IN-47725 zip and 67 year old male
plan f $163.40
plan n $114.38
being he is within 3 years of T65 only has to answear
5 Answer these health questions to determine if you are eligible for this coverage
5A. Do any of these apply to you?
• have end stage renal (kidney) disease
• currently receiving dialysis
• diagnosed with kidney disease that may require dialysis
• admitted to a hospital as an inpatient within the past
90 days
Y N
5B. Within the past two years, has a medical professional
recommended or discussed as a treatment option, any
of the following that has NOT been completed:
• hospital admittance as an inpatient
• organ transplant
• back or spine surgery
• joint replacement
• surgery for cancer
• heart surgery
• vascular surgery