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Basic Benefits include the following: Part A hospital coinsurance hospital costs up to an additional 365 days after Medicare
benefits are used up; Part B coinsurance or copayment; first 3 pints of blood per year; and Part A hospice care
coinsurance or copayment.
* Denotes that Plan F offers a high deductible option. The plan pays the same benefits as Plan F after you have paid an annual
**After you meet an out-of-pocket yearly limit (Plan K $4,660; Plan L $2,330) and the Part B deductible, the Medigap plan pays 100%
of covered services for the rest of the calendar year.
*** Medicare Part A hospital coinsurance and Part B preventive care coinsurance paid at 100%
**** Plan N pays 100% of the Part B coinsurance except up to $20 co-payment for office visits and up to $50 for emergency visits