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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AARP MedicareComplete Choice (PPO) - H3812-001-0 Benefit Details |
Lane | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $3.00 Tier 2: $6.00 Tier 3: $44.00 Tier 4: $88.00 Tier 5: 33% | $4,500 Browse Formulary | |||||
Health Net Violet Option 2 (PPO) - H5520-005-0 Benefit Details |
Lane | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: tbd | $3,400 Browse Formulary | |||||
PacificSource Medicare Essentials Rx 15 (HMO) - H3864-015-0 Benefit Details |
Lane | $0.00 | $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% | $2,500 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 | |||||||||
Trillium Advantage TLC ISNP (HMO SNP) - H2174-003-0 Benefit Details |
Lane | $18.90 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% | n/a Browse Formulary | |||||
Trillium Advantage TLC Community ISNP (HMO SNP) - H2174-005-0 Benefit Details |
Lane | $21.80 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% | n/a Browse Formulary | |||||
PacificSource Medicare Explorer 5 (PPO) - H4754-005-0 Benefit Details |
Lane | $30.00 | No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $2,500 | ||||||
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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 | |||||||||
Trillium Advantage Dual (HMO SNP) - H2174-001-0 Benefit Details |
Lane | $ 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 | |||||
Regence MedAdvantage Basic (PPO) - H3817-001-0 Benefit Details |
Lane | $35.00 | No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $3,400 | ||||||
UnitedHealthcare Nursing Home Plan (PPO SNP) - H3812-005-0 Benefit Details |
Lane | $35.20 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% Tier 5: 25% | 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 | |||||||||
Providence Medicare Choice (HMO-POS) - H9047-035-0 Benefit Details |
Lane | $40.00 | No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $3,400 | ||||||
ODS Advantage PPO (PPO) - H3813-001-0 Benefit Details |
Lane | $40.60 | No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $3,400 | ||||||
Health Net Aqua (PPO) - H5520-001-0 Benefit Details |
Lane | $45.00 | No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $2,500 | ||||||
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 | |||||||||
AARP MedicareComplete (HMO) - H3805-007-0 Benefit Details |
Lane | $49.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $3.00 Tier 2: $6.00 Tier 3: $44.00 Tier 4: $88.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Trillium Advantage (HMO) - H2174-004-0 Benefit Details |
Lane | $59.00 | No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $2,500 | ||||||
Regence MedAdvantage + Rx Classic (PPO) - H3817-002-0 Benefit Details |
Lane | $67.00 | $160 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $7.50 Tier 2: $33.00 Tier 3: $45.00 Tier 4: $90.00 Tier 5: 29% Tier 6: 29% | $3,400 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 | |||||||||
Providence Medicare Choice + RX (HMO-POS) - H9047-024-0 Benefit Details |
Lane | $76.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $7.00 Tier 2: $50.00 Tier 3: 33% | $3,400 Browse Formulary | |||||
PacificSource Medicare Explorer Rx 4 (PPO) - H4754-004-0 Benefit Details |
Lane | $78.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $3.00 Tier 2: $30.00 Tier 3: $70.00 Tier 4: 33% | $2,500 Browse Formulary | |||||
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Trillium Advantage Rx Smart (HMO) - H2174-008-0 Benefit Details |
Lane | $78.00 | $0 | Many Generics | Tier 1: $9.00 Tier 2: $45.00 Tier 3: $80.00 Tier 4: 33% | $6,700 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 | |||||||||
Providence Medicare Extra (HMO) - H9047-033-0 Benefit Details |
Lane | $87.00 | No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $2,500 | ||||||
Health Net Violet Option 1 (PPO) - H5520-002-0 Benefit Details |
Lane | $99.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: tbd | $2,500 Browse Formulary | |||||
ODS Advantage PPORX Select (PPO) - H3813-003-0 Benefit Details |
Lane | $128.30 | $120 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $33.00 Tier 3: $40.00 Tier 4: 50% Tier 5: 30% | $3,400 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 | |||||||||
Providence Medicare Extra + RX (HMO) - H9047-001-0 Benefit Details |
Lane | $130.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $7.00 Tier 2: $50.00 Tier 3: 33% | $2,500 Browse Formulary | |||||
Regence MedAdvantage + Rx Enhanced (PPO) - H3817-003-0 Benefit Details |
Lane | $135.00 | $0 | Many Generics | Tier 1: $5.00 Tier 2: $33.00 Tier 3: $45.00 Tier 4: $90.00 Tier 5: 33% Tier 6: 33% | $2,500 Browse Formulary | |||||
Health Net Healthy Heart (PPO) - H5520-009-0 Benefit Details |
Lane | $149.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: tbd | $1,750 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 | |||||||||
Trillium Advantage Rx (HMO) - H2174-002-0 Benefit Details |
Lane | $164.00 | $0 | Many Generics | Tier 1: $9.00 Tier 2: $40.00 Tier 3: $60.00 | $2,500 Browse Formulary | |||||
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