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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PacificSource Medicare Essentials 2 (HMO) - H3864-002-0 Benefit Details |
Jefferson | $19.00 | No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $3,400 | ||||||
PacificSource Medicare Essentials Rx 14 (HMO) - H3864-014-0 Benefit Details |
Jefferson | $55.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Preferred Brand: $40.00 Non-Preferred Brand: $85.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
ODS Advantage PPO (PPO) - H3813-001-0 Benefit Details |
Jefferson | $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 | |||||||||
ODS Advantage PPORX (PPO) - H3813-006-0 Benefit Details |
Jefferson | $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 1 (PPO) - H4754-001-0 Benefit Details |
Jefferson | $79.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
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PacificSource Medicare Essentials Rx 6 (HMO) - H3864-006-0 Benefit Details |
Jefferson | $99.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $5.00 Preferred Brand: $35.00 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 | |||||||||
ODS Advantage PPORX Select (PPO) - H3813-003-0 Benefit Details |
Jefferson | $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 | |||||
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