| BASIC BENEFITS | A | B | C | D | E | F/F* | G | H | I | J/J* |
|---|
| Part A Hospital (Days 61-90) | ◊ | ◊ | ◊ | ◊ | ◊ | ◊ | ◊ | ◊ | ◊ | ◊ |
| Lifetime Reserve (Days 91-150) | ◊ | ◊ | ◊ | ◊ | ◊ | ◊ | ◊ | ◊ | ◊ | ◊ |
| 365 Life Hosp. Days - 100% | ◊ | ◊ | ◊ | ◊ | ◊ | ◊ | ◊ | ◊ | ◊ | ◊ |
| Parts A and B Blood | ◊ | ◊ | ◊ | ◊ | ◊ | ◊ | ◊ | ◊ | ◊ | ◊ |
Part B Coinsurance (Generally 20%) | ◊ | ◊ | ◊ | ◊ | ◊ | ◊ | ◊ | ◊ | ◊ | ◊ |
| - - - end of basic benefits - - - | | | | | | | | | | |
| Skilled Nursing Facility Coinsurance Days 21-100 | | | ◊ | ◊ | ◊ | ◊ | ◊ | ◊ | ◊ | ◊ |
| Part A Deductible | | ◊ | ◊ | ◊ | ◊ | ◊ | ◊ | ◊ | ◊ | ◊ |
| Part B Deductible | | | ◊ | | | ◊ | | | | ◊ |
| Part B Excess Charges | | | | | | 100% | 80% | | 100% | 100% |
| Foreign Travel Emergency | | | ◊ | ◊ | ◊ | ◊ | ◊ | ◊ | ◊ | ◊ |
| At-Home Recovery | | | | ◊ | | | ◊ | | ◊ | ◊ |
| Basic Prescription Drugs ** | | | | | | | | $1,250 | $1,250 | |
| Extended Prescription Drugs ** | | | | | | | | | | $3,000 |
| Preventive Medical Care | | | | | ◊ | | | | | ◊ |
* Plan F* and J* have a $1500 calendar year deductible before benefits will be paid ** Plans H and I have a $250 deductible, plus a 50% co-payment to a maximum of $1,250 Plan J has a $250 deductible, then pays 50% to a maximum of $3,000 |