2014 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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HumanaChoice R5826-023 P (Regional PPO) - R5826-023-0 Benefit Details |
Polk | $0.00 | No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,500 | ||||||
Humana Gold Choice H8145-153 (PFFS) - H8145-153-0 Benefit Details |
Polk | $24.00 | No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | n/a | ||||||
UCare for Seniors Value (HMO-POS) - H4270-001-0 Benefit Details |
Polk | $25.00 | 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 | |||||||||
Humana Gold Plus H6622-003 (HMO) - H6622-003-0 Benefit Details |
Polk | $40.00 | $0 | Few Generics, Few Brands | Preferred Generic: $6.00 Non-Preferred Generic: $15.00 Preferred Brand: $45.00 Non-Preferred Brand: $95.00 Specialty Tier: 33% | $6,700 Browse Formulary | |||||
UCare for Seniors Essentials Rx (HMO-POS) - H4270-006-0 Benefit Details |
Polk | $48.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $5.00 Non-Preferred Generic: $25.00 Preferred Brand: $45.00 Non-Preferred Brand: $90.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Medica Prime Solution Thrift with Part D Option 1 (Cost) - H2450-007-0 Benefit Details |
Polk | $60.70 | $310 | 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 | |||||
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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 | |||||||||
HealthPartners Wisconsin Freedom Basic (Cost) - H2462-015-0 Benefit Details |
Polk | $66.00 | No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | n/a | ||||||
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Medica Prime Solution Value with Part D Option 1 (Cost) - H2450-022-0 Benefit Details |
Polk | $84.70 | $310 | 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 | |||||
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Medica Prime Solution Basic with Part D Option 1 (Cost) - H2450-016-0 Benefit Details |
Polk | $100.70 | $310 | 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 | |||||
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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 |
Polk | $106.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $5.00 Non-Preferred Generic: $15.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 25% | $3,400 Browse Formulary | |||||
HumanaChoice R5826-009 P (Regional PPO) - R5826-009-0 Benefit Details |
Polk | $112.00 | $310 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% Tier 5: 25% | $6,700 Browse Formulary | |||||
Medica Prime Solution Value with Part D Option 2 (Cost) - H2450-023-0 Benefit Details |
Polk | $125.50 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic: $10.00 Preferred Brand: $39.00 Non-Preferred Brand: $79.00 Specialty Tier: 33% | n/a 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 | |||||||||
Medica Prime Solution Basic with Part D Option 2 (Cost) - H2450-001-0 Benefit Details |
Polk | $141.50 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic: $10.00 Preferred Brand: $39.00 Non-Preferred Brand: $79.00 Specialty Tier: 33% | n/a Browse Formulary | |||||
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Medica Prime Solution Enhanced w/Part D Option 1 (Cost) - H2450-017-0 Benefit Details |
Polk | $150.70 | $310 | 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 | |||||
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HealthPartners Wisconsin Freedom Balance (Cost) - H2462-016-0 Benefit Details |
Polk | $191.00 | 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 | |||||||||
Medica Prime Solution Enhanced w/Part D Option 2 (Cost) - H2450-002-0 Benefit Details |
Polk | $191.50 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic: $10.00 Preferred Brand: $39.00 Non-Preferred Brand: $79.00 Specialty Tier: 33% | n/a Browse Formulary | |||||
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HealthPartners Wisconsin Freedom Balance with Rx (Cost) - H2462-017-0 Benefit Details |
Polk | $234.00 | $310 | 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 | |||||
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