Plan ID: H6874-002

What You Need to Know:

  • Elite Rx (PPO) is a Medicare Advantage Health Maintenance Organization Local PPO plan.
  • It must provide all of the same hospital and medical benefits as Medicare Part A and Part B, however, costs may be different.
  • It has additional benefits not included in Medicare Part A and Part B, including prescription drug coverage.
  • The plan's monthly premium is $79, which does not include your monthly Medicare Part B premium.
  • The annual deductible for this health plan is $295 (Tier 1 and 2 excluded from the Deductible.).
  • The plan includes an out-of-pocket maximum of $4,000 per year (in-network).
  • Elite Rx (PPO) includes a Part D prescription drug plan for prescription medication coverage. The annual deductible is $295 (Tier 1 and 2 excluded from the Deductible.).
  • This plan's Part D Initial Coverage Limit is $26.

$79

Monthly Premium

Medicare Plan Features
Monthly Premium: $79.00
Part C Premium: $52.70
Monthly Premium: Part C Premium: Part D Drug Premium: Part D Supplemental Premium: Total Part D Premium: Drug Deductible: Tiers with No Deductible:
$79.00 $52.70 $26.30 $0 $26.30 $295.0 1.0
Gap Coverage: No
Benchmark: not below the regional benchmark
Type of Medicare Health: Enhanced Alternative
Health Plan Type: Local PPO
Similar Plan: H6874-003
Special Needs Type: NULL
Chronic Condition: NULL
Additional Gap Coverage: No additional gap coverage, only the Donut Hole Discount
Maximum Out-of-Pocket Limit for Parts A & B (Moop): $4,000
Annual Deductible: $295 (Tier 1 and 2 excluded from the Deductible.)
Annual Initial Coverage Limit ICL: $4,130
Number of Members enrolled in this plan in Shawano, Wisconsin: Plans Summary Star Rating: Customer Service Rating: Drug Cost Rating:
less than 10 members New plan - No summary rating as of yet. New plan - not yet rated. New plan - not yet rated.
Plan Offers Mail Order: Yes
Plan Health Benefits
Total # of Formulary Drugs: 3,586 drugs
Number of Members Enrolled in this Plan in Shawano, Wisconsin: 20 members
Number of Drugs Per Tier: NULL
Preferred Pharmacy Cost Sharing During Initial Coverage Phase: NULL
Special Needs Plan SNP Eligibility Requirement: NULL
Monthly Premium Split as Follows:
Part C Premium Part D Base Premium Part D Supplemental Premium Total Premium
$52.70 $26.30 $0.00 $79.00
Monthly Premium with Extra Help Low Income Subsidy:
LIS100 Subsidy Total Monthly Premium with LIS Parts CD LIS25 Subsidy Monthly PartD Premium with LIS LIS25 Subsidy Total Monthly Premium with LIS Parts CD LIS50 Monthly PartD Premium with LIS LIS50 Subsidy Total Monthly Premium with LIS Parts CD LIS75 Monthly PartD Premium with LIS LIS75 Subsidy Total Monthly Premium with LIS Parts CD
$52.70 $19.70 $72.40 $13.10 $65.80 $6.60 $59.30
Formulary Drug Details:
Tier 1 # of Drugs per Tier Tier 1 Preferred Pharmacy Cost Sharing (initial coverage phase) Tier 2 # of Drugs per Tier Tier 2 Preferred Pharmacy Cost Sharing (initial coverage phase) Tier 3 # of Drugs per Tier Tier 3 Preferred Pharmacy Cost Sharing (initial coverage phase) Tier 4 # of Drugs per Tier Tier 4 Preferred Pharmacy Cost Sharing (initial coverage phase) Tier 5 # of Drugs per Tier Tier 6 Preferred Pharmacy Cost Sharing (initial coverage phase)
388 $2.00 1567 $10.00 288 $40.00 573 45% 770 27%

Other Medicare Advantage Plans in Shawano, Wisconsin

Plan Name Type Premium MOOP Rx Deduct. Rating
Ascend Rx (HMO-POS) (2023)Local HMO$4,500$330
4
Anthem MediBlue Plus (HMO) (2023)Local HMO$4,300$150
5
Essence Rx (HMO-POS) (2023)Local HMO$3,400$330
4
Aetna Medicare Premier (PPO) (2023)Local PPO$4,200$0
5
Aetna Medicare Value (PPO) (2023)Local PPO$4,500$0
5
AARP Medicare Advantage (HMO-POS) (2023)Local HMO$4,200$245
5
HealthPartners Robin Birch (PPO) (2023)Local PPO$5,100$200
4
HealthPartners Robin Maple (PPO) (2023)Local PPO$4,500$200
4
Humana Gold Choice H8145-006 (PFFS) (2023)PFFS$-$445
4
AARP Medicare Advantage Value (HMO-POS) (2023)Local HMO$4,900$355
5
Spirit (HMO-POS) (2023)Local HMO *$1,200$-
4
Spirit Rx (HMO-POS) (2023)Local HMO$1,200$0
4
Anthem MediBlue Access (PPO) (2023)Local PPO$4,500$95
5
Network PlatinumPlus Pharmacy (PPO) (2023)Local PPO$3,400$260
4
HumanaChoice R5361-002 (Regional PPO) (2023)Regional PPO$6,700$420
5
Essence (HMO-POS) (2023)Local HMO *$3,400$-
4
Network PlatinumPremier Pharmacy (PPO) (2023)Local PPO$3,400$260
4
Humana Gold Plus H6622-001 (HMO) (2023)Local HMO$4,500$250
4
Network PlatinumSelect (PPO) (2023)Local PPO$4,900$395
4
Aetna Medicare Eagle (PPO) (2023)Local PPO *$5,900$-
5
Anthem MediBlue Access Core (PPO) (2023)Local PPO *$5,500$-
5
Network PlatinumPlus (PPO) (2023)Local PPO *$3,400$-
4
Esteem Rx (HMO-POS) (2023)Local HMO$5,000$250
4
Network PlatinumChoice (PPO) (2023)Local PPO$4,050$260
4
Elite (PPO) (2023)Local PPO *$4,000$-
New plan - not yet rated.
Essential Rx (PPO) (2023)Local PPO$5,900$295
New plan - not yet rated.
Network PlatinumPremier (PPO) (2023)Local PPO *$3,400$-
4
HumanaChoice R5361-001 (Regional PPO) (2023)Regional PPO *$6,700$-
5
Secure Saver (MSA) (2023)MSA *$-$-
4
AARP Medicare Advantage Patriot Plan 2 (HMO-POS) (2023)Local HMO *$4,900$-
5
AARP Medicare Advantage Open Plan 1 (PPO) (2023)Local PPO$5,900$325
5
NetworkPrime (MSA) (2023)MSA *$-$-
4
Medicare Advantage Plans by Aspirus Health Plan
Elite (PPO) (2023)Local PPO *$4,000$-
New plan - not yet rated.
Essential Rx (PPO) (2023)Local PPO$5,900$295
New plan - not yet rated.

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