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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AHM_Basic (HMO) - H5774-003-0 Benefit Details |
Culebra | $0.00 | No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $2,500 | ||||||
AHM_Classic (HMO) - H5774-008-0 Benefit Details |
Culebra | $0.00 | $0 | Many Generics | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $35.00 Tier 4: $50.00 Tier 5: 33% | $2,500 Browse Formulary | |||||
AHM_Classic Plus (HMO SNP) - H5774-009-0 Benefit Details |
Culebra | $0.00 | $0 | Many Generics | Tier 1: $3.00 Tier 2: $6.00 Tier 3: $30.00 Tier 4: $50.00 Tier 5: 33% | 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 | |||||||||
AHM_Opal (HMO-POS) - H5774-014-0 Benefit Details |
Culebra | $0.00 | $0 | Many Generics | Tier 1: $5.00 Tier 2: $10.00 Tier 3: $35.00 Tier 4: $50.00 Tier 5: 33% Tier 6: $0.00 | $2,500 Browse Formulary | |||||
AHM_Platino Plus (HMO SNP) - H5774-019-0 Benefit Details |
Culebra | $ 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 | |||||
AHM_Standard (HMO) - H5774-005-0 Benefit Details |
Culebra | $0.00 | $0 | Many Generics | Tier 1: $3.00 Tier 2: $6.00 Tier 3: $30.00 Tier 4: $45.00 Tier 5: 33% Tier 6: $0.00 | $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 | |||||||||
Dorado (HMO) - H4004-025-0 Benefit Details |
Culebra | $0.00 | No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $3,250 | ||||||
Elite Dorado (HMO-POS) - H4004-015-0 Benefit Details |
Culebra | $0.00 | $0 | Many Generics | Tier 1: $5.00 Tier 2: $29.00 Tier 3: $50.00 Tier 4: 25% | $3,250 Browse Formulary | |||||
First Care+Plus (HMO) - H5887-001-0 Benefit Details |
Culebra | $0.00 | $0 | All Generics | Tier 1: $5.00 Tier 2: $25.00 Tier 3: $45.00 Tier 4: 25% | $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 | |||||||||
First+Plus Advantage (PPO) - H4011-001-0 Benefit Details |
Culebra | $0.00 | No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $6,700 | ||||||
First+Plus Advantage Plus (PPO) - H4011-003-0 Benefit Details |
Culebra | $0.00 | $0 | All Generics | Tier 1: $5.00 Tier 2: $25.00 Tier 3: $45.00 Tier 4: 25% | $6,700 Browse Formulary | |||||
First+Plus Complete (HMO SNP) - H5887-007-0 Benefit Details |
Culebra | $0.00 | $0 | All Generics | Tier 1: $4.00 Tier 2: $20.00 Tier 3: $40.00 Tier 4: 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 | |||||||||
First+Plus Platino (HMO SNP) - H5887-010-0 Benefit Details |
Culebra | $ 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 | |||||
Humana Gold Plus H4007-012 (HMO) - H4007-012-0 Benefit Details |
Culebra | $0.00 | $0 | Few Generics | Tier 1: $0.00 Tier 2: $20.00 Tier 3: $40.00 | $3,500 Browse Formulary | |||||
Humana Gold Plus SNP-DE H4007-005 (HMO SNP) - H4007-005-0 Benefit Details |
Culebra | $ 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: 25% Tier 2: 25% Tier 3: 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 | |||||||||
MAPFRE Medicare Excel (HMO-POS) - H5821-001-0 Benefit Details |
Culebra | $0.00 | $0 | Many Generics | Tier 1: $5.00 Tier 2: 25% Tier 3: 25% Tier 4: 25% | $6,700 Browse Formulary | |||||
MAPFRE Medicare Excel Extended (HMO-POS) - H5821-013-0 Benefit Details |
Culebra | $0.00 | $0 | Many Generics | Tier 1: $3.00 Tier 2: $25.00 Tier 3: $35.00 Tier 4: 30% | $6,700 Browse Formulary | |||||
MAPFRE Medicare Excel VIP (HMO) - H5821-020-0 Benefit Details |
Culebra | $0.00 | $0 | Many Generics | Tier 1: $3.00 Tier 2: $18.00 Tier 3: $45.00 Tier 4: 30% | $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 | |||||||||
MCS Classicare B-Max (HMO) - H4006-025-0 Benefit Details |
Culebra | $0.00 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $6,700 Browse Formulary | |||||
MCS Classicare InteliCare (HMO) - H5577-005-0 Benefit Details |
Culebra | $0.00 | $0 | Many Generics | Tier 1: $0.00 Tier 2: $4.00 Tier 3: $24.00 Tier 4: $48.00 Tier 5: 25% | $3,400 Browse Formulary | |||||
MCS Classicare MA (HMO) - H4006-001-0 Benefit Details |
Culebra | $0.00 | No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $3,400 | ||||||
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 | |||||||||
MCS Classicare Premium Health (HMO) - H4006-007-0 Benefit Details |
Culebra | $0.00 | $0 | Many Generics | Tier 1: $4.00 Tier 2: $25.00 Tier 3: $50.00 Tier 4: 25% | $3,400 Browse Formulary | |||||
Medicare en el Hogar Plus (HMO SNP) - H4004-035-0 Benefit Details |
Culebra | $0.00 | $0 | Many Generics | Tier 1: $5.00 Tier 2: $29.00 Tier 3: 25% | n/a Browse Formulary | |||||
Medicare y Mucho Mas - BASICO SELECT (HMO) - H4003-015-0 Benefit Details |
Culebra | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $35.00 Tier 3: 30% | $3,250 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 y Mucho Mas - DIAMANTE CHOICE (HMO SNP) - H4003-017-0 Benefit Details |
Culebra | $ 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 | |||||
Medicare y Mucho Mas - DIAMANTE EXTRA (HMO SNP) - H4003-021-0 Benefit Details |
Culebra | $ 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 | |||||
Medicare y Mucho Mas - ELITE (HMO-POS) - H4003-001-0 Benefit Details |
Culebra | $0.00 | $0 | Many Generics | Tier 1: $5.00 Tier 2: $29.00 Tier 3: $50.00 Tier 4: 25% | $3,250 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 y Mucho Mas - Original (HMO) - H4003-018-0 Benefit Details |
Culebra | $0.00 | No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $3,250 | ||||||
Medicare y Mucho Mas - SUPREMO (HMO SNP) - H4003-009-0 Benefit Details |
Culebra | $0.00 | $0 | Many Generics | Tier 1: $3.00 Tier 2: $5.00 Tier 3: $20.00 Tier 4: $45.00 Tier 5: 25% | n/a Browse Formulary | |||||
Medicare y Mucho Mas - Unico (HMO) - H4003-019-0 Benefit Details |
Culebra | $0.00 | $0 | Many Generics | Tier 1: $5.00 Tier 2: $25.00 Tier 3: $50.00 Tier 4: 25% | $3,250 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 | |||||||||
PMC Max (HMO) - H4004-050-0 Benefit Details |
Culebra | $0.00 | $0 | Many Generics | Tier 1: $5.00 Tier 2: $25.00 Tier 3: 25% | $3,250 Browse Formulary | |||||
Premier Preferred (HMO SNP) - H4004-048-0 Benefit Details |
Culebra | $ 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 | |||||
Triple-S Medicare Optimo (PPO) - H4005-001-0 Benefit Details |
Culebra | $0.00 | No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $6,700 | ||||||
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 | |||||||||
Triple-S Medicare Optimo Novel (HMO-POS) - H5732-005-0 Benefit Details |
Culebra | $0.00 | $0 | Many Generics | Tier 1: $5.00 Tier 2: $25.00 Tier 3: 25% Tier 4: 25% | $6,700 Browse Formulary | |||||
Triple-S Medicare Optimo Premier (HMO) - H5732-001-0 Benefit Details |
Culebra | $0.00 | $0 | Many Generics | Tier 1: $5.00 Tier 2: $30.00 Tier 3: $50.00 Tier 4: 25% | $6,700 Browse Formulary | |||||
Triple-S Medicare Optimo Select (HMO) (HMO) - H4012-008-0 Benefit Details |
Culebra | $0.00 | $0 | Many Generics, Few Brands | Tier 1: $0.00 Tier 2: $5.00 Tier 3: $20.00 Tier 4: 25% | $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 | |||||||||
Triple-S Medicare Selecto with Medicare Platino (HMO SNP) - H4012-003-0 Benefit Details |
Culebra | $ 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 | |||||
Triple-S Medicare Selecto with Medicare Platino 2 (HMO SNP) - H4012-009-0 Benefit Details |
Culebra | $ 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 | |||||
MCS Classicare Especial (HMO SNP) - H4006-013-0 Benefit Details |
Culebra | $ 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 | |||||
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 | |||||||||
MCS Classicare Ideal (HMO SNP) - H5577-002-0 Benefit Details |
Culebra | $ 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 | |||||
HumanaChoice H2029-001 (PPO) - H2029-001-0 Benefit Details |
Culebra | $30.70 | $0 | Some Generics, Few Brands | Tier 1: $4.00 Tier 2: $39.00 Tier 3: $77.00 Tier 4: 33% | $3,400 Browse Formulary | |||||
Triple-S Medicare Optimo Plus (PPO) - H4005-004-0 Benefit Details |
Culebra | $55.00 | $0 | Many Generics | Tier 1: $5.00 Tier 2: $15.00 Tier 3: 25% Tier 4: 25% | $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 | |||||||||
MCS Classicare Advanced Health (HMO-POS) - H4006-008-0 Benefit Details |
Culebra | $67.00 | $0 | Many Generics | Tier 1: $0.00 Tier 2: $3.00 Tier 3: $18.00 Tier 4: $36.00 Tier 5: 25% | $3,400 Browse Formulary | |||||
HumanaChoice H2029-002 (PPO) - H2029-002-0 Benefit Details |
Culebra | $79.00 | $0 | Some Generics, Few Brands | Tier 1: $3.00 Tier 2: $30.00 Tier 3: $68.00 Tier 4: 33% | $3,400 Browse Formulary | |||||
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