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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Advocare Essence (HMO-POS) - H5211-003-0 Benefit Details |
Washburn | $0.00 | No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $3,400 | ||||||
Humana Gold Choice H8145-121 (PFFS) - H8145-121-0 Benefit Details |
Washburn | $0.00 | No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $5,000 | ||||||
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HumanaChoice R5826-023 (Regional PPO) - R5826-023-0 Benefit Details |
Washburn | $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 | |||||||||
HumanaChoice H5216-007 (PPO) - H5216-007-0 Benefit Details |
Washburn | $36.00 | $0 | Few Generics, Few Brands | Tier 1: $5.00 Tier 2: $34.00 Tier 3: $75.00 Tier 4: 33% | $4,500 Browse Formulary | |||||
Advocare Essence Rx (HMO-POS) - H5211-002-0 Benefit Details |
Washburn | $39.00 | $0 | Few Generics | Tier 1: $6.00 Tier 2: $35.00 Tier 3: $70.00 Tier 4: 33% | $3,400 Browse Formulary | |||||
Medica Prime Solution Thrift with Part D Option 1 (Cost) - H2450-007-0 Benefit Details |
Washburn | $55.50 | $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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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 H8145-006 (PFFS) - H8145-006-0 Benefit Details |
Washburn | $61.00 | $0 | Few Generics, Few Brands | Tier 1: $7.00 Tier 2: $41.00 Tier 3: $80.00 Tier 4: 33% | $6,000 Browse Formulary | |||||
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UCare for Seniors Value (HMO-POS) - H4270-001-0 Benefit Details |
Washburn | $61.00 | No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $3,400 | ||||||
HealthPartners Wisconsin Freedom Basic (Cost) - H2462-015-0 Benefit Details |
Washburn | $62.00 | No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | n/a | ||||||
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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 | |||||||||
HumanaChoice R5826-009 (Regional PPO) - R5826-009-0 Benefit Details |
Washburn | $67.00 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $5,000 Browse Formulary | |||||
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UCare for Seniors Standard D (HMO-POS) - H4270-004-0 Benefit Details |
Washburn | $67.00 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% | $3,400 Browse Formulary | |||||
Medica Prime Solution Value with Part D Option 1 (Cost) - H2450-022-0 Benefit Details |
Washburn | $85.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,350 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 | |||||||||
UCare for Seniors Value Plus (HMO-POS) - H4270-003-0 Benefit Details |
Washburn | $89.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $10.00 Tier 2: $35.00 Tier 3: $70.00 Tier 4: 25% | $3,400 Browse Formulary | |||||
Medica Prime Solution Value with Part D Option 2 (Cost) - H2450-023-0 Benefit Details |
Washburn | $102.60 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
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Medica Prime Solution Basic with Part D Option 1 (Cost) - H2450-016-0 Benefit Details |
Washburn | $105.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 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 | |||||||||
Advocare Spirit (HMO-POS) - H5211-001-0 Benefit Details |
Washburn | $118.00 | No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $900 | ||||||
Medica Prime Solution Basic with Part D Option 2 (Cost) - H2450-001-0 Benefit Details |
Washburn | $122.60 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,000 Browse Formulary | |||||
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Medica Prime Solution Enhanced w/Part D Option 1 (Cost) - H2450-017-0 Benefit Details |
Washburn | $155.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 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 | |||||||||
UCare for Seniors Classic (HMO-POS) - H4270-002-0 Benefit Details |
Washburn | $159.00 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $35.00 Tier 3: $70.00 Tier 4: 25% | $3,400 Browse Formulary | |||||
Medica Prime Solution Value with Part D Option 3 (Cost) - H2450-028-0 Benefit Details |
Washburn | $161.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,350 Browse Formulary | |||||
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Advocare Spirit Rx (HMO-POS) - H5211-004-0 Benefit Details |
Washburn | $167.00 | $0 | Few Generics | Tier 1: $6.00 Tier 2: $35.00 Tier 3: $70.00 Tier 4: 33% | $900 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 | |||||||||
Medica Prime Solution Enhanced w/Part D Option 2 (Cost) - H2450-002-0 Benefit Details |
Washburn | $172.60 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,000 Browse Formulary | |||||
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Medica Prime Solution Basic with Part D Option 3 (Cost) - H2450-005-0 Benefit Details |
Washburn | $181.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,000 Browse Formulary | |||||
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Advocare Vitality (HMO-POS) - H5211-006-0 Benefit Details |
Washburn | $192.00 | No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | n/a | ||||||
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 | |||||||||
Medica Prime Solution Enhanced w/Part D Option 3 (Cost) - H2450-006-0 Benefit Details |
Washburn | $231.20 | $0 | Many Generics | Tier 1: $10.00 Tier 2: $34.00 Tier 3: $74.00 Tier 4: 25% | $3,000 Browse Formulary | |||||
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HealthPartners Wisconsin Freedom Ultimate (Cost) - H2462-016-0 Benefit Details |
Washburn | $236.00 | No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $3,000 | ||||||
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Advocare Vitality Rx (HMO-POS) - H5211-005-0 Benefit Details |
Washburn | $254.00 | $0 | Few Generics | Tier 1: $6.00 Tier 2: $35.00 Tier 3: $70.00 Tier 4: 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 | |||||||||
HealthPartners Wisconsin Freedom Ultimate with Rx (Cost) - H2462-017-0 Benefit Details |
Washburn | $258.50 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,000 Browse Formulary | |||||
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