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 Elite (PPO) | $0.00 | $6,400 | $0 | No additional gap coverage, only the Donut Hole Discount | H5522 -009 -0 | $5.00 | $24.00 | $37.00 | $37.00 | 3,281 2013 Formulary | ||
2014 Advantra Elite (PPO) | $0.00 | $6,700 | $0 | No additional gap coverage, only the Donut Hole Discount | $5.00 | $19.00 | $37.00 | $37.00 | 3,225 2014 Formulary | |||
2013 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 | 3,281 2013 Formulary | ||
2014 Advantra Silver (HMO) | $0.00 | $6,700 | $0 | No additional gap coverage, only the Donut Hole Discount | $6.00 | $19.00 | $35.00 | $35.00 | 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 |
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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 Security Blue HD (HMO) | $0.00 | $5,000 | $0 | No additional gap coverage, only the Donut Hole Discount | H3957 -036 -0 | $10.00 | $45.00 | $95.00 | $95.00 | 5,246 2013 Formulary | ||
2014 Security Blue HD (HMO) | $0.00 | $6,700 | $0 | No additional gap coverage, only the Donut Hole Discount | $5.00 | $20.00 | $40.00 | $40.00 | 4,342 2014 Formulary | |||
2013 UPMC for Life (HMO) | $0.00 | $3,400 | No Rx Coverage | H3907 -002 -0 | This plan does NOT include Prescription Drug coverage. | |||||||
2014 UPMC for Life (HMO) | $0.00 | $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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2013 Security Blue ValueRx (HMO) | $47.00 | $3,400 | $0 | No additional gap coverage, only the Donut Hole Discount | H3957 -031 -0 | $10.00 | $45.00 | $95.00 | $95.00 | 5,246 2013 Formulary | ||
2014 Security Blue ValueRx (HMO) | $20.00 | $6,700 | $0 | No additional gap coverage, only the Donut Hole Discount | $10.00 | $45.00 | $95.00 | $95.00 | 5,227 2014 Formulary | |||
2013 Freedom Blue PPO HD Rx (PPO) | $16.00 | $5,000 | $0 | No additional gap coverage, only the Donut Hole Discount | H3916 -019 -0 | $10.00 | $45.00 | $95.00 | $95.00 | 5,246 2013 Formulary | ||
2014 Freedom Blue PPO HD Rx (PPO) | $21.00 | $6,700 | $0 | No additional gap coverage, only the Donut Hole Discount | $5.00 | $20.00 | $40.00 | $40.00 | 4,342 2014 Formulary | |||
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 | ||||||
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 -036 -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 |
||||||
2013 UPMC for You Advantage (HMO SNP) | $36.60 | n/a | $325 | No additional gap coverage, only the Donut Hole Discount | H4279 -001 -0 | $6.00 | $34.00 | $75.00 | $75.00 | 3,359 2013 Formulary | ||
2014 UPMC for You Advantage (HMO SNP) | $35.50 | n/a | $310 | No additional gap coverage, only the Donut Hole Discount | $6.00 | $40.00 | $80.00 | $80.00 | 3,300 2014 Formulary | |||
2013 Security Blue Value (HMO) | $37.00 | $3,400 | No Rx Coverage | H3957 -024 -0 | This plan does NOT include Prescription Drug coverage. | |||||||
2014 Security Blue Value (HMO) | $37.00 | $6,700 | No Rx Coverage | This plan does NOT include Prescription Drug coverage. | ||||||||
2013 UPMC for Life HMO Deductible with Rx (HMO) | $36.00 | $3,400 | $0 | No additional gap coverage, only the Donut Hole Discount | H3907 -037 -0 | $9.00 | $44.00 | $95.00 | $95.00 | 3,359 2013 Formulary | ||
2014 UPMC for Life HMO Deductible with Rx (HMO) | $37.50 | $4,000 | $0 | No additional gap coverage, only the Donut Hole Discount | $10.00 | $45.00 | $95.00 | $95.00 | 3,300 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 |
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-- This plan not offered in 2013 -- |
H3916 -032 -0 | |||||||||||
2014 Freedom Blue PPO ValueRx (PPO) | $40.00 | $6,700 | $0 | No additional gap coverage, only the Donut Hole Discount | $5.00 | $15.00 | $40.00 | $40.00 | 4,342 2014 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 | H5533 -003 -0 | $9.00 | $44.00 | $95.00 | $95.00 | 3,359 2013 Formulary | ||
2014 UPMC for Life PPO High Deductible with Rx (PPO) | $40.00 | $6,700 | $0 | No additional gap coverage, only the Donut Hole Discount | $10.00 | $45.00 | $95.00 | $95.00 | 3,300 2014 Formulary | |||
2013 Advantra Silver (PPO) | $38.00 | $6,700 | $0 | No additional gap coverage, only the Donut Hole Discount | H5522 -005 -0 | $4.00 | $27.00 | $37.00 | $37.00 | 3,281 2013 Formulary | ||
2014 Advantra Silver (PPO) | $48.00 | $6,700 | $0 | No additional gap coverage, only the Donut Hole Discount | $4.00 | $22.00 | $35.00 | $35.00 | 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 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 | |||
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 UPMC for Life HMO Rx (HMO) | $77.50 | $3,400 | $0 | No additional gap coverage, only the Donut Hole Discount | H3907 -029 -0 | $8.00 | $44.00 | $95.00 | $95.00 | 3,359 2013 Formulary | ||
2014 UPMC for Life HMO Rx (HMO) | $84.00 | $3,400 | $0 | No additional gap coverage, only the Donut Hole Discount | $8.00 | $45.00 | $95.00 | $95.00 | 3,300 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 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 | |||
2013 Advantra Gold (HMO) | $83.00 | $4,300 | $0 | Some Generics | H3959 -002 -0 | $5.00 | $25.00 | $35.00 | $35.00 | 3,281 2013 Formulary | ||
2014 Advantra Gold (HMO) | $96.00 | $5,900 | $0 | Some Generics | $5.00 | $20.00 | $35.00 | $35.00 | 3,225 2014 Formulary | |||
2013 Freedom Blue PPO Select (PPO) | $98.00 | $3,400 | $0 | No additional gap coverage, only the Donut Hole Discount | H3916 -022 -0 | $9.00 | $45.00 | $90.00 | $90.00 | 5,246 2013 Formulary | ||
2014 Freedom Blue PPO Select (PPO) | $109.00 | $6,700 | $0 | No additional gap coverage, only the Donut Hole Discount | $9.00 | $45.00 | $90.00 | $90.00 | 5,227 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 -- |
H5533 -005 -0 | |||||||||||
2014 UPMC for Life PPO Rx Enhanced (PPO) | $118.50 | $6,700 | $0 | No additional gap coverage, only the Donut Hole Discount | $10.00 | $45.00 | $95.00 | $95.00 | 3,300 2014 Formulary | |||
2013 Security Blue Standard (HMO) | $178.00 | $3,400 | $0 | No additional gap coverage, only the Donut Hole Discount | H3957 -003 -0 | $9.00 | $45.00 | $90.00 | $90.00 | 5,246 2013 Formulary | ||
2014 Security Blue Standard (HMO) | $179.00 | $6,700 | $0 | No additional gap coverage, only the Donut Hole Discount | $9.00 | $45.00 | $90.00 | $90.00 | 5,227 2014 Formulary | |||
2013 UPMC for Life HMO Rx Enhanced (HMO) | $195.50 | $3,200 | $0 | No additional gap coverage, only the Donut Hole Discount | H3907 -006 -0 | $8.00 | $44.00 | $95.00 | $95.00 | 3,359 2013 Formulary | ||
2014 UPMC for Life HMO Rx Enhanced (HMO) | $224.00 | $3,400 | $0 | No additional gap coverage, only the Donut Hole Discount | $8.00 | $45.00 | $95.00 | $95.00 | 3,300 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 Freedom Blue PPO Classic (PPO) | $236.00 | $3,400 | $0 | Many Generics | H3916 -001 -0 | $8.00 | $42.00 | $90.00 | $90.00 | 5,246 2013 Formulary | ||
2014 Freedom Blue PPO Classic (PPO) | $232.00 | $6,700 | $0 | Many Generics | $8.00 | $42.00 | $90.00 | $90.00 | 5,227 2014 Formulary | |||
2013 Security Blue Deluxe (HMO) | $251.00 | $3,400 | $0 | Many Generics | H3957 -020 -0 | $8.00 | $42.00 | $90.00 | $90.00 | 5,246 2013 Formulary | ||
2014 Security Blue Deluxe (HMO) | $253.00 | $6,700 | $0 | Many Generics | $8.00 | $42.00 | $90.00 | $90.00 | 5,227 2014 Formulary | |||
2013 UPMC for Life PPO Rx (PPO) | $88.50 | $3,400 | $0 | No additional gap coverage, only the Donut Hole Discount | H5533 -004 -0 | $8.00 | $44.00 | $95.00 | $95.00 | 3,359 2013 Formulary | ||
-- Members will be assigned to UPMC for Life PPO High Deductible with Rx (PPO) H5533-003 -- | ||||||||||||
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 Security Blue Care (HMO SNP) | $34.00 | n/a | $325 | No additional gap coverage, only the Donut Hole Discount | H3957 -030 -0 | 25% | 25% | 3,389 2013 Formulary | ||||
-- This plan not offered in 2014 -- |
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2013 UnitedHealthcare Dual Complete (HMO SNP) | $30.40 | n/a | $325 | No additional gap coverage, only the Donut Hole Discount | H3920 -009 -0 | 25% | 25% | 25% | 25% | 3,825 2013 Formulary | ||
-- This plan not offered in 2014 -- |
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