.75 |
$119.67 |
$47.08 |
$101.33 |
$90.67 |
$83.75 |
| Female / 65yr / Non-tobacco / zip codes 970-972 |
$71.58 |
$83.58 |
$100.08 |
$87.58 |
$104.00 |
$40.92 |
$88.08 |
$78.83 |
$72.75 |
| Male / 65yr / Tobacco / zip codes 970-972 |
$91.50 |
$106.83 |
$127.92 |
$111.92 |
$133.00 |
$52.33 |
$112.58 |
$100.75 |
$93.08 |
| Female / 65yr / Tobacco / zip codes 970-972 |
$79.50 |
$92.83 |
$111.17 |
$97.25 |
$115.58 |
$45.50 |
$97.92 |
$87.58 |
$80.92 |
| Male / 65yr / Non-tobacco / zip codes 973-979 |
$79.33 |
$92.58 |
$110.92 |
$97.08 |
$115.33 |
$45.33 |
$97.58 |
$87.33 |
$80.67 |
| Female / 65yr / Non-tobacco / zip codes 973-979 |
$69.00 |
$80.58 |
$96.42 |
$84.42 |
$100.17 |
$39.42 |
$84.83 |
$75.92 |
$70.08 |
| Male / 65yr / Tobacco / zip codes 973-979 |
$88.08 |
$102.92 |
$123.25 |
$107.83 |
$128.08 |
$50.42 |
$108.50 |
$97.08 |
$89.67 |
| Female / 65yr / Tobacco / zip codes 973-979 |
$76.58 |
$89.42 |
$107.17 |
$93.75 |
$111.33 |
$43.83 |
$94.33 |
$84.42 |
$78.00 |
| Benefits |
Plan A |
Plan B |
Plan C |
Plan D |
Plan F |
High
Plan F |
Plan G |
Plan M |
Plan N |
| Medicare Part A Coinsurance and Hospital Benefits |
 |
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| Medicare Part A Deductible |
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50% |
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| Medicare Part B Coinsurance or Co-payment |
|
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|
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2 |
| Medicare Part B Deductible |
|
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| Medicare Part B Excess Charges |
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| Blood (First Three Pints) |
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| Hospice Care Coinsurance or Co-payment |
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| Skilled Nursing Coinsurance |
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| Foreign Travel Emergency (Up to Plan Limits)3 |
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| Medicare Preventive Care Part B Coinsurance |
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