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The Highlights

  • Options for Medicare Supplement in Wautoma, Wisconsin include Medigap 50% Cost Sharing Plan and Medigap High Deductible Plan
  • Medicare Advantage plans may include Wautoma, Wisconsin prescription drug coverage, or you may need to buy Part D coverage separately
  • Wautoma, WI Medicare options include Advantage, standalone Part D, and Medicare Supplement

If you’re eligible for Medicare in Wautoma, Wisconsin, you have a lot of choices. Major health insurance companies provide Wautoma, Wisconsin Medicare Advantage plans with a variety of coverage options to choose from. You can choose a plan that includes Wautoma, WI Part D coverage, or buy prescription coverage as a standalone policy.

Wautoma, Wisconsin Medicare Supplement plans are available from a number of companies if you choose to stick with original Medicare. These plans can pay for the out-of-pocket costs that Wautoma original Medicare plans don’t cover, like coinsurance and deductibles.

Ready to buy Wautoma, Wisconsin Medicare coverage? Enter your ZIP code to compare Wautoma, WI Medicare options available to you right now.

Medicare Advantage Companies in Wautoma, Wisconsin

Medicare Advantage in Wautoma, Wisconsin is offered by some of the same local health insurance companies you may have been covered by before. Take a look at which companies in Wautoma, WI offer Medicare Advantage as well as which plans they offer to find the coverage and provider network that’s best for you.

Medicare Advantage Companies in Wautoma, Wisconsin

Plan Name Monthly Prem. (Parts C & D) Deductible Additional Gap Coverage Preferred Pharmacy Copay/ Coinsurance 30-Day Supply MOOP for Part A & B Benefits
AARP Medicare Advantage (HMO-POS) – H5253-011-0 $27.00 $245 . Tier 1, 2 and 3 exempt No additional gap coverage, only the Donut Hole Discount Preferred Generic: $3.00, Generic: $12.00, Preferred Brand: $47.00, Non-Preferred Drug: $100.00, Specialty Tier: 28% $4,200
AARP Medicare Advantage Open Plan 1 (PPO) – H0294-004-0 $47.00 $325 . Tier 1 and 2 exempt No additional gap coverage, only the Donut Hole Discount Preferred Generic: $4.00, Generic: $12.00, Preferred Brand: $47.00, Non-Preferred Drug: $100.00, Specialty Tier: 27% $5,900
AARP Medicare Advantage Patriot Plan 2 (HMO-POS) – H5253-021-0 $0.00 No Rx Coverage No Rx Coverage This Plan does NOT include Prescription Drug coverage. $4,900
AARP Medicare Advantage Value (HMO-POS) – H5253-034-0 $0.00 $355 . Tier 1 and 2 exempt No additional gap coverage, only the Donut Hole Discount Preferred Generic: $3.00, Generic: $14.00, Preferred Brand: $47.00, Non-Preferred Drug: $100.00, Specialty Tier: 26% $4,900
Aetna Medicare Eagle (PPO) – H5521-286-0 $0.00 No Rx Coverage No Rx Coverage This Plan does NOT include Prescription Drug coverage. $5,900
Aetna Medicare Premier (PPO) – H5521-282-0 $25.00 $0 Yes, some additional gap coverage. Preferred Generic: $0.00, Generic: $0.00, Preferred Brand: $42.00, Non-Preferred Drug: $99.00, Specialty Tier: 33% $4,200
Aetna Medicare Value (PPO) – H5521-283-0 $0.00 $0 Yes, some additional gap coverage. Preferred Generic: $0.00, Generic: $0.00, Preferred Brand: $47.00, Non-Preferred Drug: $100.00, Specialty Tier: 33% $4,500
Allwell Dual Medicare (HMO D-SNP) – H8189-001-0 $0.00 for people who qualify for both Medicare and Medicaid. $0 for people who qualify for both Medicare and Medicaid. Yes, some additional gap coverage. Preferred Generic: $0.00, Generic: $20.00, Preferred Brand: $47.00, Non-Preferred Drug: 50%, Specialty Tier: 29% N/A
Anthem MediBlue Access (PPO) – H4036-009-0 $37.00 $95 . Tier 1 and 2 exempt Yes, some additional gap coverage. Preferred Generic: $4.00, Generic: $15.00, Preferred Brand: $42.00, Non-Preferred Drug: $95.00, Specialty Tier: 31%, Select Care Drugs: $0.00 $5,500
Anthem MediBlue Access Core (PPO) – H4036-016-0 $0.00 No Rx Coverage No Rx Coverage This Plan does NOT include Prescription Drug coverage. $5,500
Anthem MediBlue Dual Advantage (HMO D-SNP) – H9525-003-0 $0.00 for people who qualify for both Medicare and Medicaid. $0 for people who qualify for both Medicare and Medicaid. Yes, some additional gap coverage. Preferred Generic: $0.00, Generic: $4.00, Preferred Brand: $42.00, Non-Preferred Drug: $95.00, Specialty Tier: 25%, Select Care Drugs: $0.00 N/A
Anthem MediBlue Plus (HMO) – H9525-006-0 $0.00 $150 . Tier 1 and 2 exempt Yes, some additional gap coverage. Preferred Generic: $2.00, Generic: $9.00, Preferred Brand: $42.00, Non-Preferred Drug: $95.00, Specialty Tier: 30%, Select Care Drugs: $0.00 $4,300
Ascend Rx (HMO-POS) – H5211-013-0 $40.00 $330 . Tier 1 and 2 exempt No additional gap coverage, only the Donut Hole Discount Preferred Generic: $4.00, Generic: $12.00, Preferred Brand: $47.00, Non-Preferred Drug: $100.00, Specialty Tier: 26%, Vaccines: $0.00 $4,500
Elite (PPO) – H6874-003-0 $0.00 No Rx Coverage No Rx Coverage This Plan does NOT include Prescription Drug coverage. $4,000
Elite Rx (PPO) – H6874-002-0 $79.00 $295 . Tier 1 and 2 exempt No additional gap coverage, only the Donut Hole Discount Preferred Generic: $2.00, Generic: $10.00, Preferred Brand: $40.00, Non-Preferred Drug: 45%, Specialty Tier: 27% $4,000
Essence (HMO-POS) – H5211-003-0 $16.00 No Rx Coverage No Rx Coverage This Plan does NOT include Prescription Drug coverage. $3,400
Essence Rx (HMO-POS) – H5211-002-0 $85.00 $330 . Tier 1 and 2 exempt No additional gap coverage, only the Donut Hole Discount Preferred Generic: $4.00, Generic: $12.00, Preferred Brand: $47.00, Non-Preferred Drug: $100.00, Specialty Tier: 26%, Vaccines: $0.00 $3,400
Essential Rx (PPO) – H6874-001-0 $0.00 $295 . Tier 1 and 2 exempt No additional gap coverage, only the Donut Hole Discount Preferred Generic: $3.00, Generic: $12.00, Preferred Brand: $40.00, Non-Preferred Drug: 45%, Specialty Tier: 27% $5,900
Esteem Rx (HMO-POS) – H5211-012-0 $0.00 $250 . Tier 1 and 2 exempt No additional gap coverage, only the Donut Hole Discount Preferred Generic: $6.00, Generic: $20.00, Preferred Brand: $47.00, Non-Preferred Drug: $100.00, Specialty Tier: 28%, Vaccines: $0.00 $5,000
HealthPartners Robin Birch (PPO) – H4882-004-0 $0.00 $200 . Tier 1 and 2 exempt No additional gap coverage, only the Donut Hole Discount Preferred Generic: $2.00, Generic: $9.00, Preferred Brand: $47.00, Non-Preferred Drug: $100.00, Specialty Tier: 29% $5,100
HealthPartners Robin Maple (PPO) – H4882-005-0 $26.00 $200 . Tier 1 and 2 exempt Yes, some additional gap coverage. Preferred Generic: $2.00, Generic: $9.00, Preferred Brand: $47.00, Non-Preferred Drug: $100.00, Specialty Tier: 29% $4,500
Humana Gold Plus H6622-001 (HMO) – H6622-001-0 $0.00 $250 . Tier 1, 2 and 3 exempt No additional gap coverage, only the Donut Hole Discount Preferred Generic: $6.00, Generic: $15.00, Preferred Brand: $47.00, Non-Preferred Drug: $100.00, Specialty Tier: 28% $4,500
Humana Value Plus H5216-173 (PPO) – H5216-173-0 $33.00 $230 . Tier 1 exempt No additional gap coverage, only the Donut Hole Discount Preferred Generic: $8.00, Generic: $18.00, Preferred Brand: $47.00, Non-Preferred Drug: $100.00, Specialty Tier: 29% $6,700
HumanaChoice H5216-001 (PPO) – H5216-001-0 $78.00 $200 . Tier 1, 2 and 3 exempt No additional gap coverage, only the Donut Hole Discount Preferred Generic: $6.00, Generic: $15.00, Preferred Brand: $47.00, Non-Preferred Drug: $100.00, Specialty Tier: 29% $3,900
HumanaChoice H5216-252 (PPO) – H5216-252-0 $0.00 $300 . Tier 1 and 2 exempt No additional gap coverage, only the Donut Hole Discount Preferred Generic: $6.00, Generic: $15.00, Preferred Brand: $47.00, Non-Preferred Drug: $100.00, Specialty Tier: 27% $4,900
HumanaChoice H5216-253 (PPO) – H5216-253-0 $0.00 $275 . Tier 1, 2 and 3 exempt No additional gap coverage, only the Donut Hole Discount Preferred Generic: $6.00, Generic: $15.00, Preferred Brand: $47.00, Non-Preferred Drug: $100.00, Specialty Tier: 28% $4,200
HumanaChoice R5361-001 (Regional PPO) – R5361-001-0 $0.00 No Rx Coverage No Rx Coverage This Plan does NOT include Prescription Drug coverage. $6,700
HumanaChoice R5361-002 (Regional PPO) – R5361-002-0 $120.00 $420 . Tier 1 exempt No additional gap coverage, only the Donut Hole Discount Preferred Generic: $3.00, Generic: $9.00, Preferred Brand: $47.00, Non-Preferred Drug: $100.00, Specialty Tier: 25% $6,700
Molina Medicare Complete Care (HMO D-SNP) – H2879-001-0 $0.00 for people who qualify for both Medicare and Medicaid. $0 for people who qualify for both Medicare and Medicaid. No additional gap coverage, only the Donut Hole Discount Preferred Generic: $0.00, Generic: $0.00, Preferred Brand: $47.00, Non-Preferred Drug: 34%, Specialty Tier: 25% N/A
My Choice Wisconsin Medicare Dual Advantage Plan (HMO D-SNP) – H5209-004-0 $0.00 for people who qualify for both Medicare and Medicaid. $0 for people who qualify for both Medicare and Medicaid. No additional gap coverage, only the Donut Hole Discount Tier 1: $0.00 N/A
Network PlatinumChoice (PPO) – H5215-011-0 $31.00 $260 . Tier 1, 2 and 3 exempt No additional gap coverage, only the Donut Hole Discount Preferred Generic: $2.00, Generic: $8.00, Preferred Brand: $42.00, Non-Preferred Brand: $90.00, Specialty Tier: 28% $4,050
Network PlatinumPlus (PPO) – H5215-001-0 $51.00 No Rx Coverage No Rx Coverage This Plan does NOT include Prescription Drug coverage. $3,400
Network PlatinumPlus Pharmacy (PPO) – H5215-002-0 $124.00 $260 . Tier 1, 2 and 3 exempt No additional gap coverage, only the Donut Hole Discount Preferred Generic: $2.00, Generic: $8.00, Preferred Brand: $42.00, Non-Preferred Brand: $90.00, Specialty Tier: 28% $3,400
Network PlatinumPremier (PPO) – H5215-006-0 $185.00 No Rx Coverage No Rx Coverage This Plan does NOT include Prescription Drug coverage. $3,400
Network PlatinumPremier Pharmacy (PPO) – H5215-005-0 $297.00 $260 . Tier 1, 2 and 3 exempt No additional gap coverage, only the Donut Hole Discount Preferred Generic: $2.00, Generic: $8.00, Preferred Brand: $42.00, Non-Preferred Brand: $90.00, Specialty Tier: 28% $3,400
Network PlatinumSelect (PPO) – H5215-008-0 $0.00 $395 . Tier 1, 2 and 3 exempt No additional gap coverage, only the Donut Hole Discount Preferred Generic: $2.00, Generic: $8.00, Preferred Brand: $42.00, Non-Preferred Brand: $90.00, Specialty Tier: 25% $4,900
NetworkCares (PPO D-SNP) – H5215-007-0 $0.00 for people who qualify for both Medicare and Medicaid. $0 for people who qualify for both Medicare and Medicaid. No additional gap coverage, only the Donut Hole Discount Preferred Generic: $4.00, Generic: $8.00, Preferred Brand: $42.00, Non-Preferred Brand: $90.00, Specialty Tier: 25% N/A
NetworkPrime (MSA) – H1181-001-0 $0.00 No Rx Coverage No Rx Coverage This Plan does NOT include Prescription Drug coverage. N/A
Secure Saver (MSA) – H4388-001-0 $0.00 No Rx Coverage No Rx Coverage This Plan does NOT include Prescription Drug coverage. N/A
Spirit (HMO-POS) – H5211-001-0 $150.00 No Rx Coverage No Rx Coverage This Plan does NOT include Prescription Drug coverage. $1,200
Spirit Rx (HMO-POS) – H5211-004-0 $226.00 $0 No additional gap coverage, only the Donut Hole Discount Preferred Generic: $9.00, Generic: $20.00, Preferred Brand: $47.00, Non-Preferred Drug: $100.00, Specialty Tier: 33%, Vaccines: $0.00 $1,200
UnitedHealthcare Dual Complete LP (HMO D-SNP) – H5253-024-0 $0.00 for people who qualify for both Medicare and Medicaid. $0 for people who qualify for both Medicare and Medicaid. No additional gap coverage, only the Donut Hole Discount Tier 1: 15%, Tier 2: 15%, Tier 3: 15%, Tier 4: 15%, Tier 5: 15% N/A
UnitedHealthcare Dual Complete LP1 (HMO D-SNP) – H3794-002-0 $0.00 for people who qualify for both Medicare and Medicaid. $0 for people who qualify for both Medicare and Medicaid. No additional gap coverage, only the Donut Hole Discount Tier 1: 15%, Tier 2: 15%, Tier 3: 15%, Tier 4: 15%, Tier 5: 15% N/A
UnitedHealthcare Medicare Advantage Assist (PPO C-SNP) – H0294-002-0 $14.00 $300 . Tier 1, 2 and 3 exempt No additional gap coverage, only the Donut Hole Discount Preferred Generic: $4.00, Generic: $12.00, Preferred Brand: $47.00, Non-Preferred Drug: $100.00, Specialty Tier: 27% N/A
iCare Medicare Plan (HMO D-SNP) – H2237-001-0 $0.00 for people who qualify for both Medicare and Medicaid. $0 for people who qualify for both Medicare and Medicaid. No additional gap coverage, only the Donut Hole Discount Generic: $15.00, Brand: $45.00, Specialty Tier: 25% N/A

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Medicare Supplement Companies in Wautoma, Wisconsin

Original Medicare leaves you with some out-of-pocket costs such as deductibles and coinsurance. With Wautoma, Wisconsin Medicare Supplement plan, you can get coverage for some or all of those costs. Medicare Supplement plans in Wisconsin are standardized, but companies can choose which plans they will sell. Take a look at which companies sell Medicare Supplement (Medigap) insurance and which plans they offer.

Medicare Supplement Companies in Wautoma, Wisconsin

Company Plans
Humana (Humana Insurance Company) Medigap 25% Cost Sharing Plan,
Medigap 50% Cost Sharing Plan,
Medigap Basic Plan,
Medigap High Deductible Plan
Humana (Humana Insurance Company) (Household) Medigap 25% Cost Sharing Plan,
Medigap 50% Cost Sharing Plan,
Medigap Basic Plan,
Medigap High Deductible Plan
Humana Healthy Living (Humana Insurance Company) Medigap 25% Cost Sharing Plan,
Medigap 50% Cost Sharing Plan,
Medigap Basic Plan
Humana Healthy Living (Humana Insurance Company) (Household) Medigap 25% Cost Sharing Plan,
Medigap 50% Cost Sharing Plan,
Medigap Basic Plan
Humana Value (HumanaDental Insurance Company) Medigap 25% Cost Sharing Plan,
Medigap 50% Cost Sharing Plan,
Medigap Basic Plan
Humana Value (HumanaDental Insurance Company) (Household) Medigap 25% Cost Sharing Plan,
Medigap 50% Cost Sharing Plan,
Medigap Basic Plan
Wisconsin Physicians Service Insurance Corporation Medigap 25% Cost Sharing Plan,
Medigap 50% Cost Sharing Plan,
Medigap Basic Plan
AARP – UnitedHealthcare Insurance Company (Level 1) Medigap Basic Plan
AARP – UnitedHealthcare Insurance Company (Level 1/Household) Medigap Basic Plan
AARP – UnitedHealthcare Insurance Company (Level 2) Medigap Basic Plan
AARP – UnitedHealthcare Insurance Company (Level 2/Household) Medigap Basic Plan
AARP – UnitedHealthcare Insurance Company (Standard) Medigap Basic Plan
AARP – UnitedHealthcare Insurance Company (Standard/Household) Medigap Basic Plan
Accendo Insurance Company Medigap Basic Plan
Aetna Health and Life Insurance Company Medigap Basic Plan
American Benefit Life Insurance Company Medigap Basic Plan
Americo Financial Life and Annuity Insurance Company Medigap Basic Plan
Americo Financial Life and Annuity Insurance Company (Class 1) Medigap Basic Plan
Anthem Blue Cross and Blue Shield – Wisconsin Medigap Basic Plan
Capitol Life Insurance Company Medigap Basic Plan
Catholic United Financial Medigap Basic Plan
Cigna Health & Life Insurance Company Medigap Basic Plan
Colonial Penn Life Insurance Company Medigap Basic Plan
Colonial Penn Life Insurance Company (Substandard) Medigap Basic Plan
Garden State Life Insurance Company Medigap Basic Plan,
Medigap High Deductible Plan
Globe Life and Accident Insurance Company (Direct to Consumer) Medigap Basic Plan
Guarantee Trust Life Insurance Company Medigap Basic Plan
Humana Achieve (Emphesys Insurance Company) Medigap Basic Plan
Humana Achieve (Emphesys Insurance Company) (Household) Medigap Basic Plan
Independence American Insurance Company Medigap Basic Plan
Lumico Life Insurance Company Medigap Basic Plan
Manhattan Life Assurance Company Medigap Basic Plan
Medico Insurance Company Medigap Basic Plan
National Guardian Life Insurance Company Medigap Basic Plan
National Health Insurance Company Medigap Basic Plan
National Health Insurance Company (Household) Medigap Basic Plan
Pan-American Life Insurance Company Medigap Basic Plan
Pekin Life Insurance Company Medigap Basic Plan
Philadelphia American Life Insurance Company Medigap Basic Plan
Physicians Life Insurance Company (Attained Age) Medigap Basic Plan,
Medigap High Deductible Plan
Physicians Life Insurance Company (Issue Age) Medigap Basic Plan,
Medigap High Deductible Plan
Prosperity Life Group Medigap Basic Plan
Puritan Life Insurance Company of America Medigap Basic Plan
Security Health Plan of Wisconsin, Inc. Medigap Basic Plan
Southern Guaranty Insurance Company Medigap Basic Plan
State Farm Mutual Automobile Insurance Company Medigap Basic Plan
Union Security Insurance Company Medigap Basic Plan
United American Insurance Company Medigap Basic Plan
United Commercial Travelers of America Medigap Basic Plan
United World Life Insurance Company Medigap Basic Plan,
Medigap High Deductible Plan

Wautoma, Wisconsin Standard Medicare Plan Coverage

Wondering what’s covered by each of the standard Wisconsin Medicare Supplement plans? Take a look at all of the Wautoma, Wisconsin Medicare Supplement plans with coverage details.

Wautoma, Wisconsin Standard Medicare Plan Coverage

Plan Name Monthly Cost Copays Coinsurance Deductibles Plan Benefits
Medigap 25% Cost Sharing Plan Premiums range from $105-$569 depending on your age, sex, health status, and when you buy. 5% is generally your cost for approved Part B services up to $3,110. Then, you’ll pay $0 for the rest of the year. $371 (25% of Part A deductible) Hospital (Part A) deductible,
$203 Medical (Part B) deductible
Skilled nursing facility: Yes
Part A deductible: Yes
Part B deductible: No
Part B excess charges: No
Foreign travel emergency: No
Medigap 50% Cost Sharing Plan Premiums range from $78-$448 depending on your age, sex, health status, and when you buy. 10% is generally your cost for approved Part B services up to $6,220. Then, you’ll pay $0 for the rest of the year. $742 (50% of Part A deductible) Hospital (Part A) deductible,
$203 Medical (Part B) deductible
Skilled nursing facility: Yes
Part A deductible: Yes
Part B deductible: No
Part B excess charges: No
Foreign travel emergency: No
Medigap Basic Plan Premiums range from $98-$912 depending on your age, sex, health status, and when you buy. $0 is generally your cost for approved Part B services. $1,484 Hospital (Part A) deductible,
$203 Medical (Part B) deductible
Skilled nursing facility: Yes
Part A deductible: No
Part B deductible: No
Part B excess charges: No
Foreign travel emergency: No
Medigap High Deductible Plan Premiums range from $52-$366 depending on your age, sex, health status, and when you buy. $0 is generally your cost for approved Part B services. $2,370 total plan deductible.
After, you pay: $0 Hospital (Part A) deductible,
$0 (or $203 if not eligible for this benefit)** Medical (Part B) deductible
Skilled nursing facility: Yes
Part A deductible: Yes
Part B deductible: Yes
Part B excess charges: Yes
Foreign travel emergency: Yes

Standalone Medicare Part D Plans in Wautoma, Wisconsin

Prescription drug coverage for Medicare in Wautoma, Wisconsin is covered by a Part D plan. You can purchase Part D coverage in Wautoma, Wisconsin as a standalone plan if it’s not included in your Medicare Advantage coverage. Take a look at the options for standalone Part D plans here.

Standalone Medicare Part D Plans in Wautoma, Wisconsin

Plan Details Tiers
SilverScript SmartRx (PDP)
S5601 – 191 – 0
by Aetna Medicare
Monthly Premium: $7.30
Annual Deductible: $445
Zero Premium If Full LIS Benefits: No
ICL: $4,130
Additional Gap Coverage: No
Tier 1: $0.00
Tier 2: $19.00
Tier 3: $46.00
Tier 4: 46%
Tier 5: 25%
Clear Spring Health Premier Rx (PDP)
S6946 – 042 – 0
by Clear Spring Health
Monthly Premium: $13.60
Annual Deductible: $445
Zero Premium If Full LIS Benefits: No
ICL: $4,130
Additional Gap Coverage: No
Tier 1: $1.00
Tier 2: $3.00
Tier 3: $40.00
Tier 4: 44%
Tier 5: 25%
WellCare Wellness Rx (PDP)
S4802 – 185 – 0
by WellCare
Monthly Premium: $14.60
Annual Deductible: $445
Zero Premium If Full LIS Benefits: No
ICL: $4,130
Additional Gap Coverage: No
Tier 1: $0.00
Tier 2: $7.00
Tier 3: $43.00
Tier 4: 47%
Tier 5: 25%
WellCare Value Script (PDP)
S4802 – 132 – 0
by WellCare
Monthly Premium: $14.80
Annual Deductible: $445
Zero Premium If Full LIS Benefits: No
ICL: $4,130
Additional Gap Coverage: No
Tier 1: $0.00
Tier 2: $8.00
Tier 3: $43.00
Tier 4: 47%
Tier 5: 25%
Humana Walmart Value Rx Plan (PDP)
S5884 – 195 – 0
by Humana
Monthly Premium: $17.20
Annual Deductible: $445
Zero Premium If Full LIS Benefits: No
ICL: $4,130
Additional Gap Coverage: No
Tier 1: $1.00
Tier 2: $4.00
Tier 3: 19%
Tier 4: 35%
Tier 5: 25%
Cigna Secure-Essential Rx (PDP)
S5617 – 295 – 0
by Cigna
Monthly Premium: $24.00
Annual Deductible: $445
Zero Premium If Full LIS Benefits: No
ICL: $4,130
Additional Gap Coverage: No
Tier 1: $0.00
Tier 2: $2.00
Tier 3: 18%
Tier 4: 46%
Tier 5: 25%
Mutual of Omaha Rx Premier (PDP)
S7126 – 085 – 0
by Mutual of Omaha Rx
Monthly Premium: $24.00
Annual Deductible: $445
Zero Premium If Full LIS Benefits: No
ICL: $4,130
Additional Gap Coverage: No
Tier 1: $0.00
Tier 2: $2.00
Tier 3: 23%
Tier 4: 46%
Tier 5: 25%
Anthem MediBlue Rx Enhanced (PDP)
S5596 – 080 – 0
by Anthem MediBlue Rx (PDP)
Monthly Premium: $24.60
Annual Deductible: $290
Zero Premium If Full LIS Benefits: No
ICL: $4,130
Additional Gap Coverage: Yes
Tier 1: $0.00
Tier 2: $2.00
Tier 3: 20%
Tier 4: 37%
Tier 5: 26%
WellCare Medicare Rx Select (PDP)
S5810 – 290 – 0
by WellCare
Monthly Premium: $26.80
Annual Deductible: $300
Zero Premium If Full LIS Benefits: No
ICL: $4,130
Additional Gap Coverage: No
Tier 1: $0.00
Tier 2: $3.00
Tier 3: $47.00
Tier 4: 42%
Tier 5: 27%
Express Scripts Medicare – Saver (PDP)
S5660 – 232 – 0
by Express Scripts Medicare
Monthly Premium: $27.50
Annual Deductible: $285
Zero Premium If Full LIS Benefits: No
ICL: $4,130
Additional Gap Coverage: No
Tier 1: $2.00
Tier 2: $7.00
Tier 3: $35.00
Tier 4: 50%
Tier 5: 28%
Clear Spring Health Value Rx (PDP)
S6946 – 013 – 0
by Clear Spring Health
Monthly Premium: $29.30
Annual Deductible: $445
Zero Premium If Full LIS Benefits: Yes
ICL: $4,130
Additional Gap Coverage: No
Tier 1: $1.00
Tier 2: $3.00
Tier 3: $42.00
Tier 4: 34%
Tier 5: 25%
Express Scripts Medicare – Value (PDP)
S5660 – 118 – 0
by Express Scripts Medicare
Monthly Premium: $31.60
Annual Deductible: $445
Zero Premium If Full LIS Benefits: Yes
ICL: $4,130
Additional Gap Coverage: No
Tier 1: $1.00
Tier 2: $3.00
Tier 3: $30.00
Tier 4: 50%
Tier 5: 25%
AARP MedicareRx Walgreens (PDP)
S5921 – 397 – 0
by UnitedHealthcare
Monthly Premium: $32.00
Annual Deductible: $445
Zero Premium If Full LIS Benefits: No
ICL: $4,130
Additional Gap Coverage: No
Tier 1: $0.00
Tier 2: $6.00
Tier 3: $40.00
Tier 4: 40%
Tier 5: 25%
Cigna Secure Rx (PDP)
S5617 – 223 – 0
by Cigna
Monthly Premium: $32.10
Annual Deductible: $445
Zero Premium If Full LIS Benefits: Yes
ICL: $4,130
Additional Gap Coverage: No
Tier 1: $1.00
Tier 2: $2.00
Tier 3: $30.00
Tier 4: 50%
Tier 5: 25%
WellCare Classic (PDP)
S4802 – 097 – 0
by WellCare
Monthly Premium: $33.90
Annual Deductible: $445
Zero Premium If Full LIS Benefits: Yes
ICL: $4,130
Additional Gap Coverage: No
Tier 1: $0.00
Tier 2: $2.00
Tier 3: $30.00
Tier 4: 33%
Tier 5: 25%
SilverScript Choice (PDP)
S5601 – 032 – 0
by Aetna Medicare
Monthly Premium: $36.00
Annual Deductible: $205
Zero Premium If Full LIS Benefits: Yes
ICL: $4,130
Additional Gap Coverage: No
Tier 1: $0.00
Tier 2: $5.00
Tier 3: $35.00
Tier 4: 42%
Tier 5: 29%
Humana Basic Rx Plan (PDP)
S5884 – 139 – 0
by Humana
Monthly Premium: $37.90
Annual Deductible: $445
Zero Premium If Full LIS Benefits: Yes
ICL: $4,130
Additional Gap Coverage: No
Tier 1: $0.00
Tier 2: $1.00
Tier 3: 20%
Tier 4: 35%
Tier 5: 25%
Elixir RxPlus (PDP)
S7694 – 016 – 0
by Elixir Insurance
Monthly Premium: $39.10
Annual Deductible: $445
Zero Premium If Full LIS Benefits: Yes
ICL: $4,130
Additional Gap Coverage: No
Tier 1: $1.00
Tier 2: $6.00
Tier 3: 15%
Tier 4: 25%
Tier 5: 25%
WellCare Medicare Rx Saver (PDP)
S5810 – 050 – 0
by WellCare
Monthly Premium: $39.50
Annual Deductible: $445
Zero Premium If Full LIS Benefits: Yes
ICL: $4,130
Additional Gap Coverage: No
Tier 1: $0.00
Tier 2: $2.00
Tier 3: $35.00
Tier 4: 37%
Tier 5: 25%
AARP MedicareRx Saver Plus (PDP)
S5921 – 361 – 0
by UnitedHealthcare
Monthly Premium: $40.00
Annual Deductible: $445
Zero Premium If Full LIS Benefits: Yes
ICL: $4,130
Additional Gap Coverage: No
Tier 1: $1.00
Tier 2: $7.00
Tier 3: $31.00
Tier 4: 40%
Tier 5: 25%
SilverScript Plus (PDP)
S5601 – 033 – 0
by Aetna Medicare
Monthly Premium: $52.20
Annual Deductible: $0
Zero Premium If Full LIS Benefits: No
ICL: $4,130
Additional Gap Coverage: Yes
Tier 1: $0.00
Tier 2: $2.00
Tier 3: $47.00
Tier 4: 50%
Tier 5: 33%
Anthem MediBlue Rx Plus (PDP)
S5596 – 057 – 0
by Anthem MediBlue Rx (PDP)
Monthly Premium: $54.30
Annual Deductible: $0
Zero Premium If Full LIS Benefits: No
ICL: $4,130
Additional Gap Coverage: No
Tier 1: $1.00
Tier 2: $3.00
Tier 3: $43.00
Tier 4: 45%
Tier 5: 33%
Cigna Secure-Extra Rx (PDP)
S5617 – 261 – 0
by Cigna
Monthly Premium: $54.60
Annual Deductible: $100
Zero Premium If Full LIS Benefits: No
ICL: $4,130
Additional Gap Coverage: Yes
Tier 1: $4.00
Tier 2: $10.00
Tier 3: $42.00
Tier 4: 50%
Tier 5: 31%
Anthem MediBlue Rx Standard (PDP)
S5596 – 056 – 0
by Anthem MediBlue Rx (PDP)
Monthly Premium: $54.90
Annual Deductible: $320
Zero Premium If Full LIS Benefits: No
ICL: $4,130
Additional Gap Coverage: No
Tier 1: $1.00
Tier 2: $2.00
Tier 3: $30.00
Tier 4: 35%
Tier 5: 25%
Humana Premier Rx Plan (PDP)
S5884 – 162 – 0
by Humana
Monthly Premium: $63.30
Annual Deductible: $445
Zero Premium If Full LIS Benefits: No
ICL: $4,130
Additional Gap Coverage: No
Tier 1: $1.00
Tier 2: $4.00
Tier 3: $45.00
Tier 4: 49%
Tier 5: 25%
WellCare Medicare Rx Value Plus (PDP)
S5768 – 139 – 0
by WellCare
Monthly Premium: $76.10
Annual Deductible: $0
Zero Premium If Full LIS Benefits: No
ICL: $4,130
Additional Gap Coverage: No
Tier 1: $1.00
Tier 2: $4.00
Tier 3: $47.00
Tier 4: 45%
Tier 5: 33%
WPS MedicareRx Plan 1 (PDP)
S5753 – 006 – 0
by WPS Health Insurance
Monthly Premium: $79.30
Annual Deductible: $445
Zero Premium If Full LIS Benefits: No
ICL: $4,130
Additional Gap Coverage: No
Tier 1: $3.00
Tier 2: $15.00
Tier 3: $42.00
Tier 4: 49%
Tier 5: 25%
Express Scripts Medicare – Choice (PDP)
S5660 – 186 – 0
by Express Scripts Medicare
Monthly Premium: $80.80
Annual Deductible: $100
Zero Premium If Full LIS Benefits: No
ICL: $4,130
Additional Gap Coverage: Yes
Tier 1: $2.00
Tier 2: $7.00
Tier 3: $42.00
Tier 4: 50%
Tier 5: 31%
Mutual of Omaha Rx Plus (PDP)
S7126 – 015 – 0
by Mutual of Omaha Rx
Monthly Premium: $86.60
Annual Deductible: $445
Zero Premium If Full LIS Benefits: No
ICL: $4,130
Additional Gap Coverage: No
Tier 1: $0.00
Tier 2: $2.00
Tier 3: 20%
Tier 4: 37%
Tier 5: 25%
AARP MedicareRx Preferred (PDP)
S5820 – 015 – 0
by UnitedHealthcare
Monthly Premium: $92.80
Annual Deductible: $0
Zero Premium If Full LIS Benefits: No
ICL: $4,130
Additional Gap Coverage: No
Tier 1: $5.00
Tier 2: $10.00
Tier 3: $45.00
Tier 4: 40%
Tier 5: 33%
WPS MedicareRx Plan 2 (PDP)
S5753 – 007 – 0
by WPS Health Insurance
Monthly Premium: $132.30
Annual Deductible: $0
Zero Premium If Full LIS Benefits: No
ICL: $4,130
Additional Gap Coverage: Yes
Tier 1: $0.00
Tier 2: $11.00
Tier 3: $42.00
Tier 4: 45%
Tier 5: 33%

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