2012 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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ActiveSaver MSA (MSA) - H9788-003-0 Benefit Details |
Herkimer | $0.00 | No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | n/a | ||||||
Fidelis Medicare Advantage without Rx (HMO-POS) - H3328-001-0 Benefit Details |
Herkimer | $0.00 | No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $6,700 | ||||||
Medicare Blue PPO Plan ONE (PPO) - H3335-051-0 Benefit Details |
Herkimer | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $45.00 Tier 3: $90.00 Tier 4: 33% | $4,000 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 | |||||||||
Today's Options Premier 300 (PFFS) - H2816-007-0 Benefit Details |
Herkimer | $0.00 | No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,400 | ||||||
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UnitedHealthcare MedicareComplete Choice (Regional PPO) - R5342-001-0 Benefit Details |
Herkimer | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $3.00 Tier 2: $6.00 Tier 3: $45.00 Tier 4: $95.00 Tier 5: 33% | $4,900 Browse Formulary | |||||
UnitedHealthcare MedicareComplete Choice Essential (Regional PPO) - R5342-002-0 Benefit Details |
Herkimer | $0.00 | No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $3,900 | ||||||
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 | |||||||||
Preferred Gold (HMO-POS) - H9859-001-0 Benefit Details |
Herkimer | $14.60 | No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $3,800 | ||||||
Today's Options Premier 100 (PFFS) - H2816-001-0 Benefit Details |
Herkimer | $20.00 | No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $3,400 | ||||||
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Today's Options Premier Plus 350B (PFFS) - H2816-019-0 Benefit Details |
Herkimer | $21.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: tbd | $4,400 Browse Formulary | |||||
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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 | |||||||||
UnitedHealthcare Dual Complete RP (Regional PPO SNP) - R5342-003-0 Benefit Details |
Herkimer | $ for people who qualify for both Medicare and Medicaid. | $0 for people who qualify for both Medicare and Medicaid. | No additional gap coverage, only the Donut Hole Discount | Tier 1: 15% Tier 2: 15% | n/a Browse Formulary | |||||
Fidelis Dual Advantage (HMO SNP) - H3328-002-0 Benefit Details |
Herkimer | $ for people who qualify for both Medicare and Medicaid. | $0 for people who qualify for both Medicare and Medicaid. | No additional gap coverage, only the Donut Hole Discount | Tier 1: 15% Tier 2: 15% | n/a Browse Formulary | |||||
Fidelis Dual Advantage Flex (HMO SNP) - H3328-013-0 Benefit Details |
Herkimer | $ for people who qualify for both Medicare and Medicaid. | $0 for people who qualify for both Medicare and Medicaid. | No additional gap coverage, only the Donut Hole Discount | Tier 1: 0% Tier 2: 0% | n/a 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 | |||||||||
Fidelis Medicare Advantage Flex (HMO-POS) - H3328-003-0 Benefit Details |
Herkimer | $39.80 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $15.00 Tier 3: $35.00 Tier 4: $95.00 Tier 5: 25% | $6,700 Browse Formulary | |||||
Medicare Blue PPO Plan FOUR (PPO) - H3335-041-0 Benefit Details |
Herkimer | $40.00 | No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 | ||||||
Medicare Blue PPO Plan TWO (PPO) - H3335-005-0 Benefit Details |
Herkimer | $40.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $40.00 Tier 3: $80.00 Tier 4: 33% | $3,500 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 | |||||||||
GoldValue Rx (HMO-POS) - H9859-013-0 Benefit Details |
Herkimer | $46.20 | $0 | Few Generics | Tier 1: $8.00 Tier 2: $35.00 Tier 3: $90.00 Tier 4: 33% Tier 5: $0.00 | $4,600 Browse Formulary | |||||
Today's Options Premier Plus 150A (PFFS) - H2816-013-0 Benefit Details |
Herkimer | $72.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: tbd | $3,400 Browse Formulary | |||||
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Preferred Gold Rx (HMO-POS) - H9859-002-0 Benefit Details |
Herkimer | $72.10 | $0 | Few Generics | Tier 1: $8.00 Tier 2: $35.00 Tier 3: $90.00 Tier 4: 33% Tier 5: $0.00 | $3,800 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 | |||||||||
Medicare Blue PPO Plan THREE (PPO) - H3335-006-0 Benefit Details |
Herkimer | $80.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $40.00 Tier 3: $80.00 Tier 4: 33% | $3,500 Browse Formulary | |||||
CDPHP Classic (PPO) - H5042-004-0 Benefit Details |
Herkimer | $95.00 | No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $2,500 | ||||||
CDPHP Core Rx (PPO) - H5042-005-0 Benefit Details |
Herkimer | $99.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $0.00 Tier 2: $9.00 Tier 3: $45.00 Tier 4: $95.00 Tier 5: 33% | $3,300 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 | |||||||||
GoldAnywhere Rx (PPO) - H9615-002-0 Benefit Details |
Herkimer | $138.40 | $0 | Many Generics | Tier 1: $5.00 Tier 2: $35.00 Tier 3: $90.00 Tier 4: 33% Tier 5: $0.00 | $2,000 Browse Formulary | |||||
CDPHP Classic Rx (PPO) - H5042-001-0 Benefit Details |
Herkimer | $145.00 | $0 | Many Generics | Tier 1: $0.00 Tier 2: $8.00 Tier 3: $40.00 Tier 4: $90.00 Tier 5: 30% | $2,500 Browse Formulary | |||||
CDPHP Prime Rx (PPO) - H5042-007-0 Benefit Details |
Herkimer | $199.00 | $0 | Many Generics | Tier 1: $0.00 Tier 2: $5.00 Tier 3: $40.00 Tier 4: $75.00 Tier 5: 30% | $2,000 Browse Formulary | |||||
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