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Sterling Health Plans Medicare Supplement Plan Information
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Sterling Health Plans Medicare Supplement Rates 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 Medicare Part A Deductible   50% Medicare Part B Coinsurance or Co-payment 2 Medicare Part B Deductible             Medicare Part B Excess Charges             Blood (First Three Pints) Hospice Care Coinsurance or Co-payment Skilled Nursing Coinsurance     Foreign Travel Emergency (Up to Plan Limits)3     Medicare Preventive Care Part B Coinsurance

1. Medigap Plan F offers a high deductible option. You must pay for Medicare-covered costs up to the high-deductible amount ($2,070 in 2012) before your Medigap policy pays anything
2. 100% part B coinsurance except up to $20 copayment for office visits and up to $50 copayment for ER.
3. You must also pay a separate deductible for foreign travel emergency ($250 per year).
4. After you meet your out-of-pocket yearly limit and your yearly Part B deductible ($140 in 2012) the plan pays 100% of covered services for the rest of the calendar year (This applies only to plans K & L)
5. Modified Plan F offers an individual assistance program, as well as coverage for preventive dental care (available in some states)

• 2012 Out of Pocket Limit for Plan K is $4,660.
• 2012 Out of Pocket Limit for Plan L is $2,330.