2013 Medicare Advantage Plan Information Click here to jump to the Chart Legend & Search Tips | |||||||||||
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Plan Name | County | Monthly Prem. (Parts C & D) |
Deduct- ible |
(Donut Hole) Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance 30-Day Supply |
MOOP for Part A & B Benefits | |||||
Cust. Service Rating |
Member Plan Exper. |
RxCost Info Rating |
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Network PlatinumPremier Pharmacy (PPO) in WI - H5215-005-0 Benefit Details |
Brown | $215.00 | $0 | Many Generics | Preferred Generic: $1.00 Non-Preferred Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Brand: $70.00 Specialty Tier: 33% | $2,000 Browse Formulary | |||||
Network PlatinumPremier Pharmacy (PPO) in WI - H5215-005-0 Benefit Details |
Calumet | $215.00 | $0 | Many Generics | Preferred Generic: $1.00 Non-Preferred Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Brand: $70.00 Specialty Tier: 33% | $2,000 Browse Formulary | |||||
Network PlatinumPremier Pharmacy (PPO) in WI - H5215-005-0 Benefit Details |
Dodge | $215.00 | $0 | Many Generics | Preferred Generic: $1.00 Non-Preferred Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Brand: $70.00 Specialty Tier: 33% | $2,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Network PlatinumPremier Pharmacy (PPO) in WI - H5215-005-0 Benefit Details |
Fond du Lac | $215.00 | $0 | Many Generics | Preferred Generic: $1.00 Non-Preferred Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Brand: $70.00 Specialty Tier: 33% | $2,000 Browse Formulary | |||||
Network PlatinumPremier Pharmacy (PPO) in WI - H5215-005-0 Benefit Details |
Green Lake | $215.00 | $0 | Many Generics | Preferred Generic: $1.00 Non-Preferred Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Brand: $70.00 Specialty Tier: 33% | $2,000 Browse Formulary | |||||
Network PlatinumPremier Pharmacy (PPO) in WI - H5215-005-0 Benefit Details |
Kewaunee | $215.00 | $0 | Many Generics | Preferred Generic: $1.00 Non-Preferred Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Brand: $70.00 Specialty Tier: 33% | $2,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Network PlatinumPremier Pharmacy (PPO) in WI - H5215-005-0 Benefit Details |
Manitowoc | $215.00 | $0 | Many Generics | Preferred Generic: $1.00 Non-Preferred Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Brand: $70.00 Specialty Tier: 33% | $2,000 Browse Formulary | |||||
Network PlatinumPremier Pharmacy (PPO) in WI - H5215-005-0 Benefit Details |
Marquette | $215.00 | $0 | Many Generics | Preferred Generic: $1.00 Non-Preferred Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Brand: $70.00 Specialty Tier: 33% | $2,000 Browse Formulary | |||||
Network PlatinumPremier Pharmacy (PPO) in WI - H5215-005-0 Benefit Details |
Oconto | $215.00 | $0 | Many Generics | Preferred Generic: $1.00 Non-Preferred Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Brand: $70.00 Specialty Tier: 33% | $2,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Network PlatinumPremier Pharmacy (PPO) in WI - H5215-005-0 Benefit Details |
Outagamie | $215.00 | $0 | Many Generics | Preferred Generic: $1.00 Non-Preferred Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Brand: $70.00 Specialty Tier: 33% | $2,000 Browse Formulary | |||||
Network PlatinumPremier Pharmacy (PPO) in WI - H5215-005-0 Benefit Details |
Portage | $215.00 | $0 | Many Generics | Preferred Generic: $1.00 Non-Preferred Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Brand: $70.00 Specialty Tier: 33% | $2,000 Browse Formulary | |||||
Network PlatinumPremier Pharmacy (PPO) in WI - H5215-005-0 Benefit Details |
Shawano | $215.00 | $0 | Many Generics | Preferred Generic: $1.00 Non-Preferred Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Brand: $70.00 Specialty Tier: 33% | $2,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Network PlatinumPremier Pharmacy (PPO) in WI - H5215-005-0 Benefit Details |
Sheboygan | $215.00 | $0 | Many Generics | Preferred Generic: $1.00 Non-Preferred Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Brand: $70.00 Specialty Tier: 33% | $2,000 Browse Formulary | |||||
Network PlatinumPremier Pharmacy (PPO) in WI - H5215-005-0 Benefit Details |
Waupaca | $215.00 | $0 | Many Generics | Preferred Generic: $1.00 Non-Preferred Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Brand: $70.00 Specialty Tier: 33% | $2,000 Browse Formulary | |||||
Network PlatinumPremier Pharmacy (PPO) in WI - H5215-005-0 Benefit Details |
Waushara | $215.00 | $0 | Many Generics | Preferred Generic: $1.00 Non-Preferred Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Brand: $70.00 Specialty Tier: 33% | $2,000 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Network PlatinumPremier Pharmacy (PPO) in WI - H5215-005-0 Benefit Details |
Winnebago | $215.00 | $0 | Many Generics | Preferred Generic: $1.00 Non-Preferred Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Brand: $70.00 Specialty Tier: 33% | $2,000 Browse Formulary | |||||
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