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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Geisinger Gold Reserve (MSA) - H8468-001-0 Benefit Details |
Philadelphia | $0.00 | No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | n/a | ||||||
Advantra Silver (HMO) - H3959-031-0 Benefit Details |
Philadelphia | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $4.00 Tier 2: $25.00 Tier 3: $35.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Aetna Medicare Basic Plan (HMO) - H3931-054-0 Benefit Details |
Philadelphia | $0.00 | No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $6,700 | ||||||
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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 | |||||||||
Any, Any, Any Gold (PFFS) - H8098-001-0 Benefit Details |
Philadelphia | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
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Any, Any, Any Gold MA Only (PFFS) - H8098-003-0 Benefit Details |
Philadelphia | $0.00 | No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $6,700 | ||||||
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Bravo Achieve (HMO SNP) - H3949-024-0 Benefit Details |
Philadelphia | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $4.00 Tier 2: $10.00 Tier 3: $40.00 Tier 4: $80.00 Tier 5: 33% Tier 6: $5.00 | 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 | |||||||||
Bravo Classic (HMO) - H3949-002-0 Benefit Details |
Philadelphia | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $4.00 Tier 2: $10.00 Tier 3: $40.00 Tier 4: $80.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
Bravo Gold (HMO) - H3964-001-0 Benefit Details |
Philadelphia | $0.00 | No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $6,700 | ||||||
HumanaChoice R5826-062 (Regional PPO) - R5826-062-0 Benefit Details |
Philadelphia | $0.00 | No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $3,400 | ||||||
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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 | |||||||||
Universal Hassle-Free (PPO) - H5096-001-0 Benefit Details |
Philadelphia | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $15.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
new | new | new | |||||||||
Universal Hassle-Free MA Only (PPO) - H5096-002-0 Benefit Details |
Philadelphia | $0.00 | No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $6,700 | ||||||
new | new | new | |||||||||
Keystone 65 Select Medical Only (HMO) - H3952-048-0 Benefit Details |
Philadelphia | $15.00 | 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 | |||||||||
Bravo Gold Rx (HMO-POS) - H3964-003-0 Benefit Details |
Philadelphia | $28.00 | $185 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $8.00 Tier 2: $11.00 Tier 3: $40.00 Tier 4: $80.00 Tier 5: 28% | $6,700 Browse Formulary | |||||
UnitedHealthcare Nursing Home Plan (PPO SNP) - H3912-001-0 Benefit Details |
Philadelphia | $32.70 | $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 | |||||
Gateway Health Plan Medicare Assured (HMO SNP) - H5932-001-0 Benefit Details |
Philadelphia | $ 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 | |||||||||
Bravo Select (HMO SNP) - H3949-009-0 Benefit Details |
Philadelphia | $ 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 | |||||
Bravo Silver (HMO SNP) - H3964-002-0 Benefit Details |
Philadelphia | $ 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 | |||||
Bravo Traditions (HMO SNP) - H3949-016-0 Benefit Details |
Philadelphia | $34.30 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 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 | |||||||||
Advantra Gold (PPO) - H5522-014-0 Benefit Details |
Philadelphia | $39.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $25.00 Tier 3: $38.00 Tier 4: $80.00 Tier 5: 33% | $4,800 Browse Formulary | |||||
Aetna Medicare Standard Plan (HMO) - H3931-065-0 Benefit Details |
Philadelphia | $39.00 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $3.00 Tier 2: $27.00 Tier 3: $32.00 Tier 4: $75.00 Tier 5: 25% | $6,700 Browse Formulary | |||||
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Keystone 65 Select Rx (HMO) - H3952-049-0 Benefit Details |
Philadelphia | $42.10 | $280 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $4.00 Tier 2: $40.00 Tier 3: $80.00 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 | |||||||||
HumanaChoice R5826-081 (Regional PPO) - R5826-081-0 Benefit Details |
Philadelphia | $58.00 | $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 | |||||
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HumanaChoice R5826-002 (Regional PPO) - R5826-002-0 Benefit Details |
Philadelphia | $79.00 | $0 | Few Generics, Few Brands | Tier 1: $8.00 Tier 2: $44.00 Tier 3: $85.00 Tier 4: 33% | $5,000 Browse Formulary | |||||
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Bravo Premier (HMO) - H3949-013-0 Benefit Details |
Philadelphia | $89.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $0.00 Tier 2: $0.00 Tier 3: $35.00 Tier 4: $70.00 Tier 5: 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 | |||||||||
Keystone 65 Preferred Medical Only (HMO) - H3952-008-0 Benefit Details |
Philadelphia | $114.40 | No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $6,700 | ||||||
Aetna Medicare Premier Plan (HMO) - H3931-058-0 Benefit Details |
Philadelphia | $140.00 | $0 | Many Generics | Tier 1: $5.00 Tier 2: $33.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
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Keystone 65 Preferred Rx (HMO) - H3952-020-0 Benefit Details |
Philadelphia | $155.30 | $100 | Many Generics | Tier 1: $5.00 Tier 2: $40.00 Tier 3: $80.00 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 | |||||||||
Humana Gold Choice H8145-054 (PFFS) - H8145-054-0 Benefit Details |
Philadelphia | $191.00 | $0 | Few Generics, Few Brands | Tier 1: $8.00 Tier 2: $45.00 Tier 3: $85.00 Tier 4: 33% | $6,700 Browse Formulary | |||||
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Personal Choice 65 Medical Only (PPO) - H3909-007-0 Benefit Details |
Philadelphia | $245.00 | No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $6,700 | ||||||
Personal Choice 65 Rx (PPO) - H3909-001-0 Benefit Details |
Philadelphia | $287.30 | $240 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $4.00 Tier 2: $40.00 Tier 3: $80.00 Tier 4: 25% | $6,700 Browse Formulary | |||||
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