2012 / 2013 Medicare Advantage Plan Information Click here to jump to the Chart Legend | ||||||||||||
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Plan Name | Monthly Premium |
Part A&B Maximum Out-Of |
Part D Deduct- ible |
(Donut Hole) Additional Gap Coverage |
Plan ID |
Cost-Sharing | Total Formulary Drugs | |||||
Cust. Service Rating |
Member Plan Exper. |
RxCost Info Rating |
Tier 1 |
Tier 2 |
Tier 3 |
Tier 4 |
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2012 BlueSaver MSA (MSA) | $0.00 | n/a | No Rx Coverage | H9788 -002 -0 | This plan does NOT include Prescription Drug coverage. | |||||||
2013 BlueSaver MSA (MSA) | $0.00 | n/a | No Rx Coverage | This plan does NOT include Prescription Drug coverage. | ||||||||
-- This plan not offered in 2012 -- |
H0084 -040 -0 | |||||||||||
2013 Care Improvement Plus Copper RX (PPO SNP) | $0.00 | n/a | $0 | No additional gap coverage, only the Donut Hole Discount | $6.00 | $45.00 | $95.00 | $95.00 | 3,401 2013 Formulary | |||
2012 Care Improvement Plus Gold Rx (PPO SNP) | $0.00 | n/a | $0 | No additional gap coverage, only the Donut Hole Discount | H0084 -023 -0 | $8.00 | $45.00 | $95.00 | $95.00 | 3,159 2012 Formulary | ||
2013 Care Improvement Plus Gold Rx (PPO SNP) | $0.00 | n/a | $0 | No additional gap coverage, only the Donut Hole Discount | $6.00 | $45.00 | $95.00 | $95.00 | 3,401 2013 Formulary | |||
Plan Name | Monthly Premium |
Parts A&B MOOP |
Part D Deduct- ible |
Additional Gap Coverage |
Plan ID |
Cost-Sharing | Total Drugs | |||||
Cust. Serv. |
Plan Exper. |
Cost Info. |
Tier 1 |
Tier 2 |
Tier 3 |
Tier 4 |
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-- This plan not offered in 2012 -- |
H3328 -019 -0 | |||||||||||
2013 Fidelis Medicare $0 Premium (HMO) | $0.00 | $6,700 | $0 | No additional gap coverage, only the Donut Hole Discount | $0.00 | $15.00 | $35.00 | $35.00 | 4,789 2013 Formulary | |||
2012 Fidelis Medicare Advantage without Rx (HMO-POS) | $0.00 | $6,700 | No Rx Coverage | H3328 -001 -0 | This plan does NOT include Prescription Drug coverage. | |||||||
2013 Fidelis Medicare Advantage without Rx (HMO-POS) | $0.00 | $6,700 | No Rx Coverage | This plan does NOT include Prescription Drug coverage. | ||||||||
-- This plan not offered in 2012 -- |
H5970 -008 -0 | |||||||||||
2013 HumanaChoice H5970-008 (PPO) | $0.00 | $6,700 | $0 | Few Generics, Few Brands | $6.00 | $15.00 | $45.00 | $45.00 | 3,906 2013 Formulary | |||
Plan Name | Monthly Premium |
Parts A&B MOOP |
Part D Deduct- ible |
Additional Gap Coverage |
Plan ID |
Cost-Sharing | Total Drugs | |||||
Cust. Serv. |
Plan Exper. |
Cost Info. |
Tier 1 |
Tier 2 |
Tier 3 |
Tier 4 |
||||||
2012 Today's Options Advantage 300 (PPO) | $0.00 | $4,400 | No Rx Coverage | H2775 -094 -0 | This plan does NOT include Prescription Drug coverage. | |||||||
2013 Today's Options Advantage 400 (PPO) | $0.00 | $4,400 | No Rx Coverage | This plan does NOT include Prescription Drug coverage. | ||||||||
2012 Today's Options Premier 300 (PFFS) | $0.00 | $4,400 | No Rx Coverage | H2816 -007 -0 | This plan does NOT include Prescription Drug coverage. | |||||||
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2013 Today's Options Premier 400 (PFFS) | $0.00 | $4,400 | No Rx Coverage | This plan does NOT include Prescription Drug coverage. | ||||||||
2012 UnitedHealthcare MedicareComplete Choice (Regional PPO) | $0.00 | $4,900 | $0 | No additional gap coverage, only the Donut Hole Discount | R5342 -001 -0 | $3.00 | $6.00 | $45.00 | $45.00 | 3,614 2012 Formulary | ||
2013 UnitedHealthcare MedicareComplete Choice (Regional PPO) | $0.00 | $4,900 | $0 | No additional gap coverage, only the Donut Hole Discount | $3.00 | $6.00 | $45.00 | $45.00 | 3,825 2013 Formulary | |||
Plan Name | Monthly Premium |
Parts A&B MOOP |
Part D Deduct- ible |
Additional Gap Coverage |
Plan ID |
Cost-Sharing | Total Drugs | |||||
Cust. Serv. |
Plan Exper. |
Cost Info. |
Tier 1 |
Tier 2 |
Tier 3 |
Tier 4 |
||||||
2012 UnitedHealthcare MedicareComplete Choice Essential (Regional PPO) | $0.00 | $3,900 | No Rx Coverage | R5342 -002 -0 | This plan does NOT include Prescription Drug coverage. | |||||||
2013 UnitedHealthcare MedicareComplete Choice Essential (Regional PPO) | $0.00 | $3,900 | No Rx Coverage | This plan does NOT include Prescription Drug coverage. | ||||||||
2012 WellCare Value (HMO-POS) | $0.00 | $6,700 | $0 | No additional gap coverage, only the Donut Hole Discount | H3361 -099 -0 | $3.00 | $39.00 | $79.00 | $79.00 | 2,506 2012 Formulary | ||
2013 WellCare Value (HMO-POS) | $0.00 | $6,700 | $0 | No additional gap coverage, only the Donut Hole Discount | $3.00 | $39.00 | $79.00 | $79.00 | 2,835 2013 Formulary | |||
2012 Preferred Gold (HMO-POS) | $14.60 | $3,800 | No Rx Coverage | H9859 -001 -0 | This plan does NOT include Prescription Drug coverage. | |||||||
2013 Preferred Gold (HMO-POS) | $13.20 | $4,500 | No Rx Coverage | This plan does NOT include Prescription Drug coverage. | ||||||||
Plan Name | Monthly Premium |
Parts A&B MOOP |
Part D Deduct- ible |
Additional Gap Coverage |
Plan ID |
Cost-Sharing | Total Drugs | |||||
Cust. Serv. |
Plan Exper. |
Cost Info. |
Tier 1 |
Tier 2 |
Tier 3 |
Tier 4 |
||||||
2012 WellCare Liberty (HMO SNP) | $30.10 | n/a | $320 | No additional gap coverage, only the Donut Hole Discount | H3361 -098 -0 | $0.00 | $44.00 | $95.00 | $95.00 | 2,506 2012 Formulary | ||
2013 WellCare Liberty (HMO SNP) | $16.90 | n/a | $325 | No additional gap coverage, only the Donut Hole Discount | $0.00 | $45.00 | $95.00 | $95.00 | 2,835 2013 Formulary | |||
2012 WellCare Access (HMO SNP) | $34.90 | n/a | $320 | No additional gap coverage, only the Donut Hole Discount | H3361 -065 -0 | $0.00 | $45.00 | $95.00 | $95.00 | 2,506 2012 Formulary | ||
2013 WellCare Access (HMO SNP) | $18.90 | n/a | $325 | No additional gap coverage, only the Donut Hole Discount | $0.00 | $45.00 | $95.00 | $95.00 | 2,835 2013 Formulary | |||
2012 Today's Options Premier 100 (PFFS) | $20.00 | $3,400 | No Rx Coverage | H2816 -001 -0 | This plan does NOT include Prescription Drug coverage. | |||||||
-- | ||||||||||||
2013 Today's Options Premier 100 (PFFS) | $20.00 | n/a | No Rx Coverage | This plan does NOT include Prescription Drug coverage. | ||||||||
Plan Name | Monthly Premium |
Parts A&B MOOP |
Part D Deduct- ible |
Additional Gap Coverage |
Plan ID |
Cost-Sharing | Total Drugs | |||||
Cust. Serv. |
Plan Exper. |
Cost Info. |
Tier 1 |
Tier 2 |
Tier 3 |
Tier 4 |
||||||
2012 CDPHP Choice (HMO) | $20.00 | $2,500 | No Rx Coverage | H3388 -001 -0 | This plan does NOT include Prescription Drug coverage. | |||||||
2013 CDPHP Choice (HMO) | $25.00 | $2,500 | No Rx Coverage | This plan does NOT include Prescription Drug coverage. | ||||||||
2012 Today's Options Advantage Plus 550B (PPO) | $0.00 | $4,400 | $0 | No additional gap coverage, only the Donut Hole Discount | H2775 -088 -0 | n/a | ||||||
2013 Today's Options Advantage Plus 450B (PPO) | $26.00 | $4,400 | $0 | No additional gap coverage, only the Donut Hole Discount | $5.00 | $12.00 | $45.00 | $45.00 | 4,885 2013 Formulary | |||
2012 Today's Options Premier Plus 350B (PFFS) | $21.00 | $4,400 | $0 | No additional gap coverage, only the Donut Hole Discount | H2816 -019 -0 | n/a | ||||||
-- | ||||||||||||
2013 Today's Options Premier Plus 450B (PFFS) | $26.00 | $4,400 | $0 | No additional gap coverage, only the Donut Hole Discount | $5.00 | $12.00 | $45.00 | $45.00 | 4,885 2013 Formulary | |||
Plan Name | Monthly Premium |
Parts A&B MOOP |
Part D Deduct- ible |
Additional Gap Coverage |
Plan ID |
Cost-Sharing | Total Drugs | |||||
Cust. Serv. |
Plan Exper. |
Cost Info. |
Tier 1 |
Tier 2 |
Tier 3 |
Tier 4 |
||||||
-- This plan not offered in 2012 -- |
H9615 -007 -0 | |||||||||||
2013 GoldAnywhere Rx Option 2 (PPO) | $33.80 | $4,000 | $0 | Few Generics | $10.00 | $35.00 | $90.00 | $90.00 | 3,714 2013 Formulary | |||
2012 CDPHP Value Rx (HMO) | $25.00 | $3,300 | $0 | No additional gap coverage, only the Donut Hole Discount | H3388 -004 -0 | $0.00 | $9.00 | $45.00 | $45.00 | 3,064 2012 Formulary | ||
2013 CDPHP Value Rx (HMO) | $34.00 | $3,300 | $0 | No additional gap coverage, only the Donut Hole Discount | $0.00 | $9.00 | $45.00 | $45.00 | 3,003 2013 Formulary | |||
-- This plan not offered in 2012 -- |
H5970 -009 -0 | |||||||||||
2013 HumanaChoice H5970-009 (PPO) | $34.00 | $4,500 | $0 | Few Generics, Few Brands | $6.00 | $15.00 | $45.00 | $45.00 | 3,906 2013 Formulary | |||
Plan Name | Monthly Premium |
Parts A&B MOOP |
Part D Deduct- ible |
Additional Gap Coverage |
Plan ID |
Cost-Sharing | Total Drugs | |||||
Cust. Serv. |
Plan Exper. |
Cost Info. |
Tier 1 |
Tier 2 |
Tier 3 |
Tier 4 |
||||||
2012 Empire MediBlue Freedom I (PPO) | $0.00 | $4,500 | $60 | No additional gap coverage, only the Donut Hole Discount | H3342 -012 -0 | $9.00 | $45.00 | $85.00 | $85.00 | 4,453 2012 Formulary | ||
2013 Empire MediBlue Freedom I (PPO) | $38.00 | $4,500 | $75 | No additional gap coverage, only the Donut Hole Discount | $8.00 | $14.00 | $45.00 | $45.00 | 4,173 2013 Formulary | |||
2012 BlueShield Senior Blue HMO 601 (HMO) | $40.00 | $3,400 | No Rx Coverage | H3384 -015 -0 | This plan does NOT include Prescription Drug coverage. | |||||||
2013 BlueShield Senior Blue HMO 601 (HMO) | $40.00 | $3,400 | No Rx Coverage | This plan does NOT include Prescription Drug coverage. | ||||||||
2012 GoldValue Rx (HMO-POS) | $46.20 | $4,600 | $0 | Few Generics | H9859 -013 -0 | $8.00 | $35.00 | $90.00 | $90.00 | 3,582 2012 Formulary | ||
2013 GoldValue Rx (HMO-POS) | $41.80 | $6,000 | $0 | Few Generics | $10.00 | $35.00 | $90.00 | $90.00 | 3,714 2013 Formulary | |||
Plan Name | Monthly Premium |
Parts A&B MOOP |
Part D Deduct- ible |
Additional Gap Coverage |
Plan ID |
Cost-Sharing | Total Drugs | |||||
Cust. Serv. |
Plan Exper. |
Cost Info. |
Tier 1 |
Tier 2 |
Tier 3 |
Tier 4 |
||||||
2012 UnitedHealthcare Nursing Home Plan (HMO SNP) | $39.80 | n/a | $320 | No additional gap coverage, only the Donut Hole Discount | H3379 -022 -0 | 25% | 25% | 25% | 25% | 3,614 2012 Formulary | ||
2013 UnitedHealthcare Nursing Home Plan (HMO SNP) | $42.60 | n/a | $325 | No additional gap coverage, only the Donut Hole Discount | 25% | 25% | 25% | 25% | 3,825 2013 Formulary | |||
-- This plan not offered in 2012 -- |
H0084 -039 -0 | |||||||||||
2013 Care Improvement Plus Chrome RX (PPO SNP) | $43.20 | n/a | $325 | No additional gap coverage, only the Donut Hole Discount | 25% | 25% | 25% | 25% | 3,401 2013 Formulary | |||
2012 Care Improvement Plus Silver Rx (PPO SNP) | $39.80 | n/a | $210 | No additional gap coverage, only the Donut Hole Discount | H0084 -022 -0 | $10.00 | $45.00 | $95.00 | $95.00 | 3,159 2012 Formulary | ||
2013 Care Improvement Plus Silver Rx (PPO SNP) | $43.20 | n/a | $325 | No additional gap coverage, only the Donut Hole Discount | 25% | 25% | 25% | 25% | 3,401 2013 Formulary | |||
Plan Name | Monthly Premium |
Parts A&B MOOP |
Part D Deduct- ible |
Additional Gap Coverage |
Plan ID |
Cost-Sharing | Total Drugs | |||||
Cust. Serv. |
Plan Exper. |
Cost Info. |
Tier 1 |
Tier 2 |
Tier 3 |
Tier 4 |
||||||
2012 Fidelis Dual Advantage (HMO SNP) | $39.80 | n/a | $320 | No additional gap coverage, only the Donut Hole Discount | H3328 -002 -0 | 15% | 15% | 2,996 2012 Formulary | ||||
2013 Fidelis Dual Advantage (HMO SNP) | $43.20 | n/a | $325 | No additional gap coverage, only the Donut Hole Discount | $0.00 | $15.00 | $35.00 | $35.00 | 4,789 2013 Formulary | |||
-- This plan not offered in 2012 -- |
H3328 -017 -0 | |||||||||||
2013 Fidelis Dual Advantage Flex (HMO SNP) | $43.20 | n/a | $320 | No additional gap coverage, only the Donut Hole Discount | $0.00 | $15.00 | $35.00 | $35.00 | 4,789 2013 Formulary | |||
-- This plan not offered in 2012 -- |
H3328 -018 -0 | |||||||||||
2013 Fidelis Long Term Care Advantage (HMO SNP) | $43.20 | n/a | $325 | No additional gap coverage, only the Donut Hole Discount | 25% | 25% | 25% | 25% | 4,789 2013 Formulary | |||
Plan Name | Monthly Premium |
Parts A&B MOOP |
Part D Deduct- ible |
Additional Gap Coverage |
Plan ID |
Cost-Sharing | Total Drugs | |||||
Cust. Serv. |
Plan Exper. |
Cost Info. |
Tier 1 |
Tier 2 |
Tier 3 |
Tier 4 |
||||||
-- This plan not offered in 2012 -- |
H3328 -016 -0 | |||||||||||
2013 Fidelis Medicaid Advantage Plus (HMO SNP) | $43.20 | n/a | $325 | No additional gap coverage, only the Donut Hole Discount | $0.00 | $15.00 | $35.00 | $35.00 | 4,789 2013 Formulary | |||
2012 Fidelis Medicare Advantage Flex (HMO-POS) | $39.80 | $6,700 | $320 | No additional gap coverage, only the Donut Hole Discount | H3328 -003 -0 | $2.00 | $15.00 | $35.00 | $35.00 | 2,996 2012 Formulary | ||
2013 Fidelis Medicare Advantage Flex (HMO-POS) | $43.20 | $6,700 | $320 | No additional gap coverage, only the Donut Hole Discount | $0.00 | $15.00 | $35.00 | $35.00 | 4,789 2013 Formulary | |||
2012 Empire MediBlue Freedom II (PPO) | $47.00 | $3,400 | $0 | No additional gap coverage, only the Donut Hole Discount | H3342 -014 -0 | $8.00 | $45.00 | $85.00 | $85.00 | 4,453 2012 Formulary | ||
2013 Empire MediBlue Freedom II (PPO) | $66.00 | $3,900 | $75 | No additional gap coverage, only the Donut Hole Discount | $7.00 | $10.00 | $45.00 | $45.00 | 4,173 2013 Formulary | |||
Plan Name | Monthly Premium |
Parts A&B MOOP |
Part D Deduct- ible |
Additional Gap Coverage |
Plan ID |
Cost-Sharing | Total Drugs | |||||
Cust. Serv. |
Plan Exper. |
Cost Info. |
Tier 1 |
Tier 2 |
Tier 3 |
Tier 4 |
||||||
2012 Today's Options Advantage Plus 150A (PPO) | $63.00 | $3,400 | $0 | No additional gap coverage, only the Donut Hole Discount | H2775 -082 -0 | n/a | ||||||
2013 Today's Options Advantage Plus 150A (PPO) | $68.00 | $3,400 | $0 | No additional gap coverage, only the Donut Hole Discount | $2.00 | $7.00 | $40.00 | $40.00 | 4,885 2013 Formulary | |||
2012 BlueShield Senior Blue HMO 651 PartD (HMO) | $65.00 | $3,400 | $0 | No additional gap coverage, only the Donut Hole Discount | H3384 -053 -0 | $0.00 | $7.00 | $40.00 | $40.00 | 3,178 2012 Formulary | ||
2013 BlueShield Senior Blue HMO 651 PartD (HMO) | $69.00 | $3,400 | $0 | No additional gap coverage, only the Donut Hole Discount | $0.00 | $9.00 | $40.00 | $40.00 | 3,318 2013 Formulary | |||
2012 Today's Options Premier Plus 150A (PFFS) | $72.00 | $3,400 | $0 | No additional gap coverage, only the Donut Hole Discount | H2816 -013 -0 | n/a | ||||||
-- | ||||||||||||
2013 Today's Options Premier Plus 150A (PFFS) | $77.00 | n/a | $0 | No additional gap coverage, only the Donut Hole Discount | $2.00 | $7.00 | $40.00 | $40.00 | 4,885 2013 Formulary | |||
Plan Name | Monthly Premium |
Parts A&B MOOP |
Part D Deduct- ible |
Additional Gap Coverage |
Plan ID |
Cost-Sharing | Total Drugs | |||||
Cust. Serv. |
Plan Exper. |
Cost Info. |
Tier 1 |
Tier 2 |
Tier 3 |
Tier 4 |
||||||
2012 CDPHP Choice Rx (HMO) | $75.00 | $2,500 | $0 | Many Generics | H3388 -002 -0 | $0.00 | $8.00 | $40.00 | $40.00 | 3,064 2012 Formulary | ||
2013 CDPHP Choice Rx (HMO) | $79.00 | $2,500 | $0 | Many Generics, Few Brands | $0.00 | $8.00 | $40.00 | $40.00 | 3,003 2013 Formulary | |||
2012 Preferred Gold Rx (HMO-POS) | $72.10 | $3,800 | $0 | Few Generics | H9859 -002 -0 | $8.00 | $35.00 | $90.00 | $90.00 | 3,582 2012 Formulary | ||
2013 Preferred Gold Rx (HMO-POS) | $98.30 | $4,500 | $0 | Few Generics | $10.00 | $35.00 | $90.00 | $90.00 | 3,714 2013 Formulary | |||
2012 BlueShield Senior Blue HMO 652 PartD (HMO) | $99.00 | $3,400 | $0 | No additional gap coverage, only the Donut Hole Discount | H3384 -013 -0 | $0.00 | $7.00 | $40.00 | $40.00 | 3,178 2012 Formulary | ||
2013 BlueShield Senior Blue HMO 652 PartD (HMO) | $99.00 | $3,400 | $0 | No additional gap coverage, only the Donut Hole Discount | $0.00 | $8.00 | $40.00 | $40.00 | 3,318 2013 Formulary | |||
Plan Name | Monthly Premium |
Parts A&B MOOP |
Part D Deduct- ible |
Additional Gap Coverage |
Plan ID |
Cost-Sharing | Total Drugs | |||||
Cust. Serv. |
Plan Exper. |
Cost Info. |
Tier 1 |
Tier 2 |
Tier 3 |
Tier 4 |
||||||
2012 CDPHP Classic (PPO) | $95.00 | $2,500 | No Rx Coverage | H5042 -004 -0 | This plan does NOT include Prescription Drug coverage. | |||||||
2013 CDPHP Classic (PPO) | $100.00 | $2,500 | No Rx Coverage | This plan does NOT include Prescription Drug coverage. | ||||||||
2012 Empire MediBlue Freedom III (PPO) | $106.00 | $2,800 | $0 | No additional gap coverage, only the Donut Hole Discount | H3342 -002 -0 | $3.00 | $42.00 | $80.00 | $80.00 | 4,453 2012 Formulary | ||
2013 Empire MediBlue Freedom III (PPO) | $103.00 | $3,000 | $0 | No additional gap coverage, only the Donut Hole Discount | $6.00 | $8.00 | $45.00 | $45.00 | 4,173 2013 Formulary | |||
2012 CDPHP Core Rx (PPO) | $99.00 | $3,300 | $0 | No additional gap coverage, only the Donut Hole Discount | H5042 -005 -0 | $0.00 | $9.00 | $45.00 | $45.00 | 3,064 2012 Formulary | ||
2013 CDPHP Core Rx (PPO) | $113.00 | $3,300 | $0 | No additional gap coverage, only the Donut Hole Discount | $0.00 | $9.00 | $45.00 | $45.00 | 3,003 2013 Formulary | |||
Plan Name | Monthly Premium |
Parts A&B MOOP |
Part D Deduct- ible |
Additional Gap Coverage |
Plan ID |
Cost-Sharing | Total Drugs | |||||
Cust. Serv. |
Plan Exper. |
Cost Info. |
Tier 1 |
Tier 2 |
Tier 3 |
Tier 4 |
||||||
-- This plan not offered in 2012 -- |
H5970 -010 -0 | |||||||||||
2013 Humana Reader's Digest Healthy Living Plan (PPO) | $130.00 | $5,000 | $0 | Few Generics, Few Brands | $6.00 | $15.00 | $45.00 | $45.00 | 3,906 2013 Formulary | |||
2012 CDPHP Classic Rx (PPO) | $145.00 | $2,500 | $0 | Many Generics | H5042 -001 -0 | $0.00 | $8.00 | $40.00 | $40.00 | 3,064 2012 Formulary | ||
2013 CDPHP Classic Rx (PPO) | $159.00 | $2,500 | $0 | Many Generics, Few Brands | $0.00 | $8.00 | $40.00 | $40.00 | 3,003 2013 Formulary | |||
2012 GoldAnywhere Rx (PPO) | $138.40 | $2,000 | $0 | Many Generics | H9615 -002 -0 | $5.00 | $35.00 | $90.00 | $90.00 | 3,582 2012 Formulary | ||
2013 GoldAnywhere Rx Option 1 (PPO) | $192.00 | $2,000 | $0 | Few Generics | $8.00 | $35.00 | $90.00 | $90.00 | 3,714 2013 Formulary | |||
Plan Name | Monthly Premium |
Parts A&B MOOP |
Part D Deduct- ible |
Additional Gap Coverage |
Plan ID |
Cost-Sharing | Total Drugs | |||||
Cust. Serv. |
Plan Exper. |
Cost Info. |
Tier 1 |
Tier 2 |
Tier 3 |
Tier 4 |
||||||
2012 CDPHP Prime Rx (PPO) | $199.00 | $2,000 | $0 | Many Generics | H5042 -007 -0 | $0.00 | $5.00 | $40.00 | $40.00 | 3,064 2012 Formulary | ||
2013 CDPHP Prime Rx (PPO) | $228.00 | $2,000 | $0 | Many Generics, Few Brands | $0.00 | $5.00 | $40.00 | $40.00 | 3,003 2013 Formulary | |||
2012 BlueShield Forever Blue Medicare PPO 751 (PPO) | $240.00 | $3,400 | $0 | No additional gap coverage, only the Donut Hole Discount | H5526 -003 -0 | $0.00 | $7.25 | $45.00 | $45.00 | 3,178 2012 Formulary | ||
2013 BlueShield Forever Blue Medicare PPO 751 (PPO) | $244.00 | $3,400 | $0 | No additional gap coverage, only the Donut Hole Discount | $0.00 | $7.25 | $45.00 | $45.00 | 3,318 2013 Formulary | |||
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