MEDICARE 2013

Health plans with drug coverage

Tips on picking the best plans

Explore details of health plans with drug coverage in the chart below, and check out these guides:

What’s in the chart below

  • Type: The chart shows four types of health plans with drug coverage — HMO, PPO, HMO-POS, PFFS. They’re explained below.
  • Premium: The monthly charge for the plan. This is in addition to whatever monthly Part B payment you make to Medicare.
  • Part B rebate: Some plans pay part of your monthly Part B premium, which for most people will be $99.90 per month.
  • Doctor copay: This is your cost every time you see a doctor. The first dollar figure is for primary care physicians, the second is for specialists. Costs are listed for physicians inside the network (Net:) and outside the network (Out:).
  • Hospital copay: This is your cost for inpatient hospital care, for each admission. Costs are listed for hospitals inside the network (Net:) and outside the network (Out:).
  • Estimated total cost: This is Medicare’s horseback estimate of your annual out-of-pocket costs if you select this plan, including your Part B premium and drugs. It is based on an average person in good health and could vary greatly, depending on the drugs you take and your general health condition. The only good way to compare plans’ costs for your particular circumstances is with Medicare’s Plan Finder on www.medicare.gov.
  • Out-of-pocket cap: Your maximum payment for the year inside the network (Net:) and outside the network (Out:). The lower the cap the better.
  • Network size: The total number of providers in a network, including doctors, hospitals, nursing homes and other services. Some networks cover just a county, others a whole region, others the entire state.
  • Generics in the gap: Whether a plan pays for generic drugs in the coverage gap, or “doughnut hole,’’ which begins when total drug costs hit $2,970 and ends when your out-of-pocket costs reach $4,750.

What’s not in this chart

  • Special Needs Plans (see explanation below)
  • Copayments for other services: Plans usually charge copayments for drugs, skilled nursing homes, ambulances, emergency rooms and many other services. Check individual plans for these details.
  • Goodies: Some plans offer some dental, hearing and vision coverage, exercise classes, transportation to the doctor and other extra benefits. Check plans for details.
  • Health plans without drugs: A few plans are cheaper because they do not offer drug coverage, but choosing those plans can result in stiff penalties in subsequent years unless you receive comparable drug coverage elsewhere.

Health plans: how they differ

Medicare allows several types of private health plans, which cover all your care. Here is how they differ:

  • HMO (Health Maintenance Organization): Generally require you to use providers within a network, unless an emergency forces you to seek treatment elsewhere. A personal physician usually coordinates your care and must approve visits to specialists.
  • PPO (Preferred Provider Organization): Also encourages you to use providers within a network, with low copayments, but also allows you to use providers outside the network at a higher cost. Usually allows you to see specialists within the network without prior approval of a personal physician. “Regional’’ PPOs generally have larger networks, such as the entire state. Some bigger companies allow you to use their PPOs in other states, useful to snowbirds. Verify before signing up.
  • HMO-POS (HMO-Point of Service): A hybrid between an HMO and PPO. Usually requires you to stay within a network and seek approval of a personal physician before seeing network specialists. But also may cover some care outside the network, with a referral. Some POS plans approve very little coverage outside the network, so check plans for details.
  • PFFS (Private Fee for Service): Has network, but also allows members to get care outside the network if the provider will accept the plan’s payment. Make sure provider will accept payment before incurring bills.
  • Special Needs Plans: People with certain chronic conditions like diabetes and COPD can sometimes qualify for a Special Needs Plan, which may include extra services for managing their disease. Make sure you qualify before purchasing. People living in nursing homes may also qualify for special plans, as can poor people who qualify for both Medicare and Medicaid. These plans are not listed in the chart because only some people qualify. To compare Special Needs Plans, go to Medicare’s Plan Finder at www.medicare.gov. In Step 4, which asks if you want to Refine Your Results, look at lower left for button that says Select Special Needs Plans, mark the type of plan that interests you, then proceed to the results page.

The plans

Company TYPE Counties served Prem. PART B rebate Doctor copay Hospital copay Estimated yearly cost out-of-pocket cap NETwork SIZE GENERICS IN GAP?
AARP MedicareComplete Contact: 1-800-568-8316 HMO Pin., Hills., Pasco, Her. $0 $0 Net: $0, $30 Out: No coverage Net: $195 daily for 7 days Out: No coverage $3,500 Net: $3,900 Out: No cap 2,501-3,000 No
AARP MedicareComplete Choice PPO Pin., Hills., Pasco, Her. $0 $0 Net: $0, $35 Out: $40, $45 Net: $290 daily for 5 days Out: $375 daily for 26 days $3,650 Net: $4,500 In and out of network: $9,500 7,001-7,500 No
AARP MedicareComplete Choice Plan 2 PPO Pin., Hills., Pasco, Her. $0 $0 Net: $0, $35 Out: $40, $45 Net: $295 daily for 5 days Out: $375 daily for 27 days $3,700 Net: $4,900 In and out of network: $10,000 20,000 and above No
AARP MedicareComplete Plus HMO -POS Pin., Hills., Pasco, Her. $0 $0 Net: $0, $35 Out: $40, $45 Net: $290 daily for 5 days Out: $375 daily for 26 days $3,650 Net: $4,200 In and out of network: $9,500 2,501-3,000 No
Aetna Medicare Premier Contact: 1-888-247-1029 PPO Pin., Hills., Pasco $33 $0 Net: $10, $35 Out: 30% Net: $265 daily for 6 days Out: 30% $4,300 Net: $6,700 In and out of network: $8,800 2,001-2,500 No
Aetna Medicare Value HMO Pin., Hills., Pasco $39 $0 Net: $25, $45 Out: No coverage Net: $265 daily for 6 days Out: No coverage $4,400 Net: $3,400 Out: No cap 5,001-5,500 No
BlueMedicare Contact: 1-855-601-9465 HMO Pin., Hills., Pasco $0 $0 Net: $0, $30 Out: No coverage Net: $125 daily for 5 days Out: No coverage $2,850 Net: $5,000 Out: No cap 1,001-1,500 All
BlueMedicare (Plan H5434-002) PPO Pin., Hills., Pasco, Her. $152 $0 Net: $15, $50 Out: 30% Net: $225 daily for 7 days Out: 30% $5,550 Net: $6,700 In and out of network: $10,000 2,501-3,000 No
BlueMedicare (Plan R3332-001) PPO Pin., Hills., Pasco, Her. $0 $0 Net: $10, $45 Out: $40, $50 Net: $320 daily for 5 days Out: $495 daily for 27 days $2,850 Net: $5,900 In and out of network: $10,000 20,000 and above No
CareFree Contact: 1-855-605-6170 HMO Pin., Hills., Pasco $0 $96.40 Net: $0, $30 Out: No coverage Net: $150 daily for 5 days Out: No coverage $2,100 Net: $4,000 Out: No cap 1,001-1,500 Few, and few brands
CareOne HMO Pin., Hills., Pasco $0 $0 Net: $0, $25 Out: No coverage Net: $100 daily for 7 days Out: No coverage $3,000 Net: $5,000 Out: No cap 2,001-2,500 Some, and few brands
CareOne PLUS HMO Pin., Hills., Pasco. $0 $0 Net: $0, $25 Out: No coverage Net: $75 daily for 5 days. Out: No coverage $2,400 Net: $3,400 Out: No cap 1,001-1,500 Many, and few brands
Coventry Advantra Ideal Contact: 1-877-988-3589 HMO Pin., Hills. $0 $0 Net: $0, $15 Out: No coverage Net: $125 daily for 5 days Out: No coverage $2,400 Net: $3,400 Out: No cap 1,001-1,500 Many
Coventry Advantra Select Plus HMO -POS Pin., Hills., Her. $0 $99.90 Net: $0, $20 Out: specialist only, 25% Net: $175 daily for 5 days Out: No coverage $1,400 Net: $3,200 Out: No cap 1,501-2,000 Many
Day Break Contact: 1-855-431-1609 HMO Pin., Hills., Pasco $77.50 $99.90 Net: $0, $15 Out: No coverage Net: $150 daily for 7 days Out: No coverage $2,450 Net: $3,400 Out: No cap 501-1,000 All
Freedom Medicare Rx (Plan 5427-59) Contact: 1-888-796-0946 HMO Pin. $0 $0 Net: $0, $30 Out: No coverage Net: $195 daily for 7 days Out: No coverage $3,250 Net: $3,400 Out: No cap 5,501-6,000 Many
Freedom Medicare Rx (Plan 5427-60) HMO Hills., Pasco, Her. $0 $0 Net: $0, $20 Out: No coverage Net: $135 daily for 7 days Out: No coverage $3,000 Net: $3,400 Out: No cap 5,501-6,000 Many
Freedom Savings Rx (Plan 5427-53) HMO Pin. $0 $51 Net: $0, $30 Out: No coverage Net: $225 daily for 8 days Out: No coverage $2,800 Net: $3,400 Out: No cap 5,501-6,000 No
Freedom Savings Rx (Plan 5427-54) HMO Hills., Pasco, Her. $0 $35.50 Net: $0, $35 Out: No coverage Net: $275 daily for 8 days Out: No coverage $3,050 Net: $3,400 Out: No cap 5.501-6,000 No
Humana Gold Choice Contact: 1-866-824-6005 PFFS Pin., Hills., Pasco, Her. $102 $0 Net: $10, $35 Out: $10, $35 Net: $290 daily for 5 days Out: $290 daily for 5 days $5,450 In and out of network: $6,700 20,000 and above Few, and few brands
Humana Gold Plus HMO Pin., Hills., Pasco, Her. $0 $0 Net: $0, $25 Out: No coverage Net: $75 daily for 5 days Out: No coverage $2,500 Net: $3,400 Out: No cap 1,001-1,500* Many, and few brands
Humana Gold Plus (Plan 141) HMO Pin., Hills., Pasco, Her. $0 $96.40 Net: $0, $30 Out: No coverage Net: $150 daily for 5 days Out: No coverage $2,000 Net: $4,000 Out: No cap 1,501-2,000 Few, and few brands
Humana Reader’s Digest Healthy Living PPO Pin., Hills., Pasco, Her. $0 $0 Net: $15, $40 Out: $45, $45 Net: $300 daily for 5 days Out: $375 daily for 27 days $4,150 Net: $4,950 In and out of network: $10,000 20,000 and above Few, and few brands
Humana Choice PPO Pin., Hills., Pasco, Her. $85 $0 Net: $5, $30 Out: $40, $40 Net: $225 daily for 7 days Out: $225 daily for 7 days $4,600 Net: $4,750 In and out of network: $7,500 20,000 and above Few, and few brands
Optimum Gold Rewards Contact: 1-866-245-5360 HMO -POS Pin., Hills., Pasco, Her. $0 $96.40 Net: $0, $20 Out: specialist only, 30% Net: $95 daily for 5 days Out: No coverage $1,850 Net: $3,400 Out: No cap 2,001-2,500 Many
Optimum Platinum HMO -POS Pin., Hills., Pasco, Her. $0 $0 Net: $0, $0 Out: specialist only, 30% $0 for 5 days, $50 daily for days 6 to 10 Out: No coverage $2,600 Net: $3,400 Out: No cap 2,001-2,500 Many
Preferred Secure Option Contact: 1-866-231-7201 HMO Pin., Hills., Pasco, Her. $0 $99.90 Net: $0, $25 Out: No coverage Net: $225 daily for 7 days Out: No coverage $2,050 Net: $6,700 Out: No cap 3,001-3,500 Many, and few brands
PUP Plus Contact: 1-888-827-5787 HMO Pin., Hills., Pasco $0 $99.90 Net: $0, $25 Out: No coverage Net: $175 daily for 5 days. ** Out: No coverage $2,400 Net: $6,700 Out: No cap 5,501-6,000 No
PUP Simple HMO Pin., Hills., Pasco $0 $0 Net: $0, $5 Out: No coverage Net: $0 Out: No coverage $2,650 Net: $4,200 Out: No cap 5,501-6,000 Many
Simply Extra Contact: 1-888-577-0212 HMO Pin., Pasco, Her. $0 $50 Net: $0, $35 Out: No coverage Net: $175 daily for 10 days Out: No coverage $2,350 Net: $3,400 Out: No cap 1,001-1,500 No
Simply More HMO Pin., Hills., Pasco, Her. $0 $15 Net: $0, $10 Out: No coverage Net: $50 daily for 10 days Out: No coverage $2,000 Net: $3,400 Out: No cap 1,501-2,000 Many
Sunrise Contact: 1-855-431-1609 HMO Pin., Hills., Pasco, Her. $0 $0 Net: $0, $10 Out: No coverage Net: $50 daily for 5 days Out: No coverage $2,450 Net: $3,400 Out: No cap 501-1,000 All
Ultimate Premier Contact: 1-855-858-7526 HMO Her. $0 $80 Net: $0, $15 Out: No coverage Net: $75 daily for 4 days Out: No coverage $2,200 Net: $3,000 Out: No cap 251-500 Many
Ultimate Premier Plus HMO Her. $0 $0 Net: $0, $0 Out: No coverage Net: $0 Out: No coverage $2,700 Net: $3,000 Out: No cap 251-500 Many
Universal Any, Any, Any Contact: 1-800-965-7034 PFFS Pin., Hills., Pasco, Her. $34 $0 Net: $15, $40 Out: $15, $40 Net: $322 daily for 5 days Out: $322 daily for 5 days $4,400 In and out of network: $6,700 2,001-2,500 No
Universal Hassle-Free PPO Pin., Hills., Pasco, Her. $0 $0 Net: $20, $50 Out: $40, $50 Net: $395 daily for 5 days Out: $395 daily for 5 days $4,150 Net: $3,400 In and out of network: $5,100 2,501-3,000 No
Universal Masterpiece HMO Pin., Hills., Pasco, Her. $0 $0 Net: $0, $10 Out: No coverage Net: $50 daily for 5 days Out: No coverage $2,650 Net: $2,450 Out: No cap 1,501-2,000 Many
Universal Masterpiece Plus HMO Pin., Hills., Pasco, Her. $29 $0 Net: $15, $45 Out: No coverage Net: $300 daily for 7 days Out: No coverage $4,450 Net: $3,400 Out: No cap 9,001-10,000 No
Universal Safeguard HMO Pin., Hills., Pasco, Her. $0 $99.90 Net: $15, $40 Out: No coverage Net: $215 daily for 8 days Out: No coverage $2,650 Net: $5,000 Out: No cap 9,001-10,000 No
WellCare Dividend Contact: 1-866-765-4385 HMO Pin., Hills., Pasco, Her. $0 $96.40 Net: $0, $25 Out: No coverage Net: $100 daily for 8 days Out: No coverage $2,050 Net: $3,400 Out: No cap 3,501-4,000 All
WellCare Essential HMO Pin., Hills., Pasco, Her. $0 $0 Net: $0, $0 Out: No coverage Net: $0 Out: No coverage $2,550 Net: $5,500 Out: No cap 2,501-3,000 All
WellCare Value HMO -POS Pin., Hills., Pasco, Her. $0 $0 Net: $0, $0 Out: specialist only, 20% Net: $0 Out: 20% $2,750 Net: $5,500 Out: $5,500 2,501-3,000 All
Notes:

* Pinellas and Hillsborough network size, 1,001-1,500; Pasco network size, 500-1,001; Hernando network size, below 250
** Pinellas and Hernando hospital copay: $175 daily for 5 days; Hillsborough and Pasco hospital copay: $140 daily for 10 days