2011 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | Medica Prime Solution Basic with Enhanced Rx - WI (Cost) | ||||
Location: | Dunn, Wisconsin Click to see other locations | ||||
Plan ID: | H2450 - 010 - 0 Click to see other plans | ||||
Member Services: | 1-800-234-8755 TTY users 1-800-855-2880 | ||||
— This plan information is for research purposes only. — Click here to see plans for the current plan year | |||||
Medicare Contact Information: | Please go to Medicare.gov or call 1-800-MEDICARE (1-800-633-4227) to get information on all of your options. TTY users 1-877-486-2048 or contact your local SHIP for assistance |
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Email a copy of the Medica Prime Solution Basic with Enhanced Rx - WI (Cost) benefit details | |||||
— Medicare Plan Features — | |||||
Monthly Premium: | $175.30 (see Plan Premium Details below) | ||||
Annual Deductible: | $0 | ||||
Annual Initial Coverage Limit (ICL): | $2,840 | ||||
Health Plan Type: | Cost | ||||
Maximum Out-of-Pocket Limit for Parts A & B (MOOP): | $3,000 | ||||
Additional Gap Coverage? | Many Generics | ||||
Total Number of Formulary Drugs: | 4,830 drugs | Browse the Medica Prime Solution Basic with Enhanced Rx - WI (Cost) Formulary | |||
This plan has 4 drug tiers. See cost-sharing highlights below. | |||||
Formulary Drug Details: | Tier 1 | Tier 2 | Tier 3 | Tier 4 | Tier 5 |
• Preferred Pharmacy Cost-Sharing during initial coverage phase: | $10.00 | $34.00 | $74.00 | 25% | |
• Number of Drugs per Tier: | 1929 | 797 | 1764 | 340 | |
Plan's Pharmacy Search: | http://www.medica.com/C12/DrugFormularyPartD/default.aspx | ||||
Number of Members enrolled in this plan in (H2450 - 010): | less than 10 members | ||||
— Plan Premium Details — | |||||
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔ | 100% Subsidy | 75% Subsidy | 50% Subsidy | 25% Subsidy | |
Monthly Part D Premium with LIS: | $0.00 | $0.00 | $0.00 | $0.00 | |
— Plan Health Benefits — |