|
|
Premium
|
PCP/Specialist
|
In-Pt Hospitalization
|
Out-Pt Surgery
|
DME
|
Pharmacy (Formulary)
|
Base Dental
|
Optional Supplemental
Benefits
|
|
Aetna
Golden Medicare Plan
(Los
Angeles)
|
$0
Must
pay Medicare
Part
B Premium & Part D Prescription Drug Benefits
|
$5
/ $10
|
$75
per day (days 1-5)
$0
per day (days 6-90)
|
$100
copay
|
20%
of Medicare
|
$2
Tier 1 Generic 30 day
$20
Tier 2 Brand 30 day
$40
Tier 3 Non-Pref 30 day
$6
Tier 1 Generic 90 day
$60
Tier 2 Brand 90 day
$120
Tier 3 Non-Pref 90 day
Annual
Out Pocket Max $3600
$2
Gen/Brand multi-source
$5
for all others or 5% co-Ins
|
None
|
Preventive
Dental Plan:
($5
additional monthly premium)
Advantage
Dental Plan:
($10
additional monthly premium)
|
|
Aetna
Golden Medicare Plan
(Orange
County)
|
$0
Must
pay Medicare
Part
B Premium &
Part
D Prescription Drug Benefits
|
$5
/ $10
|
$75
per day (days 1-5)
$0
per day (days 6-90)
|
$100
copay
|
20%
of Medicare
|
$10
Generic 30 day supply
$20
Generic 90 day mail order
$25
Brand 30 day supply
$50
Brand up to 90 day supply
Annual
Out Pocket Max $3600
$2
Gen/Brand multi-source
$5
for all others or 5% co-Ins
|
None
|
Preventive
Dental Plan:
($5
additional monthly premium)
Advantage
Dental Plan:
($10
additional monthly premium)
|
|
Blue
Cross Senior Secure Plan I
(Los
Angeles & Orange County)
|
$0
Must
pay Medicare
Part
B Premium &
Part
D Prescription Drug Benefits
|
$5
/ $10
|
$75
per day (days 1-21)
$0
per day (days 22-90
|
$100
each Medicare
covered
visit
|
20%
of Medicare
|
$10
Generic 30 day supply
$30
Brand 90 day supply
$60
Form Brand 30 day supply
30%
co-Ins non-spec Injectable
$30
Generic 90 day supply
$90
Form Pref Brand 90 day
$180
Form Brand 90 day
Annual
Out Pocket Max $3600
$2
Gen/Brand multi-source
$5
for all others or 5% co-Ins
|
1
Oral exam, 2 cleanings, 1 x-ray covered per year.
|
Not
offered
|
|
Blue
Shield 65 Plus
(Los
Angeles)
|
$0
Must
pay Medicare
Part
B Premium & Part D Prescription Drug Benefits
|
$5
/ $10
|
$200
per day (days 1-10)
$0 per day (days 11-90)
$2,000 annual max out of pocket
|
$125
each Medicare
covered
visit
|
20%
of Medicare
|
$10
Generic 30 day supply
$35
Form Pref-brand 30 day
25%
co-Ins Form-spec 30 day
20%
co-Ins Part B/D drugs
$30
Generic 90 day(low cost)
$30
Generic 90 day(high cost)
$105
Form pref-brand 90 day
Annual
Out Pocket Max $3600
$2
Gen/Brand multi-source
$5
for all others or 5% co-Ins
|
None
|
Not
Offered
|
|
Blue
Shield 65 Plus
(Orange
County)
|
$0
|
$5
/ $10
|
$200
per day (days 1-10)
$0 per day (days 11-90)
$2,000 annual max out of pocket
|
$125
each Medicare
covered
visit
|
20%
of Medicare
|
$10
Generic 30 day supply
$35 Brand 30 day supply
25%
Co-Ins. 30 day Form Spec.
20%
Co-Ins. 30 day Part B/D
$30
Form Gen 90 day supply
$105
Brand 90 day supply
Annual
Out Pocket Max $3600
$2
Gen/Brand multi-source
$5
for all others or 5% co-Ins
|
None
|
Not
Offered
|
|
HealthNet
Seniority Plus
(Los
Angeles)
|
$0
Must
pay Medicare
Part
B Premium &
Part
D Prescription Drug Benefits
|
$10
/ $10
|
$100
per day (days 1-4)
$0
per day (day 5-90)
|
$100
deduct
|
20%
of Medicare
|
$5
Generic 30 day supply
$15
Generic 90 day mail order
$29
Brand 30 day supply
$87
Brand 90 day mail order
$165
Non Pref-Brand 90 day
$55
non-pref Generic/Brand
25%
co-Ins Inj & Spec 30 day
Annual
Out Pocket Max $3600
$2
Gen/Brand multi-source
$5
for all others or 5% co-Ins
|
None
|
Benefits
Buy Up Option:
($15
additional monthly premium)
|
|
HealthNet
Seniority Plus
(Orange
County)
|
$0
Must
pay Medicare Part B & Part D for Prescription Drug Ben.
|
$10
/ $10
|
$100
per day (days 1-4)
$0
per day (day 5-90)
|
$100
for each Medicare covered visit
|
20%
of Medicare
|
$5
Generic 30 day supply
$15
Generic 90 day supply
$29
Brand 30 day supply
$87
Brand 90 day supply
$55
Non-pref 30 day Gen/Brnd
$165
Non-Pref 90 day Gen/Bd
25%
co-Ins Injectables
Annual
Out Pocket Max $3600
$2
Gen/Brand multi-source
$5
for all others or 5% co-Ins
|
None
|
Benefits
Buy Up Option:
($15
additional monthly premium)
|
|
SCAN
(Los
Angeles)
|
$0
Must
pay Medicare Part B & Part D for Prescription Drug Ben.
|
$10
/ $10
|
$50
per day (days 1-8)
$0 per day (day 9-90)
$400 max out of pocket each stay
|
$50
copay
|
0%
to 10% of Medicare
|
$7
Generic 30 day supply
$30
Form-Pref Brand 30 day
$40
Brand 30 day in-Net
20%
co-Ins Rout Inj 30 day
25%
co-Ins Spec Inj 30 day
$14
Generic 90 day supply
$60
Form Pref Brand 90 day
$80
Brand 90 day
$10
Generic 30 day Out-Net
$40
Pref Brand 30 day Out-Net
$60
Brand 30 day Out-Net
Annual
Out Pocket Max $3600
$2
Gen/Brand multi-source
$5
for all others or 5% co-Ins
|
None
|
Not
offered
|
|
SCAN
(Orange
County)
|
$0
|
$10
/ $10
|
$50
per day (days 1-10)
$0 per day (day 11 & beyond)
$500 max out of pocket each stay
|
$50
copay
|
0%
to 10% of Medicare
|
$10
Generic 30 day supply
$20
Generic 90 day mail order
$30-$50
Brand 30 day supply
$60-$100
Brand 90 day mail
$1,600
annual drug benefit w/ $400 per quarter for Brand
|
None
|
Not
offered
|
|
Secure
Horizons (Los Angeles)
Value
Plan
|
$0
Must
pay Medicare Part B & Part D for Prescription Drug Ben.
|
$5
/ $10
|
$150
for each Medicare covered stay
|
$150
each Medicare
covered
benefit
|
20%
of Medicare cost
|
$8.50
Generic 30 day supply
$25.50
Generic 90 day supply
$26.75
Brand 30 day supply
$80.25
Brand 90 day mail
50%
co-Ins for Non-Pref
33%
co-Ins Spec 30 day
Annual
Out Pocket Max $3600
$2
Gen/Brand multi-source
$5
for all others or 5% co-Ins
|
None
|
Optional
Dental Plan:
($5 additional monthly premium)
High Option Dental Plan:
($18 additional monthly premium)
Optional Dental Plan 2:
($5 additional monthly premium)
|
|
Secure
Horizons (Orange County)
Premier
Plan & Standard Plan I
|
$0
Must
pay Medicare Part B & Part D for Prescription Drug Ben.
|
$0
/ $5
|
$200
– No copay for additional days
|
$100
each Medicare
covered
benefit
|
|
$8.50
Generic 30 day supply
$25.50
Generic 90 day supply
$26.85
Brand 30 day supply
$80.55
Brand 90 day supply
50%
co-Ins Non-pref 30 day
33%
co-Ins Specialty 30/90 day
50%
co-Ins Non-Pref 90 day
|
None
|
Optional
Dental Plan:
($5 additional monthly premium)
High Option Dental Plan:
($17 additional monthly premium)
Optional Plus Plan:
($15 additional monthly premium)
|
|
UHP
(Los
Angeles & Orange County)
|
$0
Must
pay Medicare
Part
B & D Premium
|
$10
/ $10
|
$200
per medicare covered stay. No copay for additional days
|
$10
for each Medi-
care
covered surgery
|
No
copay for Medicare
covered
items
|
$8
Generic 30 day supply
$16
Generic 90 day
$15
Brand 30 day
$30
Brand 90 day
$40
Non-Pref 30 day
$80
Non-Pref 90 day
20%
co-Ins High-cost Form
Annual
Out Pocket Max $3600
$2
Gen/Brand multi-source
$5
for all others or 5% co-Ins
|
1
Oral Exam & 1 Cleaning covered every 6 months. X-ray 1 per year covered.
Additional Available
|
Not
offered
|
|
Universal
Care Plan A
(Los
Angeles)
|
$0
Must
pay Medicare
Part
B Premium & Part D
|
$0
/ $5
|
No
copay, at a network hospital,
you
are covered for 90-days each
benefit
period
|
$100
each Medicare covered benefit
|
20%
of Medicare
|
$250
yearly deductible
$5
Generic 30 day In-Net
$20
Brand 30 day In-Net
25%co-Ins
non-pref 30 day
25%
co-Ins Spec 30 day
$15
Generic 90 day
$60
Brand 90 day
25%
coins non-pref Brand 30 day
25%
coins Spec 90 day
$2800
Annual Max
|
$25
oral exam 1x
$25
cleaning 2x
$9
fluoride 1x
$15
x-rays 1x
Annual
benefits
|
Not
offered
|
|
Universal
Care Plan A
(Orange
County)
|
$0
Must
pay Medicare
Part
B Premium & Part D
|
$10/
$15
|
$175
per day (days 1-20)
$0
per day (days 21-90)
Maximum
$3500
|
$100
each Medicare covered benefit
|
20%
of Medicare
|
$250
yearly deductible
$5
Generic 30 day In-Net
$20
Brand 30 day In-Net
25%co-Ins
non-pref 30 day
25%
co-Ins Spec 30 day
$15
Generic 90 day
$60
Brand 90 day
25%
coins non-pref Brand 30 day
25%
coins Spec 90 day
$2350
Annual Max
|
$25
oral exam 1x
$25
cleaning 2x
$9
fluoride 1x
$15
x-rays 1x
Annual
benefits
|
Not
offered
|