Lasso Healthcare (MSA) - H1924-001-0
Benefit Details
|
Dauphin |
$0.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | n/a |
|
|
|
|
AARP Medicare Advantage Choice Plan 3 (PPO) - H2228-086-0
Benefit Details
|
Dauphin |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $6,700 Browse Formulary |
|
|
|
|
Aetna Medicare Advantra Core (HMO) - H3959-041-0
Benefit Details
|
Dauphin |
$0.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,900 |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible | Additional Gap Coverage | Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Aetna Medicare Advantra Credit Value (PPO) - H5522-017-0
Benefit Details
|
Dauphin |
$0.00 |
$250 Tier 1 and 2 exempt |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $7.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 28%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare Advantra Silver (PPO) - H5522-004-0
Benefit Details
|
Dauphin |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare PinnacleHealth Prime (HMO) - H3931-091-0
Benefit Details
|
Dauphin |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible | Additional Gap Coverage | Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Aetna Medicare Value (PPO) - H5521-263-0
Benefit Details
|
Dauphin |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $2.00 Generic: $5.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Allwell Medicare (HMO) - H2915-006-0
Benefit Details
|
Dauphin |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
-- |
-- |
|
|
BlueJourney Essential (HMO) - H3962-007-0
Benefit Details
|
Dauphin |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $40.00 Non-Preferred Brand: $93.00 Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible | Additional Gap Coverage | Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Community Blue Medicare HMO Signature (HMO) - H3957-042-2
Benefit Details
|
Dauphin |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $5,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Community Blue Medicare PPO Signature (PPO) - H3916-037-2
Benefit Details
|
Dauphin |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Geisinger Gold Classic Essential Rx (HMO) - H3954-159-17
Benefit Details
|
Dauphin |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33% Vaccines: $0.00
| $6,700 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible | Additional Gap Coverage | Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Geisinger Gold Preferred Complete Rx (PPO) - H3924-060-17
Benefit Details
|
Dauphin |
$0.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33% Vaccines: $0.00
| $6,700 Browse Formulary |
|
|
|
|
Health Partners Medicare Simple (HMO-POS) - H9207-011-0
Benefit Details
|
Dauphin |
$0.00 |
$350 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: 25% Specialty Tier: 26%
| $6,700 Browse Formulary |
|
|
|
|
Humana Gold Plus H6622-035 (HMO) - H6622-035-0
Benefit Details
|
Dauphin |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible | Additional Gap Coverage | Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Humana Honor (PPO) - H5216-221-0
Benefit Details
|
Dauphin |
$0.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $6,700 |
|
|
|
|
HumanaChoice H5216-116 (PPO) - H5216-116-0
Benefit Details
|
Dauphin |
$0.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $3,900 |
|
|
|
|
HumanaChoice H5525-038 (PPO) - H5525-038-0
Benefit Details
|
Dauphin |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible | Additional Gap Coverage | Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
HumanaChoice R0923-001 (Regional PPO) - R0923-001-0
Benefit Details
|
Dauphin |
$0.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,900 |
|
-- |
|
|
UPMC for Life HMO No Rx (HMO) - H3907-002-0
Benefit Details
|
Dauphin |
$0.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $3,400 |
|
|
|
|
UPMC for Life HMO Premier Rx (HMO) - H3907-052-0
Benefit Details
|
Dauphin |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible | Additional Gap Coverage | Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Vibra Health Plan Essential (PPO) - H9408-001-0
Benefit Details
|
Dauphin |
$0.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $40.00 Non-Preferred Brand: $93.00 Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
AARP Medicare Advantage (HMO) - H1944-024-0
Benefit Details
|
Dauphin |
$15.50 |
$130 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Generic: $12.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $6,700 Browse Formulary |
|
|
|
|
Aetna Medicare Advantra Cares (HMO D-SNP) - H3959-036-0
Benefit Details
|
Dauphin |
$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 | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 29%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible | Additional Gap Coverage | Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
UPMC for Life HMO Deductible with Rx (HMO) - H3907-037-0
Benefit Details
|
Dauphin |
$22.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
UnitedHealthcare Dual Complete (HMO D-SNP) - H3113-009-0
Benefit Details
|
Dauphin |
$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 | : $0.00 Tier 2: $0.00 Tier 3: $0.00 Tier 4: $0.00 Tier 5: $0.00
| n/a Browse Formulary |
|
|
|
|
AARP Medicare Advantage Choice Plan 1 (PPO) - H2228-035-0
Benefit Details
|
Dauphin |
$25.00 |
$95 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 31%
| $6,700 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible | Additional Gap Coverage | Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
BlueJourney Alliance Heart and Diabetes Care (HMO C-SNP) - H3962-019-0
Benefit Details
|
Dauphin |
$25.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $40.00 Non-Preferred Brand: $93.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Vibra Health Plan Enhanced Complete (PPO) - H9408-005-0
Benefit Details
|
Dauphin |
$25.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $40.00 Non-Preferred Brand: $93.00 Specialty Tier: 33% Select Care Drugs: $0.00
| $5,800 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Aetna Medicare Advantra Premier (HMO) - H3959-039-0
Benefit Details
|
Dauphin |
$27.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible | Additional Gap Coverage | Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Aetna Medicare Advantra Silver Plus (PPO) - H5522-013-0
Benefit Details
|
Dauphin |
$28.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice H5525-006 (PPO) - H5525-006-0
Benefit Details
|
Dauphin |
$28.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Humana Gold Plus SNP-DE H6622-038 (HMO D-SNP) - H6622-038-0
Benefit Details
|
Dauphin |
$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 | Preferred Generic: $0.00 Generic: $19.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 25%
| n/a Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible | Additional Gap Coverage | Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Geisinger Gold Classic Advantage (HMO) - H3954-156-17
Benefit Details
|
Dauphin |
$30.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $3,400 |
|
|
|
|
BlueJourney Alliance Lung Care (HMO C-SNP) - H3962-018-0
Benefit Details
|
Dauphin |
$33.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $40.00 Non-Preferred Brand: $93.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Allwell Dual Medicare (HMO D-SNP) - H2915-007-0
Benefit Details
|
Dauphin |
$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 | : $0.00
| n/a Browse Formulary |
-- |
-- |
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible | Additional Gap Coverage | Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Community Blue Medicare PPO Distinct (PPO) - H3916-034-3
Benefit Details
|
Dauphin |
$35.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $5,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP) - H0710-017-0
Benefit Details
|
Dauphin |
$35.40 |
$435 |
No additional gap coverage, only the Donut Hole Discount | : 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% Tier 5: 25%
| n/a Browse Formulary |
|
-- |
|
|
AmeriHealth Caritas VIP Care (HMO D-SNP) - H4227-002-0
Benefit Details
|
Dauphin |
$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 | Generic: $6.00 Brand: 25%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible | Additional Gap Coverage | Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Gateway Health Medicare Assured Diamond (HMO D-SNP) - H5932-001-0
Benefit Details
|
Dauphin |
$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 | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: 44% Specialty Tier: 25%
| n/a Browse Formulary |
|
|
|
|
Gateway Health Medicare Assured Ruby (HMO D-SNP) - H5932-009-0
Benefit Details
|
Dauphin |
$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 | Preferred Generic: $0.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: 44% Specialty Tier: 25%
| n/a Browse Formulary |
|
|
|
|
Geisinger Gold Secure Rx (HMO D-SNP) - H3954-097-0
Benefit Details
|
Dauphin |
$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 | : 15%
| n/a Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible | Additional Gap Coverage | Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Health Partners Medicare Prime (HMO-POS) - H9207-002-0
Benefit Details
|
Dauphin |
$35.60 |
$350 Tier 1, 2 and 6 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: 25% Specialty Tier: 26% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
|
Health Partners Medicare Special (HMO D-SNP) - H9207-004-0
Benefit Details
|
Dauphin |
$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 | : 15%
| n/a Browse Formulary |
|
|
|
|
UPMC for Life Dual (HMO D-SNP) - H4279-001-0
Benefit Details
|
Dauphin |
$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 | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $10.00 Non-Preferred Drug: 46% Specialty Tier: 25%
| n/a Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible | Additional Gap Coverage | Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Geisinger Gold Classic Complete Rx (HMO) - H3954-158-17
Benefit Details
|
Dauphin |
$38.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33% Vaccines: $0.00
| $4,900 Browse Formulary |
|
|
|
|
Humana Gold Choice H8145-055 (PFFS) - H8145-055-0
Benefit Details
|
Dauphin |
$38.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | n/a |
|
-- |
|
|
BlueJourney Alliance Assisted Care (HMO I-SNP) - H3962-020-0
Benefit Details
|
Dauphin |
$40.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $40.00 Non-Preferred Brand: $93.00 Specialty Tier: 33% Select Care Drugs: $0.00
| n/a Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible | Additional Gap Coverage | Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
UPMC for Life HMO Rx Choice (HMO) - H3907-049-0
Benefit Details
|
Dauphin |
$40.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $4,250 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Geisinger Gold Preferred Enhanced Rx (PPO) - H3924-062-17
Benefit Details
|
Dauphin |
$45.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33% Vaccines: $0.00
| $5,500 Browse Formulary |
|
|
|
|
UPMC for Life PPO Rx Enhanced (PPO) - H5533-008-0
Benefit Details
|
Dauphin |
$47.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible | Additional Gap Coverage | Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
BlueJourney Classic (PPO) - H3923-013-0
Benefit Details
|
Dauphin |
$49.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $40.00 Non-Preferred Brand: $93.00 Specialty Tier: 33% Select Care Drugs: $0.00
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
BlueJourney Value (HMO) - H3962-004-0
Benefit Details
|
Dauphin |
$50.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $40.00 Non-Preferred Brand: $93.00 Specialty Tier: 33% Select Care Drugs: $0.00
| $4,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
AARP Medicare Advantage Choice Plan 2 (PPO) - H2228-036-0
Benefit Details
|
Dauphin |
$58.00 |
$150 Tier 1, 2 and 3 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Generic: $8.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 30%
| $5,900 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible | Additional Gap Coverage | Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Aetna Medicare Silver (HMO) - H3931-070-0
Benefit Details
|
Dauphin |
$59.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Freedom Blue PPO ValueRx (PPO) - H3916-018-0
Benefit Details
|
Dauphin |
$70.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $13.00 Preferred Brand: $45.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $5,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
HumanaChoice R0923-002 (Regional PPO) - R0923-002-0
Benefit Details
|
Dauphin |
$71.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Drug: $99.00 Specialty Tier: 33%
| $6,700 Browse Formulary |
|
-- |
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible | Additional Gap Coverage | Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Aetna Medicare Advantra Premier Plus (PPO) - H5522-002-0
Benefit Details
|
Dauphin |
$72.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $5,900 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Humana Gold Choice H8145-052 (PFFS) - H8145-052-0
Benefit Details
|
Dauphin |
$74.00 |
$360 Tier 1 and 2 exempt |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Generic: $17.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 26%
| n/a Browse Formulary |
|
-- |
|
Higher cost-sharing at standard network pharmacies. Details:
|
Freedom Blue PPO Basic (PPO) - H3916-012-0
Benefit Details
|
Dauphin |
$77.00 |
No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $5,900 |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible | Additional Gap Coverage | Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
UPMC for Life HMO Rx (HMO) - H3907-029-0
Benefit Details
|
Dauphin |
$81.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Geisinger Gold Preferred Advantage Rx (PPO) - H3924-059-17
Benefit Details
|
Dauphin |
$87.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33% Vaccines: $0.00
| $4,000 Browse Formulary |
|
|
|
|
HumanaChoice H5216-120 (PPO) - H5216-120-0
Benefit Details
|
Dauphin |
$126.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $5.00 Generic: $15.00 Preferred Brand: $47.00 Non-Preferred Drug: $97.00 Specialty Tier: 33%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible | Additional Gap Coverage | Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
Aetna Medicare Gold Plan (PPO) - H5521-122-0
Benefit Details
|
Dauphin |
$146.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $2.00 Generic: $5.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $6,700 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
BlueJourney Premier (HMO) - H3962-001-0
Benefit Details
|
Dauphin |
$148.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $0.00 Preferred Brand: $40.00 Non-Preferred Brand: $93.00 Specialty Tier: 33% Select Care Drugs: $0.00
| $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Geisinger Gold Classic Advantage Rx (HMO) - H3954-157-17
Benefit Details
|
Dauphin |
$149.00 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $3.00 Generic: $20.00 Preferred Brand: $47.00 Non-Preferred Brand: $100.00 Specialty Tier: 33% Vaccines: $0.00
| $3,400 Browse Formulary |
|
|
|
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible | Additional Gap Coverage | Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
BlueJourney Prime (PPO) - H3923-017-0
Benefit Details
|
Dauphin |
$170.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $5.00 Preferred Brand: $40.00 Non-Preferred Brand: $93.00 Specialty Tier: 33% Select Care Drugs: $0.00
| $4,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Freedom Blue PPO Standard (PPO) - H3916-015-0
Benefit Details
|
Dauphin |
$185.50 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $13.00 Preferred Brand: $45.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $5,000 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Freedom Blue PPO Deluxe (PPO) - H3916-005-0
Benefit Details
|
Dauphin |
$288.50 |
$0 |
Yes, some additional gap coverage. | Preferred Generic: $0.00 Generic: $13.00 Preferred Brand: $45.00 Non-Preferred Drug: $95.00 Specialty Tier: 33%
| $4,500 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|
Plan Name |
County |
Monthly Prem. |
Deduct- ible | Additional Gap Coverage | Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
Service |
Exper. |
Cost Info |
UPMC for Life HMO Rx Enhanced (HMO) - H3907-006-0
Benefit Details
|
Dauphin |
$301.00 |
$0 |
No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Generic: $10.00 Preferred Brand: $47.00 Non-Preferred Drug: $100.00 Specialty Tier: 33%
| $3,400 Browse Formulary |
|
|
|
Higher cost-sharing at standard network pharmacies. Details:
|