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 PacificSource Medicare Essentials 2 (HMO) | $19.00 | $3,400 | No Rx Coverage | H3864 -002 -0 | This plan does NOT include Prescription Drug coverage. | |||||||
2013 PacificSource Medicare Essentials 2 (HMO) | $19.00 | $3,400 | No Rx Coverage | This plan does NOT include Prescription Drug coverage. | ||||||||
2012 PacificSource Medicare Essentials Rx 14 (HMO) | $59.00 | $3,400 | $0 | No additional gap coverage, only the Donut Hole Discount | H3864 -014 -0 | $8.00 | $40.00 | $85.00 | $85.00 | 4,794 2012 Formulary | ||
2013 PacificSource Medicare Essentials Rx 14 (HMO) | $55.00 | $3,400 | $0 | No additional gap coverage, only the Donut Hole Discount | $8.00 | $40.00 | $85.00 | $85.00 | 4,762 2013 Formulary | |||
2012 ODS Advantage PPO (PPO) | $40.60 | $3,400 | No Rx Coverage | H3813 -001 -0 | This plan does NOT include Prescription Drug coverage. | |||||||
2013 ODS Advantage PPO (PPO) | $57.00 | $3,400 | 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 |
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-- This plan not offered in 2012 -- |
H3813 -006 -0 | |||||||||||
2013 ODS Advantage PPORX (PPO) | $68.00 | $3,400 | $120 | No additional gap coverage, only the Donut Hole Discount | $5.00 | $33.00 | $41.00 | $41.00 | 3,458 2013 Formulary | |||
-- This plan not offered in 2012 -- |
H4754 -001 -0 | |||||||||||
-- | ||||||||||||
2013 PacificSource Medicare Explorer Rx 1 (PPO) | $79.00 | $3,400 | $0 | No additional gap coverage, only the Donut Hole Discount | $5.00 | $35.00 | $80.00 | $80.00 | 4,762 2013 Formulary | |||
2012 PacificSource Medicare Essentials Rx 6 (HMO) | $99.00 | $3,400 | $0 | No additional gap coverage, only the Donut Hole Discount | H3864 -006 -0 | $5.00 | $35.00 | $80.00 | $80.00 | 4,794 2012 Formulary | ||
2013 PacificSource Medicare Essentials Rx 6 (HMO) | $99.00 | $3,400 | $0 | No additional gap coverage, only the Donut Hole Discount | $5.00 | $35.00 | $80.00 | $80.00 | 4,762 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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2012 ODS Advantage PPORX Select (PPO) | $128.30 | $3,400 | $120 | No additional gap coverage, only the Donut Hole Discount | H3813 -003 -0 | $5.00 | $33.00 | $40.00 | $40.00 | 3,377 2012 Formulary | ||
2013 ODS Advantage PPORX Select (PPO) | $139.00 | $3,400 | $120 | No additional gap coverage, only the Donut Hole Discount | $5.00 | $33.00 | $41.00 | $41.00 | 3,458 2013 Formulary | |||
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