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BACK TO ALL MEDIGAP PLANS

Plan L has an Out of Pocket Maximum (OOPM) instead of a deductible.
This plan provides coverage before you meet the OOPM.
Once you have met the OOPM of $3,470, Plan L pays at 100% the remainder of that year.
The $226 Part B deductible is not included in this Out of Pocket Maximum.

		PLAN L
	DEDUCTIBLE / OOPM	Out of Pocket Maximum: $3,470
SERVICES	MEDICARE PAYS	Plan L Pays	You Pay
HOSPITALIZATION Semiprivate room and board, general nursing and misc. services and supplies First 60 days -Before Plan Ded./OOPM -After Plan Ded./OOPM 61st thru 90th day -Before Plan Ded./OOPM -After Plan Ded./OOPM 91st day and after, while using 60 lifetime reserve days -Before Plan Ded./OOPM -After Plan Ded./OOPM Once reserve days are used: Additional 365 days -Before Plan Ded./OOPM -After Plan Ded./OOPM Beyond additional 365 days -Before Plan Ded./OOPM -After Plan Ded./OOPM	Part A Pays All but $1,600 All but $1,600 All but $400 / day All but $400 / day All but $800 / day All but $800 / day $0 $0 $0 $0	Plan L Pays $1,200 $0 $400 / day $400 / day $800 / day $800 / day 100% 100% $0 $0	You Pay $400 $0 $0 $0 $0 $0 $0 $0 100% 100%
SKILLED NURSING FACILITY CARE You must meet Medicare's requirements, including having been in a hospital for at least 3 days and entered a Medicare- approved facility within 30 days after leaving the hospital First 20 days - Copay/Day -Before Plan Ded./OOPM -After Plan Ded./OOPM 21st - 100th day- Copay/Day -Before Plan Ded./OOPM -After Plan Ded./OOPM 101st day and after	Part A Pays All approved amounts All approved amounts All but $200 / day All but $200 / day $0	Plan L Pays $0 $0 $150 / day $200 / day $0	You Pay $0 $0 $50 / day $0 100%
BLOOD First 3 pints -Before Plan Ded./OOPM -After Plan Ded./OOPM Additional amounts -Before Plan Ded./OOPM -After Plan Ded./OOPM	Part A Pays $0 $0 100% 100%	Plan L Pays 75% 100% $0 $0	You Pay 25% $0 $0 $0
HOSPICE CARE You must meet Medicare's requirements, including a doctor's certification of terminal illness. -Before Plan Ded./OOPM -After Plan Ded./OOPM	Part A Pays All except small copayment or coinsurance.	Plan L Pays 75% 100%	You Pay 25% $0
MEDICAL EXPENSES - IN OR OUT OF THE HOSPITAL AND OUTPATIENT HOSPITAL TREATMENT, such as Physician's services, inpatient and outpatient medical and surgical services and supplies, physical and speech therapy, diagnostic tests, durable medical equipment. First $226 of Medicare Approved Amounts -Before Plan Ded./OOPM -After Plan Ded./OOPM	Part B Pays $0 $0	Plan L $0 $0	You Pay $226 $226
Remainder of Part B Approved claims after $226 -Before Plan Ded./OOPM -After Plan Ded./OOPM	Part B Pays 80% 80%	Plan L 15% 20%	You Pay 5% 0%
EXCESS CHARGES -Before Plan Ded./OOPM -After Plan Ded./OOPM	Part B Pays $0 $0	Plan L $0 $0	You Pay 100% 100%
BlOOD First 3 pints -Before Plan Ded./OOPM -After Plan Ded./OOPM Next $226 of Medicare approved amounts -Before Plan Ded./OOPM -After Plan Ded./OOPM Remainder of Medicare approved amounts -Before Plan Ded./OOPM -After Plan Ded./OOPM	Part B Pays $0 $0 $0 $0 80% 80%	Plan L 75% 100% $0 $0 15% 20%	You Pay 25% $0 $226 $226 5% $0
CLINICAL LABORATORY SERVICES Tests for Diagnostic Services	Part B Pays 100%	Plan L 0%	You Pay 0%
HOME HEALTH CARE Medicare approved services Medically necessary skilled care services and medical supplies	Part A&B Pay 100%	Plan L 0%	You Pay 0%