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MEDICARE |
HUMANA |
BLUE CROSS OF CALIFORNIA |
BLUE SHIELD |
AETNA |
UNITED HEALTHCARE |
HEALTHNET |
PACIFICARE |
CIGNA |
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| TIERS |
APPROVED |
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www.bluecrossca.com |
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www.pacificare.com |
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| COST / COPAYS |
STANDARD PLAN |
Standard
S5884-090 |
Enhanced S5884-030 |
Complete S5884-060 |
MedicareRx
Value |
MedicareRx Plus |
MedicareRx Gold |
Plan 001 |
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EssentialsSM Plan |
PlusSM Plan |
PremierSM Plan |
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|
Orange Option
1 |
Orange Option 2 |
Saver Plan |
Select Plan |
Comprehensive Plan |
Value Plan |
Plus Plan |
Complete Plan |
| |
$32.20 |
$5.41 |
$11.25 |
$50.91 |
$20.04 |
$28.56 |
$35.29 |
$32.67 |
|
$27.50 |
$36.94 |
$51.84 |
$23.22 |
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|
$17.65 |
$21.99 |
$20.40 |
$34.14 |
$37.67 |
$30.37 |
$35.91 |
$42.63 |
| |
$386.40 |
$64.92 |
$135.00 |
$610.92 |
$240.48 |
$342.72 |
$423.48 |
$392.04 |
|
$330.00 |
$443.28 |
$622.08 |
$278.64 |
$0.00 |
$0.00 |
$211.80 |
$263.88 |
$244.80 |
$409.68 |
$452.04 |
$364.44 |
$430.92 |
$511.56 |
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| Deductible |
$250 |
$250 |
$0 |
$0 |
$250 |
$0 |
$0 |
$0 |
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$250 |
$0 |
$0 |
$0 |
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$0 |
$0 |
$0 |
$0 |
$0 |
$250 |
$0 |
$0 |
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| $0-$250 |
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| T1:Generic |
100% |
100% |
$7 |
$7 |
100% |
$10 |
$10 |
$10 |
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$5 |
$7 |
$2 |
$5 |
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$5 |
$5 |
$7.50 - $8.25 |
$7.50 |
$7.50 |
$4 |
$5.00 |
$5.00 |
| T2:Brand
Pref |
100% |
100% |
$30 |
$30 |
100% |
$30 |
$30 |
$29 |
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$25 |
$35 |
$20 |
$28 |
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$35 |
$26 |
$22 |
$22 |
$22 |
$20 |
$30 |
$30 |
| T3:Non-Preferred |
100% |
100% |
$60 |
$60 |
100% |
100% |
$60 |
25% |
|
100% |
100% |
$40 |
$55 |
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|
100% |
$53 |
100% |
100% |
100% |
$40 |
$50 |
$50 |
| Exclusive |
100% |
n/a |
n/a |
n/a |
n/a |
n/a |
n/a |
n/a |
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n/a |
n/a |
n/a |
n/a |
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n/a |
n/a |
47.10 - 53.35 |
55.10 - 72.50 |
49.10 - 54.35 |
n/a |
n/a |
n/a |
| Specialty |
100% |
100% |
25% |
25% |
100% |
30% |
30% |
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25% |
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25% |
25% |
33% |
33% |
33% |
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| $251-$2,250 |
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| T1:Generic |
25% |
25% |
$7 |
$7 |
$5 |
$10 |
$10 |
$10 |
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$5 |
$7 |
$2 |
$5 |
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$5 |
$5 |
$7.50 - $8.25 |
$7.50 |
$7.50 |
$4 |
$5.00 |
$5.00 |
| T2:Brand
Pref |
25% |
25% |
$30 |
$30 |
$25 |
$30 |
$30 |
$29 |
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$25 |
$35 |
$20 |
$28 |
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$35 |
$26 |
$22 |
$22 |
$22 |
$20 |
$30 |
$30 |
| T3:Non-Preferred |
25% |
25% |
$60 |
$60 |
100% |
100% |
$60 |
25% |
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$40 |
$55 |
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100% |
$53 |
100% |
100% |
100% |
$40 |
$50 |
$50 |
| Exclusive |
25% |
n/a |
n/a |
n/a |
n/a |
n/a |
n/a |
n/a |
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n/a |
n/a |
n/a |
n/a |
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n/a |
n/a |
$47.10 - 53.35 |
$55.10 - 72.50 |
$49.10 - 54.35 |
n/a |
n/a |
n/a |
| Specialty |
25% |
25% |
25% |
25% |
25% |
30% |
30% |
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25% |
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25% |
25% |
33% |
33% |
33% |
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| Over
$2,250 |
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| T1:Generic |
100% |
100% |
100% |
$7 |
100% |
100% |
$10 |
100% |
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100% |
$7 |
$2 |
100% |
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100% |
100% |
100% |
100% |
$7.50 |
100% |
100% |
$5.00 |
| T2:Brand
Pref |
100% |
100% |
100% |
$30 |
100% |
100% |
100% |
100% |
|
100% |
100% |
$40 |
100% |
|
|
100% |
100% |
100% |
100% |
100% |
100% |
100% |
100% |
| T3:Non-Preferred |
100% |
100% |
100% |
$60 |
100% |
100% |
100% |
100% |
|
100% |
100% |
100% |
100% |
|
|
100% |
100% |
100% |
100% |
100% |
100% |
100% |
100% |
| Exclusive |
100% |
n/a |
n/a |
n/a |
n/a |
n/a |
n/a |
n/a |
|
n/a |
n/a |
n/a |
n/a |
|
|
100% |
100% |
100% |
100% |
100% |
100% |
100% |
100% |
| Specialty |
100% |
100% |
100% |
25% |
100% |
100% |
100% |
100% |
|
100% |
100% |
100% |
100% |
|
|
100% |
100% |
100% |
100% |
100% |
100% |
100% |
100% |
| |
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