There are 80 Medicare Advantage plans meeting your criteria.
2021 / 2022 Medicare Advantage Plan Information
Click here to jump to the Chart Legend |
Plan Name |
Monthly Premium |
Part A&B Maximum Out-Of Pocket |
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 |
2021 Lasso Healthcare Growth (MSA)
| $0.00 |
n/a |
No Rx Coverage |
H1924 -001 -0 | This plan does NOT include Prescription Drug coverage. | |
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|
|
|
2022 Lasso Healthcare Growth (MSA)
| $0.00 |
n/a |
No Rx Coverage | This plan does NOT include Prescription Drug coverage. | |
|
2021 Lasso Healthcare Growth Plus (MSA)
| $0.00 |
n/a |
No Rx Coverage |
H1924 -004 -0 | This plan does NOT include Prescription Drug coverage. | |
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|
|
|
2022 Lasso Healthcare Growth Plus (MSA)
| $0.00 |
n/a |
No Rx Coverage | This plan does NOT include Prescription Drug coverage. | |
|
2021 Aetna Medicare Advantra Credit Value (PPO)
| $0.00 |
$7,550 |
$250 | Yes, some additional gap coverage. |
H5522 -017 -0 | $3.00 | $7.00 | $47.00 | $47.00 | 3,659
2021 Formulary |
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|
|
|
2022 Aetna Medicare Advantra Credit Value (PPO)
| $0.00 |
$7,550 |
$250 | Yes, some additional gap coverage. | $3.00 | $7.00 | $47.00 | $47.00 | 3,672 2022 Formulary |
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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 |
-- This plan not offered in 2021 --
|
H3959 -057 -0 | | | | | |
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|
|
2022 Aetna Medicare Advantra Eagle (HMO)
| $0.00 |
$4,000 |
No Rx Coverage | This plan does NOT include Prescription Drug coverage. | |
|
2021 Aetna Medicare Advantra Value (HMO)
| $0.00 |
$7,550 |
$0 | Yes, some additional gap coverage. |
H3959 -052 -0 | $0.00 | $5.00 | $47.00 | $47.00 | 3,659
2021 Formulary |
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|
|
|
2022 Aetna Medicare Advantra Value (HMO)
| $0.00 |
$7,550 |
$0 | Yes, some additional gap coverage. | $0.00 | $0.00 | $47.00 | $47.00 | 3,672 2022 Formulary |
|
2021 Aetna Medicare Elite (HMO)
| $0.00 |
$7,550 |
$150 | Yes, some additional gap coverage. |
H3931 -112 -0 | $0.00 | $5.00 | $47.00 | $47.00 | 3,659
2021 Formulary |
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|
|
2022 Aetna Medicare Elite (HMO)
| $0.00 |
$7,550 |
$150 | Yes, some additional gap coverage. | $0.00 | $5.00 | $47.00 | $47.00 | 3,672 2022 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 |
2021 Aetna Medicare Main Line Health Prime (HMO)
| $0.00 |
$7,550 |
$150 | Yes, some additional gap coverage. |
H3931 -105 -0 | $0.00 | $5.00 | $47.00 | $47.00 | 3,659
2021 Formulary |
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|
|
|
2022 Aetna Medicare Philly Suburban Value (HMO)
| $0.00 |
$7,550 |
$150 | Yes, some additional gap coverage. | $0.00 | $5.00 | $47.00 | $47.00 | 3,672 2022 Formulary |
|
2021 Aetna Medicare Value (PPO)
| $0.00 |
$7,550 |
$0 | Yes, some additional gap coverage. |
H5521 -263 -0 | $2.00 | $5.00 | $47.00 | $47.00 | 3,659
2021 Formulary |
|
|
|
|
2022 Aetna Medicare Value (PPO)
| $0.00 |
$7,550 |
$0 | Yes, some additional gap coverage. | $2.00 | $5.00 | $47.00 | $47.00 | 3,672 2022 Formulary |
|
2021 Cigna Achieve Medicare (HMO C-SNP)
| $0.00 |
n/a |
$0 | No additional gap coverage, only the Donut Hole Discount |
H3949 -024 -0 | $0.00 | $5.00 | $42.00 | $42.00 | 3,446
2021 Formulary |
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|
|
|
2022 Cigna Achieve Medicare (HMO C-SNP)
| $0.00 |
n/a |
$0 | No additional gap coverage, only the Donut Hole Discount | $0.00 | $5.00 | $42.00 | $42.00 | 3,459 2022 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 |
2021 Cigna Alliance Medicare (HMO)
| $0.00 |
$6,900 |
$0 | Yes, some additional gap coverage. |
H3949 -031 -0 | $0.00 | $5.00 | $42.00 | $42.00 | 3,446
2021 Formulary |
|
|
|
|
2022 Cigna Alliance Medicare (HMO)
| $0.00 |
$6,900 |
$0 | Yes, some additional gap coverage. | $0.00 | $5.00 | $42.00 | $42.00 | 3,459 2022 Formulary |
|
2021 Cigna Fundamental Medicare (HMO)
| $0.00 |
$6,900 |
No Rx Coverage |
H3949 -026 -0 | This plan does NOT include Prescription Drug coverage. | |
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|
|
2022 Cigna Fundamental Medicare (HMO)
| $0.00 |
$5,900 |
No Rx Coverage | This plan does NOT include Prescription Drug coverage. | |
|
2021 Cigna True Choice Medicare (PPO)
| $0.00 |
$7,200 |
$0 | Yes, some additional gap coverage. |
H7849 -006 -0 | $0.00 | $5.00 | $42.00 | $42.00 | 3,446
2021 Formulary |
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|
|
|
2022 Cigna True Choice Medicare (PPO)
| $0.00 |
$7,200 |
$0 | Yes, some additional gap coverage. | $0.00 | $5.00 | $42.00 | $42.00 | 3,459 2022 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 |
2021 Clover Health Choice (PPO)
| $0.00 |
$7,550 |
$0 | No additional gap coverage, only the Donut Hole Discount |
H5141 -038 -0 | $0.00 | $10.00 | $40.00 | $40.00 | 3,358
2021 Formulary |
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2022 Clover Health Choice (PPO)
| $0.00 |
$7,550 |
$0 | No additional gap coverage, only the Donut Hole Discount | $0.00 | $10.00 | $37.00 | $37.00 | 3,358 2022 Formulary |
|
2021 Erickson Advantage Liberty with Drugs (HMO-POS)
| $0.00 |
$6,700 |
$400 | No additional gap coverage, only the Donut Hole Discount |
H5652 -008 -0 | $5.00 | $20.00 | $45.00 | $45.00 | 3,604
2021 Formulary |
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2022 Erickson Advantage Liberty with Drugs (HMO-POS)
| $0.00 |
$6,700 |
$400 | Yes, some additional gap coverage. | $5.00 | $20.00 | $45.00 | $45.00 | 3,654 2022 Formulary |
|
2021 Erickson Advantage Liberty without Drugs (HMO-POS)
| $0.00 |
$6,700 |
No Rx Coverage |
H5652 -002 -0 | This plan does NOT include Prescription Drug coverage. | |
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2022 Erickson Advantage Liberty without Drugs (HMO-POS)
| $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 |
2021 Health Partners Medicare Complete (HMO-POS)
| $0.00 |
$7,550 |
$0 | No additional gap coverage, only the Donut Hole Discount |
H9207 -012 -0 | $0.00 | $10.00 | $47.00 | $47.00 | 3,791
2021 Formulary |
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-- |
|
|
2022 Health Partners Medicare Complete (HMO-POS)
| $0.00 |
$7,550 |
$0 | No additional gap coverage, only the Donut Hole Discount | $0.00 | $10.00 | $47.00 | $47.00 | 3,668 2022 Formulary |
|
2021 Humana Gold Plus H6622-037 (HMO)
| $0.00 |
$6,200 |
$0 | No additional gap coverage, only the Donut Hole Discount |
H6622 -037 -0 | $2.00 | $8.00 | $47.00 | $47.00 | 3,382
2021 Formulary |
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2022 Humana Gold Plus H6622-037 (HMO)
| $0.00 |
$6,900 |
$0 | No additional gap coverage, only the Donut Hole Discount | $0.00 | $5.00 | $47.00 | $47.00 | 3,408 2022 Formulary |
|
2021 Humana Honor (PPO)
| $0.00 |
$6,700 |
No Rx Coverage |
H5216 -221 -0 | This plan does NOT include Prescription Drug coverage. | |
|
|
|
|
2022 Humana Honor (PPO)
| $0.00 |
$6,700 |
No Rx Coverage | This plan does NOT include Prescription Drug coverage. | |
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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 |
2021 HumanaChoice H5216-116 (PPO)
| $0.00 |
$3,900 |
No Rx Coverage |
H5216 -116 -0 | This plan does NOT include Prescription Drug coverage. | |
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|
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2022 HumanaChoice H5216-116 (PPO)
| $0.00 |
$3,900 |
No Rx Coverage | This plan does NOT include Prescription Drug coverage. | |
|
-- This plan not offered in 2021 --
|
H5525 -051 -2 | | | | | |
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|
|
2022 HumanaChoice H5525-051 (PPO)
| $0.00 |
$7,200 |
$0 | No additional gap coverage, only the Donut Hole Discount | $3.00 | $15.00 | $47.00 | $47.00 | 3,408 2022 Formulary |
|
2021 HumanaChoice R0923-001 (Regional PPO)
| $0.00 |
$4,900 |
No Rx Coverage |
R0923 -001 -0 | This plan does NOT include Prescription Drug coverage. | |
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|
|
2022 HumanaChoice R0923-001 (Regional PPO)
| $0.00 |
$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 |
2021 Keystone 65 Basic Rx (HMO)
| $0.00 |
$7,550 |
$0 | No additional gap coverage, only the Donut Hole Discount |
H3952 -056 -0 | $1.00 | $10.00 | $47.00 | $47.00 | 4,216
2021 Formulary |
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|
|
|
2022 Keystone 65 Basic Rx (HMO)
| $0.00 |
$7,550 |
$0 | No additional gap coverage, only the Donut Hole Discount | $0.00 | $10.00 | $47.00 | $47.00 | 4,333 2022 Formulary |
|
2021 Personal Choice 65 Prime Rx (PPO)
| $0.00 |
$7,550 |
$0 | No additional gap coverage, only the Donut Hole Discount |
H3909 -015 -0 | $1.00 | $10.00 | $47.00 | $47.00 | 4,216
2021 Formulary |
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|
|
|
2022 Personal Choice 65 Prime Rx (PPO)
| $0.00 |
$7,550 |
$0 | No additional gap coverage, only the Donut Hole Discount | $0.00 | $10.00 | $47.00 | $47.00 | 4,333 2022 Formulary |
|
-- This plan not offered in 2021 --
|
H3909 -016 -0 | | | | | |
|
|
|
|
2022 Personal Choice 65 Saver Rx (PPO)
| $0.00 |
$7,550 |
$0 | No additional gap coverage, only the Donut Hole Discount | $0.00 | $10.00 | $47.00 | $47.00 | 4,333 2022 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 2021 --
|
H2915 -012 -0 | | | | | |
|
|
|
|
2022 Wellcare Giveback (HMO)
| $0.00 |
$7,550 |
$0 | No additional gap coverage, only the Donut Hole Discount | $0.00 | $5.00 | $37.00 | $37.00 | 3,375 2022 Formulary |
|
-- This plan not offered in 2021 --
|
H2128 -004 -0 | | | | | |
new |
new |
new |
|
2022 Wellcare Giveback Open (PPO)
| $0.00 |
$7,550 |
$350 | Yes, some additional gap coverage. | $0.00 | $5.00 | $37.00 | $37.00 | 3,375 2022 Formulary |
|
-- This plan not offered in 2021 --
|
H2915 -016 -0 | | | | | |
|
|
|
|
2022 Wellcare No Premium (HMO)
| $0.00 |
$6,700 |
$0 | No additional gap coverage, only the Donut Hole Discount | $0.00 | $5.00 | $37.00 | $37.00 | 3,375 2022 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 2021 --
|
H2128 -002 -0 | | | | | |
new |
new |
new |
|
2022 Wellcare No Premium Open (PPO)
| $0.00 |
$6,700 |
$160 | No additional gap coverage, only the Donut Hole Discount | $0.00 | $7.00 | $37.00 | $37.00 | 3,375 2022 Formulary |
|
2021 Allwell Medicare Simple (HMO)
| $0.00 |
$4,900 |
No Rx Coverage |
H2915 -013 -0 | This plan does NOT include Prescription Drug coverage. | |
|
|
|
|
2022 Wellcare Patriot Giveback (HMO)
| $0.00 |
$4,900 |
No Rx Coverage | This plan does NOT include Prescription Drug coverage. | |
|
2021 Keystone 65 Focus Rx (HMO-POS)
| $15.00 |
$6,500 |
$0 | No additional gap coverage, only the Donut Hole Discount |
H3952 -054 -0 | $1.00 | $10.00 | $47.00 | $47.00 | 4,216
2021 Formulary |
|
|
|
|
2022 Keystone 65 Focus Rx (HMO-POS)
| $15.00 |
$6,500 |
$0 | No additional gap coverage, only the Donut Hole Discount | $0.00 | $10.00 | $47.00 | $47.00 | 4,333 2022 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 |
2021 Aetna Medicare Advantra Premier (HMO)
| $49.00 |
$7,550 |
$150 | Yes, some additional gap coverage. |
H3959 -033 -0 | $0.00 | $5.00 | $47.00 | $47.00 | 3,659
2021 Formulary |
|
|
|
|
2022 Aetna Medicare Advantra Premier (HMO)
| $16.00 |
$7,550 |
$0 | Yes, some additional gap coverage. | $0.00 | $0.00 | $47.00 | $47.00 | 3,672 2022 Formulary |
|
-- This plan not offered in 2021 --
|
H6622 -078 -2 | | | | | |
|
|
|
|
2022 Humana Gold Plus SNP-DE H6622-078 (HMO D-SNP)
| $23.70 |
n/a |
$450 | No additional gap coverage, only the Donut Hole Discount | $2.00 | $20.00 | $47.00 | $47.00 | 3,408 2022 Formulary |
|
-- This plan not offered in 2021 --
|
H2128 -001 -0 | | | | | |
new |
new |
new |
|
2022 Wellcare Assist Open (PPO)
| $24.70 |
$6,700 |
$480 | No additional gap coverage, only the Donut Hole Discount | $0.00 | $20.00 | $43.00 | $43.00 | 3,375 2022 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 |
2021 Aetna Medicare Advantra Cares (HMO D-SNP)
| $30.90 |
n/a |
$130 | No additional gap coverage, only the Donut Hole Discount |
H3959 -035 -0 | $0.00 | $0.00 | $47.00 | $47.00 | 3,659
2021 Formulary |
|
|
|
|
2022 Aetna Medicare Advantra Cares (HMO D-SNP)
| $28.00 |
n/a |
$350 | No additional gap coverage, only the Donut Hole Discount | $0.00 | $5.00 | $47.00 | $47.00 | 3,672 2022 Formulary |
|
-- This plan not offered in 2021 --
|
H2128 -003 -0 | | | | | |
new |
new |
new |
|
2022 Wellcare Low Premium Open (PPO)
| $29.00 |
$5,000 |
$100 | No additional gap coverage, only the Donut Hole Discount | $0.00 | $7.00 | $37.00 | $37.00 | 3,375 2022 Formulary |
|
2021 Cigna TotalCare (HMO D-SNP)
| $25.50 |
n/a |
$445 | No additional gap coverage, only the Donut Hole Discount |
H3949 -009 -0 | | | | | 3,446
2021 Formulary |
|
|
|
|
2022 Cigna TotalCare (HMO D-SNP)
| $29.80 |
n/a |
$480 | No additional gap coverage, only the Donut Hole Discount | | | | | 3,459 2022 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 2021 --
|
H3949 -037 -0 | | | | | |
|
|
|
|
2022 Cigna TotalCare Plus (HMO D-SNP)
| $29.80 |
n/a |
$480 | No additional gap coverage, only the Donut Hole Discount | | | | | 3,459 2022 Formulary |
|
2021 Erickson Advantage Guardian (HMO-POS I-SNP)
| $28.80 |
n/a |
$0 | No additional gap coverage, only the Donut Hole Discount |
H5652 -003 -0 | $0.00 | $0.00 | $28.00 | $28.00 | 3,604
2021 Formulary |
|
|
|
|
2022 Erickson Advantage Guardian (HMO-POS I-SNP)
| $32.30 |
n/a |
$0 | Some Generics | $0.00 | $0.00 | $28.00 | $28.00 | 3,654 2022 Formulary |
|
2021 UnitedHealthcare Dual Complete (HMO D-SNP)
| $30.10 |
n/a |
$445 | No additional gap coverage, only the Donut Hole Discount |
H3113 -009 -0 | | | | | 3,604
2021 Formulary |
|
|
|
|
2022 UnitedHealthcare Dual Complete (HMO D-SNP)
| $33.90 |
n/a |
$480 | No additional gap coverage, only the Donut Hole Discount | | | | | 3,654 2022 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 |
2021 Cigna Preferred Medicare (HMO)
| $29.00 |
$5,900 |
$0 | Yes, some additional gap coverage. |
H3949 -030 -0 | $0.00 | $5.00 | $42.00 | $42.00 | 3,446
2021 Formulary |
|
|
|
|
2022 Cigna Preferred Medicare (HMO)
| $35.00 |
$5,900 |
$0 | Yes, some additional gap coverage. | $0.00 | $5.00 | $42.00 | $42.00 | 3,459 2022 Formulary |
|
2021 Allwell Medicare Complement (HMO)
| $29.50 |
$7,550 |
$445 | No additional gap coverage, only the Donut Hole Discount |
H2915 -011 -0 | $2.00 | $15.00 | $42.00 | $42.00 | 3,352
2021 Formulary |
|
|
|
|
2022 Wellcare Assist (HMO)
| $36.00 |
$7,550 |
$480 | No additional gap coverage, only the Donut Hole Discount | $0.00 | $20.00 | $47.00 | $47.00 | 3,375 2022 Formulary |
|
2021 UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP)
| $37.20 |
n/a |
$445 | No additional gap coverage, only the Donut Hole Discount |
H0710 -017 -0 | | | | | 3,604
2021 Formulary |
|
-- |
|
|
2022 UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP)
| $40.60 |
n/a |
$480 | No additional gap coverage, only the Donut Hole Discount | | | | | 3,654 2022 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 |
2021 Clover Health Choice Value (PPO)
| $37.50 |
$7,550 |
$445 | No additional gap coverage, only the Donut Hole Discount |
H5141 -039 -0 | $0.00 | 22% | 22% | 22% | 3,358
2021 Formulary |
|
|
|
|
2022 Clover Health Choice Value (PPO)
| $40.70 |
$7,550 |
$480 | No additional gap coverage, only the Donut Hole Discount | $0.00 | 22% | 22% | 22% | 3,358 2022 Formulary |
|
-- This plan not offered in 2021 --
|
H5932 -012 -0 | | | | | |
|
|
|
|
2022 Gateway Health Medicare Assured Diamond (HMO D-SNP)
| $40.70 |
n/a |
$480 | No additional gap coverage, only the Donut Hole Discount | $0.00 | $20.00 | $41.00 | $41.00 | 3,320 2022 Formulary |
|
-- This plan not offered in 2021 --
|
H5932 -013 -0 | | | | | |
|
|
|
|
2022 Gateway Health Medicare Assured Ruby (HMO D-SNP)
| $40.70 |
n/a |
$480 | No additional gap coverage, only the Donut Hole Discount | $0.00 | $20.00 | $47.00 | $47.00 | 3,320 2022 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 |
2021 Health Partners Medicare Prime (HMO-POS)
| $37.50 |
$7,550 |
$0 | No additional gap coverage, only the Donut Hole Discount |
H9207 -002 -0 | $0.00 | $10.00 | $47.00 | $47.00 | 3,791
2021 Formulary |
|
-- |
|
|
2022 Health Partners Medicare Prime (HMO-POS)
| $40.70 |
$7,550 |
$0 | No additional gap coverage, only the Donut Hole Discount | $0.00 | $10.00 | $47.00 | $47.00 | 3,668 2022 Formulary |
|
2021 Health Partners Medicare Special (HMO D-SNP)
| $37.50 |
n/a |
$445 | No additional gap coverage, only the Donut Hole Discount |
H9207 -004 -0 | | | | | 3,736
2021 Formulary |
|
-- |
|
|
2022 Health Partners Medicare Special (HMO D-SNP)
| $40.70 |
n/a |
$480 | No additional gap coverage, only the Donut Hole Discount | | | | | 3,650 2022 Formulary |
|
2021 Keystone First VIP Choice (HMO D-SNP)
| $37.40 |
n/a |
$445 | No additional gap coverage, only the Donut Hole Discount |
H4227 -001 -0 | $5.00 | 25% | | | 3,407
2021 Formulary |
|
|
|
|
2022 Keystone First VIP Choice (HMO D-SNP)
| $40.70 |
n/a |
$480 | No additional gap coverage, only the Donut Hole Discount | $6.00 | 25% | | | 3,477 2022 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 |
2021 Provider Partners Pennsylvania Advantage Plan (HMO I-SNP)
| $37.50 |
n/a |
$445 | No additional gap coverage, only the Donut Hole Discount |
H4093 -001 -0 | | | | | 3,578
2021 Formulary |
|
-- |
|
|
2022 Provider Partners Pennsylvania Advantage Plan (HMO I-SNP)
| $40.70 |
n/a |
$480 | No additional gap coverage, only the Donut Hole Discount | | | | | 3,497 2022 Formulary |
|
2021 Provider Partners Pennsylvania Community Plan (HMO I-SNP)
| $37.50 |
n/a |
$445 | No additional gap coverage, only the Donut Hole Discount |
H4093 -004 -0 | | | | | 3,578
2021 Formulary |
|
-- |
|
|
2022 Provider Partners Pennsylvania Community Plan (HMO I-SNP)
| $40.70 |
n/a |
$480 | No additional gap coverage, only the Donut Hole Discount | | | | | 3,497 2022 Formulary |
|
-- This plan not offered in 2021 --
|
H3113 -014 -0 | | | | | |
|
|
|
|
2022 UnitedHealthcare Dual Complete Select (HMO D-SNP)
| $40.70 |
n/a |
$480 | No additional gap coverage, only the Donut Hole Discount | | | | | 3,654 2022 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 |
2021 UPMC for Life Complete Care (HMO D-SNP)
| $37.50 |
n/a |
$445 | No additional gap coverage, only the Donut Hole Discount |
H7123 -001 -0 | $5.00 | $10.00 | $18.00 | $18.00 | 3,547
2021 Formulary |
|
|
|
|
2022 UPMC for Life Complete Care (HMO D-SNP)
| $40.70 |
n/a |
$480 | No additional gap coverage, only the Donut Hole Discount | $5.00 | $10.00 | $19.00 | $19.00 | 3,703 2022 Formulary |
|
2021 Allwell Dual Medicare (HMO D-SNP)
| $37.50 |
n/a |
$445 | No additional gap coverage, only the Donut Hole Discount |
H2915 -002 -0 | $0.00 | $5.00 | $40.00 | $40.00 | 3,352
2021 Formulary |
|
|
|
|
2022 Wellcare Dual Access (HMO D-SNP)
| $40.70 |
n/a |
$480 | No additional gap coverage, only the Donut Hole Discount | $0.00 | $5.00 | $37.00 | $37.00 | 3,375 2022 Formulary |
|
2021 Keystone 65 Select Medical Only (HMO)
| $49.50 |
$4,900 |
No Rx Coverage |
H3952 -050 -0 | This plan does NOT include Prescription Drug coverage. | |
|
|
|
|
2022 Keystone 65 Select Medical Only (HMO)
| $49.50 |
$4,900 |
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 |
2021 Aetna Medicare Advantra Premier Plus (PPO)
| $49.00 |
$7,000 |
$0 | Yes, some additional gap coverage. |
H5522 -014 -0 | $0.00 | $0.00 | $47.00 | $47.00 | 3,679
2021 Formulary |
|
|
|
|
2022 Aetna Medicare Advantra Premier Plus (PPO)
| $50.00 |
$6,700 |
$0 | Yes, some additional gap coverage. | $0.00 | $0.00 | $47.00 | $47.00 | 3,698 2022 Formulary |
|
-- This plan not offered in 2021 --
|
H3909 -017 -0 | | | | | |
|
|
|
|
2022 Personal Choice 65 Elite Rx (PPO)
| $51.00 |
$6,500 |
$0 | No additional gap coverage, only the Donut Hole Discount | $0.00 | $10.00 | $47.00 | $47.00 | 4,333 2022 Formulary |
|
2021 Cigna True Choice Plus Medicare (PPO)
| $59.00 |
$6,100 |
$0 | Yes, some additional gap coverage. |
H7849 -007 -0 | $0.00 | $5.00 | $42.00 | $42.00 | 3,446
2021 Formulary |
|
|
|
|
2022 Cigna True Choice Plus Medicare (PPO)
| $60.00 |
$6,100 |
$0 | Yes, some additional gap coverage. | $0.00 | $5.00 | $42.00 | $42.00 | 3,459 2022 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 |
2021 HumanaChoice H5525-005 (PPO)
| $62.00 |
$6,700 |
$0 | No additional gap coverage, only the Donut Hole Discount |
H5525 -005 -0 | $5.00 | $15.00 | $47.00 | $47.00 | 3,386
2021 Formulary |
|
|
|
|
2022 HumanaChoice H5525-005 (PPO)
| $62.00 |
$6,700 |
$0 | No additional gap coverage, only the Donut Hole Discount | $5.00 | $15.00 | $47.00 | $47.00 | 3,408 2022 Formulary |
|
2021 Aetna Medicare Silver (HMO)
| $69.00 |
$7,550 |
$0 | Yes, some additional gap coverage. |
H3931 -070 -0 | $0.00 | $5.00 | $47.00 | $47.00 | 3,659
2021 Formulary |
|
|
|
|
2022 Aetna Medicare Silver (HMO)
| $65.00 |
$7,550 |
$0 | Yes, some additional gap coverage. | $0.00 | $5.00 | $47.00 | $47.00 | 3,672 2022 Formulary |
|
2021 Erickson Advantage Freedom (HMO-POS)
| $70.00 |
$4,300 |
$200 | No additional gap coverage, only the Donut Hole Discount |
H5652 -006 -0 | $5.00 | $15.00 | $45.00 | $45.00 | 3,604
2021 Formulary |
|
|
|
|
2022 Erickson Advantage Freedom (HMO-POS)
| $70.00 |
$4,300 |
$200 | Yes, some additional gap coverage. | $5.00 | $15.00 | $45.00 | $45.00 | 3,654 2022 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 |
2021 HumanaChoice R0923-002 (Regional PPO)
| $63.00 |
$6,700 |
$0 | No additional gap coverage, only the Donut Hole Discount |
R0923 -002 -0 | $6.00 | $20.00 | $47.00 | $47.00 | 3,386
2021 Formulary |
|
|
|
|
2022 HumanaChoice R0923-002 (Regional PPO)
| $72.00 |
$6,700 |
$0 | No additional gap coverage, only the Donut Hole Discount | $6.00 | $20.00 | $47.00 | $47.00 | 3,416 2022 Formulary |
|
2021 Keystone 65 Select Rx (HMO)
| $82.50 |
$4,900 |
$0 | No additional gap coverage, only the Donut Hole Discount |
H3952 -051 -0 | $1.00 | $9.00 | $47.00 | $47.00 | 4,216
2021 Formulary |
|
|
|
|
2022 Keystone 65 Select Rx (HMO)
| $83.50 |
$4,900 |
$0 | No additional gap coverage, only the Donut Hole Discount | $0.00 | $9.00 | $47.00 | $47.00 | 4,333 2022 Formulary |
|
2021 Aetna Medicare Premier (HMO)
| $100.00 |
$7,550 |
$0 | Yes, some additional gap coverage. |
H3931 -064 -0 | $0.00 | $5.00 | $47.00 | $47.00 | 3,659
2021 Formulary |
|
|
|
|
2022 Aetna Medicare Premier (HMO-POS)
| $96.00 |
$7,550 |
$0 | Yes, some additional gap coverage. | $0.00 | $5.00 | $47.00 | $47.00 | 3,672 2022 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 |
2021 HumanaChoice H5216-120 (PPO)
| $127.00 |
$6,700 |
$0 | No additional gap coverage, only the Donut Hole Discount |
H5216 -120 -0 | $5.00 | $15.00 | $47.00 | $47.00 | 3,386
2021 Formulary |
|
|
|
|
2022 HumanaChoice H5216-120 (PPO)
| $128.00 |
$6,700 |
$0 | No additional gap coverage, only the Donut Hole Discount | $5.00 | $15.00 | $47.00 | $47.00 | 3,413 2022 Formulary |
|
2021 Cigna Preferred Plus Medicare (HMO)
| $139.00 |
$5,100 |
$0 | Yes, some additional gap coverage. |
H3949 -013 -0 | $0.00 | $5.00 | $42.00 | $42.00 | 3,446
2021 Formulary |
|
|
|
|
2022 Cigna Preferred Plus Medicare (HMO)
| $135.00 |
$4,900 |
$0 | Yes, some additional gap coverage. | $0.00 | $5.00 | $42.00 | $42.00 | 3,459 2022 Formulary |
|
2021 Aetna Medicare Premier Plus (HMO)
| $185.00 |
$7,550 |
$0 | Yes, some additional gap coverage. |
H3931 -004 -0 | $0.00 | $0.00 | $47.00 | $47.00 | 3,679
2021 Formulary |
|
|
|
|
2022 Aetna Medicare Premier Plus (HMO)
| $146.00 |
$7,550 |
$0 | Yes, some additional gap coverage. | $0.00 | $0.00 | $47.00 | $47.00 | 3,698 2022 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 |
2021 Personal Choice 65 Rx (PPO)
| $161.00 |
$5,000 |
$0 | No additional gap coverage, only the Donut Hole Discount |
H3909 -009 -0 | $1.00 | $9.00 | $47.00 | $47.00 | 4,216
2021 Formulary |
|
|
|
|
2022 Personal Choice 65 Rx (PPO)
| $165.00 |
$5,000 |
$0 | No additional gap coverage, only the Donut Hole Discount | $0.00 | $9.00 | $47.00 | $47.00 | 4,333 2022 Formulary |
|
2021 Aetna Medicare Gold Plan (PPO)
| $169.00 |
$7,550 |
$0 | Yes, some additional gap coverage. |
H5521 -122 -0 | $2.00 | $5.00 | $47.00 | $47.00 | 3,659
2021 Formulary |
|
|
|
|
2022 Aetna Medicare Gold Plan (PPO)
| $170.00 |
$7,550 |
$0 | Yes, some additional gap coverage. | $2.00 | $5.00 | $47.00 | $47.00 | 3,672 2022 Formulary |
|
2021 Keystone 65 Preferred Medical Only (HMO)
| $194.00 |
$4,000 |
No Rx Coverage |
H3952 -044 -0 | This plan does NOT include Prescription Drug coverage. | |
|
|
|
|
2022 Keystone 65 Preferred Medical Only (HMO)
| $187.00 |
$3,800 |
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 |
2021 Erickson Advantage Champion (HMO-POS C-SNP)
| $199.00 |
n/a |
$0 | No additional gap coverage, only the Donut Hole Discount |
H5652 -004 -0 | $5.00 | $15.00 | $45.00 | $45.00 | 3,604
2021 Formulary |
|
|
|
|
2022 Erickson Advantage Champion (HMO-POS C-SNP)
| $199.00 |
n/a |
$0 | Some Generics | $5.00 | $15.00 | $45.00 | $45.00 | 3,654 2022 Formulary |
|
2021 Erickson Advantage Signature with Drugs (HMO-POS)
| $199.00 |
$2,600 |
$0 | No additional gap coverage, only the Donut Hole Discount |
H5652 -001 -0 | $5.00 | $10.00 | $45.00 | $45.00 | 3,604
2021 Formulary |
|
|
|
|
2022 Erickson Advantage Signature with Drugs (HMO-POS)
| $199.00 |
$2,600 |
$0 | Yes, some additional gap coverage. | $5.00 | $10.00 | $45.00 | $45.00 | 3,654 2022 Formulary |
|
2021 Keystone 65 Preferred Rx (HMO)
| $258.00 |
$4,000 |
$0 | No additional gap coverage, only the Donut Hole Discount |
H3952 -045 -0 | $1.00 | $9.00 | $47.00 | $47.00 | 4,216
2021 Formulary |
|
|
|
|
2022 Keystone 65 Preferred Rx (HMO)
| $258.00 |
$3,800 |
$0 | No additional gap coverage, only the Donut Hole Discount | $0.00 | $9.00 | $47.00 | $47.00 | 4,333 2022 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 |
2021 Gateway Health Medicare Assured Diamond (HMO D-SNP)
| $37.50 |
n/a |
$445 | No additional gap coverage, only the Donut Hole Discount |
H5932 -001 -0 | $0.00 | $19.00 | $38.00 | $38.00 | 3,253
2021 Formulary |
|
|
|
|
-- Members will be assigned to Highmark Wholecare Medicare Assured Diamond (HMO D-SNP) H5932-012 --
| | | | | |
|
2021 Gateway Health Medicare Assured Ruby (HMO D-SNP)
| $37.50 |
n/a |
$445 | No additional gap coverage, only the Donut Hole Discount |
H5932 -009 -0 | $0.00 | $20.00 | $47.00 | $47.00 | 3,253
2021 Formulary |
|
|
|
|
-- Members will be assigned to Highmark Wholecare Medicare Assured Ruby (HMO D-SNP) H5932-013 --
| | | | | |
|
2021 Humana Gold Plus SNP-DE H6622-038 (HMO D-SNP)
| $26.10 |
n/a |
$445 | No additional gap coverage, only the Donut Hole Discount |
H6622 -038 -0 | $1.00 | $19.00 | $47.00 | $47.00 | 3,382
2021 Formulary |
|
|
|
|
-- Members will be assigned to Humana Gold Plus SNP-DE (HMO D-SNP) H6622-078 --
| | | | | |
|
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 |
2021 HumanaChoice H5525-038 (PPO)
| $0.00 |
$6,700 |
$0 | No additional gap coverage, only the Donut Hole Discount |
H5525 -038 -0 | $7.00 | $17.00 | $47.00 | $47.00 | 3,386
2021 Formulary |
|
|
|
|
-- Members will be assigned to HumanaChoice H5525-051 (PPO) H5525-051 --
| | | | | |
|
2021 HumanaChoice H5525-047 (PPO)
| $0.00 |
$6,700 |
$0 | No additional gap coverage, only the Donut Hole Discount |
H5525 -047 -0 | $3.00 | $15.00 | $47.00 | $47.00 | 3,386
2021 Formulary |
|
|
|
|
-- Members will be assigned to HumanaChoice H5525-051 (PPO) H5525-051 --
| | | | | |
|
2021 Allwell Medicare Boost (HMO)
| $0.00 |
$7,550 |
$0 | No additional gap coverage, only the Donut Hole Discount |
H2915 -014 -0 | $0.00 | $10.00 | $47.00 | $47.00 | 3,370
2021 Formulary |
|
|
|
|
-- Members will be assigned to Wellcare Giveback (HMO) H2915-012 --
| | | | | |
|
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 |
2021 Allwell Medicare (HMO)
| $0.00 |
$6,700 |
$0 | No additional gap coverage, only the Donut Hole Discount |
H2915 -015 -3 | $0.00 | $10.00 | $47.00 | $47.00 | 3,370
2021 Formulary |
|
|
|
|
-- Members will be assigned to Wellcare No Premium (HMO) H2915-016 --
| | | | | |
|
2021 Cigna Traditions Medicare (HMO I-SNP)
| $24.50 |
n/a |
$445 | No additional gap coverage, only the Donut Hole Discount |
H3949 -016 -0 | | | | | 3,446
2021 Formulary |
|
|
|
|
-- This plan not offered in 2022 --
|
| | | | |
|