2013 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 | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $45.00 Non-Preferred Brand: $95.00 Specialty Tier: 33% | $4,500 Browse Formulary | |||||
AARP MedicareComplete Plan 2 (HMO) - H3805-013-0 Benefit Details |
Lane | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Non-Preferred Generic: $7.00 Preferred Brand: $45.00 Non-Preferred Brand: $95.00 Specialty Tier: 33% | $4,200 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 | Preferred Generic: $3.00 Non-Preferred Generic: $20.00 Preferred Brand: $45.00 Non-Preferred Brand: $95.00 Specialty Tier: 33% | $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 | |||||||||
PacificSource Medicare Essentials Rx 15 (HMO) - H3864-015-0 Benefit Details |
Lane | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $5.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $2,750 Browse Formulary | |||||
Providence Medicare Choice (HMO-POS) - H9047-035-0 Benefit Details |
Lane | $20.00 | No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $3,000 | ||||||
Trillium Advantage (HMO) - H2174-004-0 Benefit Details |
Lane | $25.00 | 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 | |||||||||
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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Trillium Advantage Dual (HMO SNP) - H2174-001-0 Benefit Details |
Lane | $0.00 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% Tier 4: 25% | n/a Browse Formulary | |||||
Trillium Advantage TLC Community ISNP (HMO SNP) - H2174-005-0 Benefit Details |
Lane | $34.00 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% 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 | |||||||||
Trillium Advantage TLC ISNP (HMO SNP) - H2174-003-0 Benefit Details |
Lane | $34.00 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | 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 | $37.50 | $325 | 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 | |||||||||
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 | ||||||
AARP MedicareComplete Plan 1 (HMO) - H3805-007-0 Benefit Details |
Lane | $49.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $44.00 Non-Preferred Brand: $88.00 Specialty Tier: 33% | $3,750 Browse Formulary | |||||
Trillium Advantage Rx Smart (HMO) - H2174-008-0 Benefit Details |
Lane | $49.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic: $8.00 Preferred Brand: $45.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $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 | $52.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Non-Preferred Generic: $11.00 Preferred Brand: $35.00 Non-Preferred Brand: $70.00 Injectable Drugs: 33% Specialty Tier: 33% | $3,000 Browse Formulary | |||||
Regence MedAdvantage + Rx Classic (PPO) - H3817-002-0 Benefit Details |
Lane | $53.00 | $165 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.50 Non-Preferred Generic: $33.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 29% Injectable Drugs: 29% | $3,400 Browse Formulary | |||||
ODS Advantage PPO (PPO) - H3813-001-0 Benefit Details |
Lane | $57.00 | 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 | |||||||||
Providence Medicare Extra Part B Only + RX (HMO) - H9047-013-0 Benefit Details |
LANE | $59.60 | $0 | n/a | Preferred Generic: $6.00 Non-Preferred Generic: $11.00 Preferred Brand: $35.00 Non-Preferred Brand: $70.00 Injectable Drugs: 33% Specialty Tier: 33% | n/a Browse Formulary | |||||
ODS Advantage PPORX (PPO) - H3813-006-0 Benefit Details |
Lane | $68.00 | $120 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $5.00 Non-Preferred Generic: $33.00 Preferred Brand: $41.00 Non-Preferred Brand: 50% Specialty Tier: 30% | $3,400 Browse Formulary | |||||
PacificSource Medicare Explorer Rx 4 (PPO) - H4754-004-0 Benefit Details |
Lane | $73.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Brand: $75.00 Specialty Tier: 33% | $2,500 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 | |||||||||
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 | Preferred Generic: $3.00 Non-Preferred Generic: $15.00 Preferred Brand: $42.00 Non-Preferred Brand: $95.00 Specialty Tier: 33% | $2,500 Browse Formulary | |||||
Providence Medicare Extra + RX (HMO) - H9047-001-0 Benefit Details |
Lane | $133.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Non-Preferred Generic: $11.00 Preferred Brand: $35.00 Non-Preferred Brand: $70.00 Injectable Drugs: 33% Specialty Tier: 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 | |||||||||
ODS Advantage PPORX Select (PPO) - H3813-003-0 Benefit Details |
Lane | $139.00 | $120 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $5.00 Non-Preferred Generic: $33.00 Preferred Brand: $41.00 Non-Preferred Brand: 50% Specialty Tier: 30% | $3,400 Browse Formulary | |||||
Regence MedAdvantage + Rx Enhanced (PPO) - H3817-003-0 Benefit Details |
Lane | $143.00 | $0 | Many Generics | Preferred Generic: $5.00 Non-Preferred Generic: $33.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 33% Injectable Drugs: 33% | $2,500 Browse Formulary | |||||
Health Net Healthy Heart (PPO) - H5520-009-0 Benefit Details |
Lane | $159.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $10.00 Preferred Brand: $35.00 Non-Preferred Brand: $95.00 Specialty Tier: 33% | $2,000 Browse Formulary | |||||
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