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 Geisinger Gold Reserve (MSA) | $0.00 | n/a | No Rx Coverage | H8468 -001 -0 | This plan does NOT include Prescription Drug coverage. | |||||||
2013 Geisinger Gold Reserve (MSA) | $0.00 | n/a | No Rx Coverage | This plan does NOT include Prescription Drug coverage. | ||||||||
2012 Advantra Elite (PPO) | $0.00 | $6,550 | $0 | No additional gap coverage, only the Donut Hole Discount | H5522 -009 -0 | $5.00 | $24.00 | $37.00 | $37.00 | 3,230 2012 Formulary | ||
2013 Advantra Elite (PPO) | $0.00 | $6,400 | $0 | No additional gap coverage, only the Donut Hole Discount | $5.00 | $24.00 | $37.00 | $37.00 | 3,281 2013 Formulary | |||
2012 Advantra Silver (HMO) | $0.00 | $6,700 | $0 | No additional gap coverage, only the Donut Hole Discount | H3959 -011 -0 | $6.00 | $24.00 | $35.00 | $35.00 | 3,230 2012 Formulary | ||
2013 Advantra Silver (HMO) | $0.00 | $6,700 | $0 | No additional gap coverage, only the Donut Hole Discount | $6.00 | $24.00 | $35.00 | $35.00 | 3,281 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 -- |
H5932 -007 -0 | |||||||||||
2013 Gateway Health Plan Medicare Assured Select (HMO SNP) | $0.00 | n/a | $0 | No additional gap coverage, only the Donut Hole Discount | $4.00 | $10.00 | $45.00 | $45.00 | 2,470 2013 Formulary | |||
2012 HumanaChoice R5826-062 (Regional PPO) | $0.00 | $3,400 | No Rx Coverage | R5826 -062 -0 | This plan does NOT include Prescription Drug coverage. | |||||||
2013 HumanaChoice R5826-062 (Regional PPO) | $0.00 | $3,400 | No Rx Coverage | This plan does NOT include Prescription Drug coverage. | ||||||||
2012 SecurityBlue HD (HMO) | $0.00 | $3,000 | $0 | No additional gap coverage, only the Donut Hole Discount | H3957 -036 -0 | $10.00 | $45.00 | $95.00 | $95.00 | 4,948 2012 Formulary | ||
2013 Security Blue HD (HMO) | $0.00 | $5,000 | $0 | No additional gap coverage, only the Donut Hole Discount | $10.00 | $45.00 | $95.00 | $95.00 | 5,246 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 UPMC for Life (HMO) | $0.00 | $3,400 | No Rx Coverage | H3907 -002 -0 | This plan does NOT include Prescription Drug coverage. | |||||||
2013 UPMC for Life (HMO) | $0.00 | $3,400 | No Rx Coverage | This plan does NOT include Prescription Drug coverage. | ||||||||
2012 UPMC for Life PPO High Deductible with Rx (PPO) | $0.00 | $3,400 | $0 | No additional gap coverage, only the Donut Hole Discount | H5533 -003 -0 | $5.00 | $42.00 | $95.00 | $95.00 | 3,270 2012 Formulary | ||
2013 UPMC for Life PPO High Deductible with Rx (PPO) | $0.00 | $3,400 | $0 | No additional gap coverage, only the Donut Hole Discount | $9.00 | $44.00 | $95.00 | $95.00 | 3,359 2013 Formulary | |||
2012 FreedomBlue PPO HD Rx (PPO) | $0.00 | $3,000 | $0 | No additional gap coverage, only the Donut Hole Discount | H3916 -019 -0 | $10.00 | $45.00 | $95.00 | $95.00 | 4,948 2012 Formulary | ||
2013 Freedom Blue PPO HD Rx (PPO) | $16.00 | $5,000 | $0 | No additional gap coverage, only the Donut Hole Discount | $10.00 | $45.00 | $95.00 | $95.00 | 5,246 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 Dual Complete (HMO SNP) | $25.90 | n/a | $320 | No additional gap coverage, only the Donut Hole Discount | H3920 -009 -0 | 0% | 0% | 3,614 2012 Formulary | ||||
2013 UnitedHealthcare Dual Complete (HMO SNP) | $30.40 | n/a | $325 | No additional gap coverage, only the Donut Hole Discount | 25% | 25% | 25% | 25% | 3,825 2013 Formulary | |||
2012 SecurityBlue Care (HMO SNP) | $31.00 | n/a | $320 | No additional gap coverage, only the Donut Hole Discount | H3957 -030 -0 | 15% | 15% | 3,173 2012 Formulary | ||||
2013 Security Blue Care (HMO SNP) | $34.00 | n/a | $325 | No additional gap coverage, only the Donut Hole Discount | 25% | 25% | 3,389 2013 Formulary | |||||
-- This plan not offered in 2012 -- |
H3907 -037 -0 | |||||||||||
2013 UPMC for Life HMO Deductible with Rx (HMO) | $36.00 | $3,400 | $0 | No additional gap coverage, only the Donut Hole Discount | $9.00 | $44.00 | $95.00 | $95.00 | 3,359 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 -- |
H5932 -009 -0 | |||||||||||
2013 Gateway Health Plan Medicare Assured 3 (HMO SNP) | $36.50 | n/a | $325 | No additional gap coverage, only the Donut Hole Discount | 25% | 2,470 2013 Formulary | ||||||
2012 Gateway Health Plan Medicare Assured (HMO SNP) | $34.00 | n/a | $320 | No additional gap coverage, only the Donut Hole Discount | H5932 -001 -0 | 0% | 0% | 2,304 2012 Formulary | ||||
2013 Gateway Health Plan Medicare Assured (HMO SNP) | $36.50 | n/a | $325 | No additional gap coverage, only the Donut Hole Discount | 25% | 2,470 2013 Formulary | ||||||
-- This plan not offered in 2012 -- |
H4279 -001 -0 | |||||||||||
-- | -- | -- | ||||||||||
2013 UPMC for You Advantage (HMO SNP) | $36.60 | n/a | $325 | No additional gap coverage, only the Donut Hole Discount | $6.00 | $34.00 | $75.00 | $75.00 | 3,359 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 SecurityBlue Value (HMO) | $30.00 | $3,400 | No Rx Coverage | H3957 -024 -0 | This plan does NOT include Prescription Drug coverage. | |||||||
2013 Security Blue Value (HMO) | $37.00 | $3,400 | No Rx Coverage | This plan does NOT include Prescription Drug coverage. | ||||||||
2012 Advantra Silver (PPO) | $23.00 | $5,900 | $0 | No additional gap coverage, only the Donut Hole Discount | H5522 -005 -0 | $4.00 | $27.00 | $37.00 | $37.00 | 3,230 2012 Formulary | ||
2013 Advantra Silver (PPO) | $38.00 | $6,700 | $0 | No additional gap coverage, only the Donut Hole Discount | $4.00 | $27.00 | $37.00 | $37.00 | 3,281 2013 Formulary | |||
-- This plan not offered in 2012 -- |
H3959 -036 -0 | |||||||||||
2013 Advantra Cares (HMO SNP) | $38.80 | n/a | $325 | No additional gap coverage, only the Donut Hole Discount | 25% | 25% | 25% | 3,113 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 -- |
H5932 -008 -0 | |||||||||||
2013 Gateway Health Plan Medicare Assured Select Plus (HMO SNP) | $44.50 | n/a | $0 | No additional gap coverage, only the Donut Hole Discount | $0.00 | $10.00 | $45.00 | $45.00 | 2,470 2013 Formulary | |||
2012 SecurityBlue ValueRx (HMO) | $38.00 | $3,400 | $0 | No additional gap coverage, only the Donut Hole Discount | H3957 -031 -0 | $10.00 | $45.00 | $95.00 | $95.00 | 4,948 2012 Formulary | ||
2013 Security Blue ValueRx (HMO) | $47.00 | $3,400 | $0 | No additional gap coverage, only the Donut Hole Discount | $10.00 | $45.00 | $95.00 | $95.00 | 5,246 2013 Formulary | |||
2012 HumanaChoice R5826-081 (Regional PPO) | $58.00 | $6,700 | $320 | No additional gap coverage, only the Donut Hole Discount | R5826 -081 -0 | 25% | 25% | 25% | 25% | 3,798 2012 Formulary | ||
2013 HumanaChoice R5826-081 (Regional PPO) | $75.00 | $6,700 | $325 | No additional gap coverage, only the Donut Hole Discount | 25% | 25% | 25% | 25% | 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 UPMC for Life HMO Rx (HMO) | $69.50 | $3,400 | $0 | No additional gap coverage, only the Donut Hole Discount | H3907 -029 -0 | $5.00 | $42.00 | $95.00 | $95.00 | 3,270 2012 Formulary | ||
2013 UPMC for Life HMO Rx (HMO) | $77.50 | $3,400 | $0 | No additional gap coverage, only the Donut Hole Discount | $8.00 | $44.00 | $95.00 | $95.00 | 3,359 2013 Formulary | |||
2012 Advantra Gold (HMO) | $72.00 | $4,300 | $0 | Some Generics | H3959 -002 -0 | $5.00 | $25.00 | $35.00 | $35.00 | 3,230 2012 Formulary | ||
2013 Advantra Gold (HMO) | $83.00 | $4,300 | $0 | Some Generics | $5.00 | $25.00 | $35.00 | $35.00 | 3,281 2013 Formulary | |||
2012 HumanaChoice R5826-002 (Regional PPO) | $79.00 | $5,000 | $0 | Few Generics, Few Brands |
R5826 -002 -0 | $8.00 | $44.00 | $85.00 | $85.00 | 3,798 2012 Formulary | ||
2013 HumanaChoice R5826-002 (Regional PPO) | $85.00 | $5,300 | $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 UPMC for Life PPO Rx (PPO) | $81.50 | $3,400 | $0 | No additional gap coverage, only the Donut Hole Discount | H5533 -004 -0 | $5.00 | $42.00 | $95.00 | $95.00 | 3,270 2012 Formulary | ||
2013 UPMC for Life PPO Rx (PPO) | $88.50 | $3,400 | $0 | No additional gap coverage, only the Donut Hole Discount | $8.00 | $44.00 | $95.00 | $95.00 | 3,359 2013 Formulary | |||
2012 FreedomBlue PPO Select (PPO) | $76.00 | $3,400 | $0 | No additional gap coverage, only the Donut Hole Discount | H3916 -022 -0 | $9.00 | $45.00 | $90.00 | $90.00 | 4,948 2012 Formulary | ||
2013 Freedom Blue PPO Select (PPO) | $98.00 | $3,400 | $0 | No additional gap coverage, only the Donut Hole Discount | $9.00 | $45.00 | $90.00 | $90.00 | 5,246 2013 Formulary | |||
2012 SecurityBlue Standard (HMO) | $156.00 | $3,400 | $0 | No additional gap coverage, only the Donut Hole Discount | H3957 -003 -0 | $9.00 | $45.00 | $90.00 | $90.00 | 4,948 2012 Formulary | ||
2013 Security Blue Standard (HMO) | $178.00 | $3,400 | $0 | No additional gap coverage, only the Donut Hole Discount | $9.00 | $45.00 | $90.00 | $90.00 | 5,246 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 UPMC for Life HMO Rx Enhanced (HMO) | $196.50 | $3,200 | $0 | No additional gap coverage, only the Donut Hole Discount | H3907 -006 -0 | $5.00 | $42.00 | $95.00 | $95.00 | 3,270 2012 Formulary | ||
2013 UPMC for Life HMO Rx Enhanced (HMO) | $195.50 | $3,200 | $0 | No additional gap coverage, only the Donut Hole Discount | $8.00 | $44.00 | $95.00 | $95.00 | 3,359 2013 Formulary | |||
2012 FreedomBlue PPO Classic (PPO) | $205.00 | $3,400 | $0 | Many Generics | H3916 -001 -0 | $8.00 | $42.00 | $90.00 | $90.00 | 4,948 2012 Formulary | ||
2013 Freedom Blue PPO Classic (PPO) | $236.00 | $3,400 | $0 | Many Generics | $8.00 | $42.00 | $90.00 | $90.00 | 5,246 2013 Formulary | |||
2012 SecurityBlue Deluxe (HMO) | $228.00 | $3,400 | $0 | Many Generics | H3957 -020 -0 | $8.00 | $42.00 | $90.00 | $90.00 | 4,948 2012 Formulary | ||
2013 Security Blue Deluxe (HMO) | $251.00 | $3,400 | $0 | Many Generics | $8.00 | $42.00 | $90.00 | $90.00 | 5,246 2013 Formulary | |||
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