Benex00660069ts ChartMaking SMART health choicesPlan Comparison Worksheethly Contribution Calculation Worksheet to calculate Monthly Contribution Calculation Worksheet1 Select and enter rates f ID: 858280
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1 Medicare Supplement Plan F Bene&#
Medicare Supplement Plan F Bene�ts Chart Making SMART health choices Plan Comparison Worksheet hly Contribution Calculation Worksheet to calculate Monthly Contribution Calculation Worksheet 1. Select and enter rates for desired coverage Medicare plans Retiree Spouse Dependent Total HMO KelseyCare HMO TexanPlus Texas HealthSpring PPO and POS Aetna PPO KelseyCare POS Network-free Aetna PFFS Medicare Supplement Plan F BCBSTX plans Retiree Retiree + 1 Retiree + family Total BCBSTX HMO BCBSTX PPO 2. Add $25 if any BCBSTX HMO or PPO members use tobacco products 3. Total monthly contribution 1. Select and enter rates for desired coverage.
2 2. Total the rows and add row totals to
2. Total the rows and add row totals to get your total monthly contribution amount. Your choice of doctor is important. In the box below �ll in the doctor you prefer to go to and put a that covers that doctor. Prescription Drugs Prescription name Which plan covers your prescriptions Aetna PPO and PFFS KelseyCare Advantage HMO & POS TexanPlus Texas HealthSpring Medicare Supplement Plan F companion drug plan BCBSTX HMO and PPO Doctor Doctor name Which plan covers the doctor you prefer Aetna PPO and PFFS KelseyCare Advantage HMO & POS TexanPlus Texas HealthSpring Medicare Supplement Plan F BCBSTX HMO and PPO Retiree Chart City of Houston