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Plan Recap 2017

We want to help you fully understand your chosen plan and options

Fill out this worksheet with your LIcensed Sales Representative. It will walk you through all of the details to help you make sure this plan fits your needs.

Plan Information

Here are some details about your plan and coverage

Pre - Existing Conditions and Eligibility

I Must Have           Medicare Part A and

                                Medicare Part B to enroll in this plan

+ Add Plan Type : Medicare Supplement Insurance Medigap plan : This is a Part C Health Maintenance Organization (HMO) plan

                                Medicare Advantage Plan Part C

                               Medicare Part D plan

+ Add Name of Plan

This plan coverage begins Effective Date : MM/DD/YYYY

This Plans Coverage Ends Expiration Date : MM/DD/YYYY

My Plany Type is : HMO , HMO -POS , LPPO RPPO , PFFS , Selfpay 

My Plan type Requires Referrals : Yes or No

+ Add Rider : I have purchased Additional Riders , Rider Name , Rider Description , Cost

Premium information

What you need to know about paying a monthly premium

I need to continue to pay my Medicare Part B premium unless the State or another Third party Pays this Premium For Me = _____________________

What Benefits Does Each Eligibility Level Cover ?

Eligibility Level Part A Premium Part B Premium Part D Premium Medicare Deductibles , Co-pays , Coinsurance  Full Medicaid Benefits

QMB Only

QMB Plus






My Plan has a Monthly premium. I must pay this monthly premium to stay in this plan = ___________________

If I owe a Late Enrollment Penalty (LEP) , it is not included in my monthly premium. I will need to add it to my monthly premium each month

There is An Out-Of-Pocket Spending Limit Each Plan Year. Once you reach this Limit , the Plan will Pay % of the Costs For Covered Services

Prescription Drug Coverage

Know what is covered by your prescription drug plan

My Plans deductible for drugs in Tiers ________________ =___________________ (Only Applicable for Plans With A Deductible)

The Cost Difference between Retail Pharmacies = ______________  and Mail Order Pharmacies = ___________________

Know My Current Medications  and Tier Levels

Drug Stages and how they impact my Costs