2013 / 2014 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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2013 Geisinger Gold Reserve (MSA) | $0.00 | n/a | No Rx Coverage | H8468 -001 -0 | This plan does NOT include Prescription Drug coverage. | |||||||
2014 Geisinger Gold Reserve (MSA) | $0.00 | n/a | No Rx Coverage | This plan does NOT include Prescription Drug coverage. | ||||||||
2013 Advantra Silver (HMO) | $0.00 | $6,700 | $0 | No additional gap coverage, only the Donut Hole Discount | H3959 -031 -0 | $4.00 | $25.00 | $35.00 | $35.00 | 3,281 2013 Formulary | ||
2014 Advantra Silver (HMO) | $0.00 | $6,700 | $0 | No additional gap coverage, only the Donut Hole Discount | $4.00 | $20.00 | $35.00 | $35.00 | 3,225 2014 Formulary | |||
2013 Aetna Medicare Basic Plan (HMO) | $0.00 | $6,700 | No Rx Coverage | H3931 -054 -0 | This plan does NOT include Prescription Drug coverage. | |||||||
2014 Aetna Medicare Basic Plan (HMO) | $0.00 | $6,700 | 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 2013 -- |
H3949 -026 -0 | |||||||||||
2014 Cigna-HealthSpring Advantage (HMO) | $0.00 | $6,700 | No Rx Coverage | This plan does NOT include Prescription Drug coverage. | ||||||||
-- This plan not offered in 2013 -- |
H9207 -001 -0 | |||||||||||
new | new | new | ||||||||||
2014 Health Partners Medicare Basic (HMO) | $0.00 | $6,700 | No Rx Coverage | This plan does NOT include Prescription Drug coverage. | ||||||||
-- This plan not offered in 2013 -- |
H9207 -002 -0 | |||||||||||
new | new | new | ||||||||||
2014 Health Partners Medicare Prime (HMO) | $0.00 | $6,700 | $0 | No additional gap coverage, only the Donut Hole Discount | $0.00 | $45.00 | 33% | 2,963 2014 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 2013 -- |
H6859 -006 -0 | |||||||||||
new | new | new | ||||||||||
2014 Humana Gold Plus H6859-006 (HMO) | $0.00 | $6,700 | No Rx Coverage | This plan does NOT include Prescription Drug coverage. | ||||||||
2013 HumanaChoice R5826-062 (Regional PPO) | $0.00 | $3,400 | No Rx Coverage | R5826 -062 -0 | This plan does NOT include Prescription Drug coverage. | |||||||
2014 HumanaChoice R5826-062 (Regional PPO) | $0.00 | $3,400 | No Rx Coverage | This plan does NOT include Prescription Drug coverage. | ||||||||
2013 Keystone 65 Select Medical Only (HMO) | $0.00 | $6,700 | No Rx Coverage | H3952 -048 -0 | This plan does NOT include Prescription Drug coverage. | |||||||
2014 Keystone 65 Select Medical Only (HMO) | $0.00 | $6,700 | 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 |
||||||
2013 Keystone 65 Select Rx (HMO) | $31.50 | $6,700 | $280 | No additional gap coverage, only the Donut Hole Discount | H3952 -049 -0 | $4.00 | $40.00 | $80.00 | $80.00 | 3,921 2013 Formulary | ||
2014 Keystone 65 Select Rx (HMO) | $0.00 | $6,700 | $280 | No additional gap coverage, only the Donut Hole Discount | $3.00 | $8.00 | $45.00 | $45.00 | 3,833 2014 Formulary | |||
2013 Bravo-HealthSpring Achieve (HMO SNP) | $0.00 | n/a | $0 | No additional gap coverage, only the Donut Hole Discount | H3949 -024 -0 | $4.00 | $10.00 | $40.00 | $40.00 | 3,057 2013 Formulary | ||
2014 Cigna-HealthSpring Achieve (HMO SNP) | $20.00 | n/a | $0 | No additional gap coverage, only the Donut Hole Discount | $4.00 | $10.00 | $40.00 | $40.00 | 2,946 2014 Formulary | |||
2013 Bravo-HealthSpring Classic (HMO) | $0.00 | $6,700 | $0 | No additional gap coverage, only the Donut Hole Discount | H3949 -002 -0 | $4.00 | $10.00 | $40.00 | $40.00 | 3,056 2013 Formulary | ||
2014 Cigna-HealthSpring Preferred (HMO) | $20.00 | $6,700 | $0 | No additional gap coverage, only the Donut Hole Discount | $4.00 | $10.00 | $40.00 | $40.00 | 2,946 2014 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 2013 -- |
H6859 -004 -0 | |||||||||||
new | new | new | ||||||||||
2014 Humana Gold Plus H6859-004 (HMO) | $22.00 | $6,700 | $175 | Few Generics, Few Brands | $6.00 | $18.00 | $45.00 | $45.00 | 3,711 2014 Formulary | |||
2013 UnitedHealthcare Nursing Home Plan (PPO SNP) | $33.70 | n/a | $325 | No additional gap coverage, only the Donut Hole Discount | H3912 -001 -0 | 25% | 25% | 25% | 25% | 3,825 2013 Formulary | ||
-- | ||||||||||||
2014 UnitedHealthcare Nursing Home Plan (PPO SNP) | $29.50 | n/a | $310 | No additional gap coverage, only the Donut Hole Discount | 25% | 25% | 25% | 25% | 3,604 2014 Formulary | |||
2013 Bravo-HealthSpring Select (HMO SNP) | $36.60 | n/a | $325 | No additional gap coverage, only the Donut Hole Discount | H3949 -009 -0 | 25% | 3,025 2013 Formulary | |||||
2014 Cigna-HealthSpring TotalCare (HMO SNP) | $30.40 | n/a | $310 | No additional gap coverage, only the Donut Hole Discount | 15% | 2,946 2014 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 |
||||||
2013 Gateway Health Plan Medicare Assured 3 (HMO SNP) | $36.50 | n/a | $325 | No additional gap coverage, only the Donut Hole Discount | H5932 -009 -0 | 25% | 2,470 2013 Formulary | |||||
2014 Gateway Health Medicare Assured Ruby (HMO SNP) | $32.70 | n/a | $310 | No additional gap coverage, only the Donut Hole Discount | 15% | 2,610 2014 Formulary | ||||||
2013 Bravo-HealthSpring Traditions (HMO SNP) | $36.60 | n/a | $325 | No additional gap coverage, only the Donut Hole Discount | H3949 -016 -0 | 25% | 3,025 2013 Formulary | |||||
2014 Cigna-HealthSpring Traditions (HMO SNP) | $33.60 | n/a | $310 | No additional gap coverage, only the Donut Hole Discount | 25% | 2,946 2014 Formulary | ||||||
-- This plan not offered in 2013 -- |
H3949 -027 -0 | |||||||||||
2014 Cigna-HealthSpring Premier (HMO-POS) | $34.00 | $6,700 | $180 | No additional gap coverage, only the Donut Hole Discount | $7.00 | $10.00 | $40.00 | $40.00 | 2,946 2014 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 |
||||||
2013 Gateway Health Plan Medicare Assured Select (HMO SNP) | $0.00 | n/a | $0 | No additional gap coverage, only the Donut Hole Discount | H5932 -007 -0 | $4.00 | $10.00 | $45.00 | $45.00 | 2,470 2013 Formulary | ||
2014 Gateway Health Medicare Assured Gold (HMO SNP) | $34.20 | n/a | $0 | No additional gap coverage, only the Donut Hole Discount | $4.00 | $10.00 | $45.00 | $45.00 | 2,610 2014 Formulary | |||
2013 Advantra Cares (HMO SNP) | $38.80 | n/a | $325 | No additional gap coverage, only the Donut Hole Discount | H3959 -035 -0 | 25% | 25% | 25% | 3,113 2013 Formulary | |||
2014 Advantra Cares (HMO SNP) | $35.50 | n/a | $310 | No additional gap coverage, only the Donut Hole Discount | 15% | 15% | 15% | 15% | 3,177 2014 Formulary | |||
2013 Gateway Health Plan Medicare Assured (HMO SNP) | $36.50 | n/a | $325 | No additional gap coverage, only the Donut Hole Discount | H5932 -001 -0 | 25% | 2,470 2013 Formulary | |||||
2014 Gateway Health Medicare Assured Diamond (HMO SNP) | $35.50 | n/a | $310 | No additional gap coverage, only the Donut Hole Discount | 0% | 2,610 2014 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 2013 -- |
H9207 -004 -0 | |||||||||||
new | new | new | ||||||||||
2014 Health Partners Medicare Special (HMO SNP) | $35.50 | n/a | $310 | No additional gap coverage, only the Donut Hole Discount | 15% | 15% | 15% | 2,963 2014 Formulary | ||||
2013 Keystone VIP Choice (HMO SNP) | $36.50 | n/a | $325 | No additional gap coverage, only the Donut Hole Discount | H4227 -001 -0 | 25% | 25% | 25% | 25% | 3,884 2013 Formulary | ||
-- | -- | -- | ||||||||||
2014 Keystone VIP Choice (HMO SNP) | $35.50 | n/a | $310 | No additional gap coverage, only the Donut Hole Discount | tbd | |||||||
-- This plan not offered in 2013 -- |
H9207 -003 -0 | |||||||||||
new | new | new | ||||||||||
2014 Health Partners Medicare PrimePlus (HMO) | $52.00 | $6,700 | $0 | No additional gap coverage, only the Donut Hole Discount | $0.00 | $45.00 | 33% | 2,963 2014 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 |
||||||
2013 Gateway Health Plan Medicare Assured Select Plus (HMO SNP) | $44.50 | n/a | $0 | No additional gap coverage, only the Donut Hole Discount | H5932 -008 -0 | $0.00 | $10.00 | $45.00 | $45.00 | 2,470 2013 Formulary | ||
2014 Gateway Health Medicare Assured Platinum (HMO SNP) | $56.40 | n/a | $0 | No additional gap coverage, only the Donut Hole Discount | $0.00 | $10.00 | $45.00 | $45.00 | 2,610 2014 Formulary | |||
-- This plan not offered in 2013 -- |
H5525 -005 -0 | |||||||||||
2014 HumanaChoice H5525-005 (PPO) | $67.00 | $6,700 | $0 | Few Generics, Few Brands | $7.00 | $18.00 | $45.00 | $45.00 | 3,711 2014 Formulary | |||
2013 Advantra Gold (PPO) | $48.00 | $5,300 | $0 | No additional gap coverage, only the Donut Hole Discount | H5522 -014 -0 | $6.00 | $25.00 | $38.00 | $38.00 | 3,281 2013 Formulary | ||
2014 Advantra Gold (PPO) | $72.00 | $6,700 | $0 | No additional gap coverage, only the Donut Hole Discount | $6.00 | $20.00 | $38.00 | $38.00 | 3,225 2014 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 |
||||||
2013 Aetna Medicare Standard Plan (HMO) | $39.00 | $6,700 | $325 | No additional gap coverage, only the Donut Hole Discount | H3931 -065 -0 | $5.00 | $30.00 | $37.00 | $37.00 | 3,323 2013 Formulary | ||
2014 Aetna Medicare Standard Plan (HMO) | $75.50 | $6,700 | $260 | No additional gap coverage, only the Donut Hole Discount | $7.00 | $41.00 | $95.00 | $95.00 | 3,134 2014 Formulary | |||
2013 HumanaChoice R5826-081 (Regional PPO) | $75.00 | $6,700 | $325 | No additional gap coverage, only the Donut Hole Discount | R5826 -081 -0 | 25% | 25% | 25% | 25% | 3,906 2013 Formulary | ||
2014 HumanaChoice R5826-081 (Regional PPO) | $78.00 | $6,700 | $310 | No additional gap coverage, only the Donut Hole Discount | 25% | 25% | 25% | 25% | 3,711 2014 Formulary | |||
2013 HumanaChoice R5826-002 (Regional PPO) | $85.00 | $5,300 | $0 | Few Generics, Few Brands |
R5826 -002 -0 | $6.00 | $15.00 | $45.00 | $45.00 | 3,906 2013 Formulary | ||
2014 HumanaChoice R5826-002 (Regional PPO) | $88.00 | $5,900 | $0 | Few Generics, Few Brands | $7.00 | $18.00 | $45.00 | $45.00 | 3,711 2014 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 |
||||||
2013 Bravo-HealthSpring Premier (HMO) | $104.00 | $6,700 | $0 | No additional gap coverage, only the Donut Hole Discount | H3949 -013 -0 | $0.00 | $0.00 | $35.00 | $35.00 | 3,056 2013 Formulary | ||
2014 Cigna-HealthSpring Preferred Plus (HMO) | $106.00 | $6,700 | $0 | No additional gap coverage, only the Donut Hole Discount | $4.00 | $8.00 | $35.00 | $35.00 | 2,946 2014 Formulary | |||
2013 Keystone 65 Preferred Medical Only (HMO) | $125.40 | $6,700 | No Rx Coverage | H3952 -008 -0 | This plan does NOT include Prescription Drug coverage. | |||||||
2014 Keystone 65 Preferred Medical Only (HMO) | $125.40 | $6,700 | No Rx Coverage | This plan does NOT include Prescription Drug coverage. | ||||||||
2013 Personal Choice 65 Medical Only (PPO) | $245.00 | $6,700 | No Rx Coverage | H3909 -007 -0 | This plan does NOT include Prescription Drug coverage. | |||||||
2014 Personal Choice 65 Medical Only (PPO) | $145.00 | $6,700 | 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 |
||||||
2013 Aetna Medicare Premier Plan (HMO) | $140.00 | $5,900 | $0 | Some Generics | H3931 -058 -0 | $6.00 | $33.00 | $45.00 | $45.00 | 3,323 2013 Formulary | ||
2014 Aetna Medicare Premier Plan (HMO) | $172.00 | $6,700 | $0 | Few Generics | $7.00 | $45.00 | $95.00 | $95.00 | 3,134 2014 Formulary | |||
2013 Keystone 65 Preferred Rx (HMO) | $171.80 | $6,700 | $100 | Many Generics | H3952 -020 -0 | $5.00 | $40.00 | $80.00 | $80.00 | 5,233 2013 Formulary | ||
2014 Keystone 65 Preferred Rx (HMO) | $182.60 | $6,700 | $100 | Many Generics | $4.00 | $40.00 | $80.00 | $80.00 | 5,236 2014 Formulary | |||
2013 Humana Gold Choice H8145-053 (PFFS) | $194.00 | n/a | $0 | Few Generics, Few Brands |
H8145 -053 -0 | $6.00 | $15.00 | $45.00 | $45.00 | 3,906 2013 Formulary | ||
2014 Humana Gold Choice H8145-053 (PFFS) | $197.00 | n/a | $0 | Few Generics, Few Brands | $6.00 | $18.00 | $45.00 | $45.00 | 3,711 2014 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 |
||||||
2013 Personal Choice 65 Rx (PPO) | $288.80 | $6,700 | $285 | No additional gap coverage, only the Donut Hole Discount | H3909 -001 -0 | $5.00 | $40.00 | $80.00 | $80.00 | 5,233 2013 Formulary | ||
2014 Personal Choice 65 Rx (PPO) | $222.50 | $6,700 | $285 | No additional gap coverage, only the Donut Hole Discount | $5.00 | $40.00 | $80.00 | $80.00 | 5,236 2014 Formulary | |||
2013 Bravo-HealthSpring Silver (HMO SNP) | $36.60 | n/a | $325 | No additional gap coverage, only the Donut Hole Discount | H3964 -002 -0 | 25% | 3,025 2013 Formulary | |||||
-- Members will be assigned to Cigna-HealthSpring TotalCare (HMO SNP) H3949-009 -- | ||||||||||||
2013 Bravo-HealthSpring Gold (HMO) | $0.00 | $6,700 | No Rx Coverage | H3964 -001 -0 | This plan does NOT include Prescription Drug coverage. | |||||||
-- This plan not offered in 2014 -- |
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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 |
||||||
2013 Bravo-HealthSpring Gold Rx (HMO-POS) | $32.00 | $6,700 | $180 | No additional gap coverage, only the Donut Hole Discount | H3964 -003 -0 | $7.00 | $10.00 | $40.00 | $40.00 | 3,056 2013 Formulary | ||
-- This plan not offered in 2014 -- |
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