Plan ID: H6874-003

What You Need to Know:

  • Elite (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 $0, which does not include your monthly Medicare Part B premium.
  • The annual deductible for this health plan is no drug coverage.
  • The plan includes an out-of-pocket maximum of $4,000 per year (in-network).
  • Elite (PPO) includes a Part D prescription drug plan for prescription medication coverage. The annual deductible is no drug coverage.
  • This plan's Part D Initial Coverage Limit is .

$0

Monthly Premium

Medicare Plan Features
Monthly Premium: $0
Part C Premium: NULL
Monthly Premium: Part C Premium: Part D Drug Premium: Part D Supplemental Premium: Total Part D Premium: Drug Deductible: Tiers with No Deductible:
$0 NULL NULL NULL NULL NULL NULL
Gap Coverage: NULL
Benchmark: NULL
Type of Medicare Health: NULL
Health Plan Type: Local PPO *
Similar Plan: H6874-001
Special Needs Type: NULL
Chronic Condition: NULL
Additional Gap Coverage: NULL
Maximum Out-of-Pocket Limit for Parts A & B (Moop): $4,000
Annual Deductible: no drug coverage
Annual Initial Coverage Limit ICL: NULL
Number of Members enrolled in this plan in Juneau, 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: NULL
Plan Health Benefits
Total # of Formulary Drugs: NULL
Number of Members Enrolled in this Plan in Juneau, Wisconsin: 1 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
NULL NULL NULL NULL
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
NULL NULL NULL NULL NULL NULL NULL
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)
NULL NULL NULL NULL NULL NULL NULL NULL NULL NULL

Other Medicare Advantage Plans in Juneau, Wisconsin

Plan Name Type Premium MOOP Rx Deduct. Rating
Ascend Rx (HMO-POS) (2023)Local HMO$4,500$330
4
AARP Medicare Advantage Open (PPO) (2023)Local PPO$5,700$385
5
AARP Medicare Advantage Open Premier (PPO) (2023)Local PPO$4,200$100
5
Essence Rx (HMO-POS) (2023)Local HMO$3,400$330
4
Gundersen Quartz Med Advantage Value (HMO) (2023)Local HMO *$3,450$-
3
Gundersen Quartz Med Advantage Elite (HMO) (2023)Local HMO *$3,000$-
3
Spirit Rx (HMO-POS) (2023)Local HMO$1,200$0
4
Humana Gold Choice H8145-006 (PFFS) (2023)PFFS$-$445
4
Spirit (HMO-POS) (2023)Local HMO *$1,200$-
4
Essence (HMO-POS) (2023)Local HMO *$3,400$-
4
HumanaChoice R5361-002 (Regional PPO) (2023)Regional PPO$6,700$420
5
Anthem MediBlue Access (PPO) (2023)Local PPO$5,500$95
5
Anthem MediBlue Access Core (PPO) (2023)Local PPO *$5,500$-
5
Essential Rx (PPO) (2023)Local PPO$5,900$295
New plan - not yet rated.
Esteem Rx (HMO-POS) (2023)Local HMO$5,000$250
4
Anthem MediBlue Plus (HMO) (2023)Local HMO$4,900$175
5
Elite Rx (PPO) (2023)Local PPO$4,000$295
New plan - not yet rated.
HumanaChoice R5361-001 (Regional PPO) (2023)Regional PPO *$6,700$-
5
Secure Saver (MSA) (2023)MSA *$-$-
4
AARP Medicare Advantage Patriot Plan 1 (PPO) (2023)Local PPO *$6,700$-
5
NetworkPrime (MSA) (2023)MSA *$-$-
4
Medicare Advantage Plans by Aspirus Health Plan
Essential Rx (PPO) (2023)Local PPO$5,900$295
New plan - not yet rated.
Elite Rx (PPO) (2023)Local PPO$4,000$295
New plan - not yet rated.

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