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BC LIFE & HEALTH INSURANCE COMPANY Freedom Blue Plan I Regional PPO $7.00 $7.00 $0 • 92 • Alameda BC LIFE & HEALTH INSURANCE COMPANY Freedom Blue Plan II Regional PPO $32.00 $22.00 $0 • 92 • Alameda Health Net Of CA Health Net Seniority Plus Local HMO $39.00 $14.66 $0 • 100 • Alameda Health Net Of CA Health Net Seniority Plus Local HMO $39.00 - Alameda Kaiser Permanente Kaiser Permanente Senior Advantage Local HMO $70.00 $0.00 $0 • 69 Alameda Kaiser Permanente Kaiser Permanente Senior Advantage Local HMO $341.00 $0.00 $0 • 69 Alameda Secure Horizons Medicare Advantage Plan Secure Horizons Medical Plan Local HMO $35.00 - Alameda Secure Horizons Medicare Advantage Plan Secure Horizons Classic Plan Local HMO $59.00 $16.03 $0 • 82 • Alameda Secure Horizons Medicare Advantage Plan Secure Horizons Classic Plan II Local HMO $150.00 $17.31 $0 • 82 • Alameda Secure Horizons Medicare Advantage Plan Secure Horizons Part B Only Plan Local HMO $340.53 $21.68 $250 82 • Alpine BC LIFE & HEALTH INSURANCE COMPANY Freedom Blue Plan I Regional PPO $7.00 $7.00 $0 • 92 • Alpine BC LIFE & HEALTH INSURANCE COMPANY Freedom Blue Plan II Regional PPO $32.00 $22.00 $0 • 92 • Alpine SecureHorizons Direct SecureHorizons Direct Plan 1 PFFS $0.00 - Alpine SecureHorizons Direct SecureHorizons Direct Premier Plan 200 PFFS $85.00 - Amador BC LIFE & HEALTH INSURANCE COMPANY Freedom Blue Plan I Regional PPO $7.00 $7.00 $0 • 92 • Amador BC LIFE & HEALTH INSURANCE COMPANY Freedom Blue Plan II Regional PPO $32.00 $22.00 $0 • 92 • Amador Kaiser Permanente Kaiser Permanente Senior Advantage Local HMO $70.00 $0.00 $0 • 69 Amador Kaiser Permanente Kaiser Permanente Senior Advantage Local HMO $341.00 $0.00 $0 • 69 Butte BC LIFE & HEALTH INSURANCE COMPANY Freedom Blue Plan I Regional PPO $7.00 $7.00 $0 • 92 • Butte BC LIFE & HEALTH INSURANCE COMPANY Freedom Blue Plan II Regional PPO $32.00 $22.00 $0 • 92 • Calaveras BC LIFE & HEALTH INSURANCE COMPANY Freedom Blue Plan I Regional PPO $7.00 $7.00 $0 • 92 • Calaveras BC LIFE & HEALTH INSURANCE COMPANY Freedom Blue Plan II Regional PPO $32.00 $22.00 $0 • 92 • Colusa BC LIFE & HEALTH INSURANCE COMPANY Freedom Blue Plan I Regional PPO $7.00 $7.00 $0 • 92 • Colusa BC LIFE & HEALTH INSURANCE COMPANY Freedom Blue Plan II Regional PPO $32.00 $22.00 $0 • 92 • Aetna Medicare Aetna Medicare Rx Essentials $30.70 $250 • 86 • Aetna Medicare Aetna Medicare Rx Plus $40.95 $0 • G 86 • Aetna Medicare Aetna Medicare Rx Premier $56.39 $0 • G 100 • CIGNA HealthCare CIGNATURE Rx Value Plan $34.20 $250 • 99 • CIGNA HealthCare CIGNATURE Rx Plus Plan $39.54 $0 • 99 • CIGNA HealthCare CIGNATURE Rx Complete Plan $47.88 $0 • G 99 • Coventry AdvantraRx AdvantraRx Value $23.24 $0 • 78 • Coventry AdvantraRx AdvantraRx Premier $33.72 $0 • 100 • Coventry AdvantraRx AdvantraRx Premier Plus $45.04 $0 • 100 • Elder Health PDP Texas Elder Health PDP Texas $29.75 $250 • 91 • HISC - Blue Cross Blue Shield of Texas Blue Medicare Rx - Standard $25.53 $250 100 • HISC - Blue Cross Blue Shield of Texas Blue Medicare Rx - Value $25.73 $0 • 100 • HISC - Blue Cross Blue Shield of Texas Blue Medicare Rx - Plus $43.32 $0 • 100 • Humana Inc. Humana PDP Standard S5884- 080 $10.31 $250 99 • Humana Inc. Humana PDP Enhanced S5884- 020 $14.13 $0 • 99 • Humana Inc. Humana PDP Complete S5884- 050 $58.69 $0 • G/B 99 • Marquette National Life Insurance Company Prescription Pathway Silver Plan Reg 22 $40.66 $250 • 92 Health Alliance Medicare PPO 10 Local PPO $85.00 - Adams Health Alliance Medical Plans Health Alliance Medicare PPO 10 with Rx Local PPO $130.63 $45.63 $0 • 87 • Adams Humana Insurance Company Humana Gold Choice PFFS H1804-137 PFFS $0.00 $0.00 $0 • 99 • Adams Health Alliance Medical Plans Health Alliance Medicare PPO 10 Local PPO $85.00 - Adams Health Alliance Medical Plans Health Alliance Medicare PPO 10 with Rx Local PPO $130.63 $45.63 $0 • 87 • Adams Humana Insurance Company Humana Gold Choice PFFS H1804-137 PFFS $0.00 $0.00 $0 • 99 • Adams Humana Insurance Company HumanaChoicePPO PPO R5826- 023 Regional PPO $0.00 - Adams Humana Insurance Company HumanaChoicePPO PPO R5826- 037 Regional PPO $35.00 $14.24 $250 99 • Adams Humana Insurance Company HumanaChoicePPO PPO R5826- 009 Regional PPO $46.00 $24.77 $0 • 99 • Adams SecureHorizons Direct SecureHorizons Direct Plan 4 PFFS $25.00 - Adams SecureHorizons Direct SecureHorizons Direct Premier Plan 200 PFFS $85.00 - Alexander Humana Insurance Company Humana Gold Choice PFFS H1804-137 PFFS $0.00 $0.00 $0 • 99 • Alexander Humana Insurance Company HumanaChoicePPO PPO R5826- 023 Regional PPO $0.00 - Alexander Humana Insurance Company HumanaChoicePPO PPO R5826- 037 Regional PPO $35.00 $14.24 $250 99 • Alexander Humana Insurance Company HumanaChoicePPO PPO R5826- 009 Regional PPO $46.00 $24.77 $0 • 99 • Alexander Unicare Life & Health Ins. Company SecurityChoice Classic PFFS $0.00 - Alexander Unicare Life & Health Ins. Company SecurityChoice Plus PFFS $13.00 $9.00 $250 • 92 • Bond Humana Insurance Company Humana Gold Choice PFFS H1804-137 PFFS $0.00 $0.00 $0 • 99 • Bond Humana Insurance Company HumanaChoicePPO PPO R5826- 023 Regional PPO $0.00 - Bond Humana Insurance Company HumanaChoicePPO PPO R5826- 037 Regional PPO $35.00 $14.24 $250 99 • Bond Humana Insurance Company HumanaChoicePPO PPO R5826- 009 Regional PPO $46.00 $24.77 $0 • 99 • Boone Humana Insurance Company Humana Gold Choice PFFS H1804-137 PFFS $0.00 $0.00 $0 • 99 • Boone Humana Insurance Company HumanaChoicePPO PPO R5826- 023 Regional PPO $0.00 - Boone Humana Insurance Company HumanaChoicePPO PPO R5826- 037 Regional PPO $35.00 $14.24 $250 99 • Boone Humana Insurance Company HumanaChoicePPO PPO R5826- 009 Regional PPO $46.00 $24.77 $0 • 99 • Boone OSF Care Preferred OSF Care Preferred Local PPO $68.00 - Boone OSF Care Preferred OSF Care Preferred Basic Rx Local PPO $98.00 $30.48 $250 • 98 • Coverage Cost Description Plans approved as of: 11/13/05 1 of 44 Formulary data as of : 11/16/05 Adams Humana Insurance Company HumanaChoicePPO PPO R5826- 023 Regional PPO $0.00 - Adams Humana Insurance Company HumanaChoicePPO PPO R5826- 037 Regional PPO $35.00 $14.24 $250 99 • Adams Humana Insurance Company HumanaChoicePPO PPO R5826- 009 Regional PPO $46.00 $24.77 $0 • 99 • Adams SecureHorizons Direct SecureHorizons Direct Plan 4 PFFS $25.00 - Adams SecureHorizons Direct SecureHorizons Direct Premier Plan 200 PFFS $85.00 - Alexander Humana Insurance Company Humana Gold Choice PFFS H1804-137 PFFS $0.00 $0.00 $0 • 99 • Alexander Humana Insurance Company HumanaChoicePPO PPO R5826- 023 Regional PPO $0.00 - Alexander Humana Insurance Company HumanaChoicePPO PPO R5826- 037 Regional PPO $35.00 $14.24 $250 99 • Alexander Humana Insurance Company HumanaChoicePPO PPO R5826- 009 Regional PPO $46.00 $24.77 $0 • 99 • Alexander Unicare Life & Health Ins. Company SecurityChoice Classic PFFS $0.00 - Alexander Unicare Life & Health Ins. Company SecurityChoice Plus PFFS $13.00 $9.00 $250 • 92 • Bond Humana Insurance Company Humana Gold Choice PFFS H1804-137 PFFS $0.00 $0.00 $0 • 99 • Bond Humana Insurance Company HumanaChoicePPO PPO R5826- 023 Regional PPO $0.00 - Bond Humana Insurance Company HumanaChoicePPO PPO R5826- 037 Regional PPO $35.00 $14.24 $250 99 • Bond Humana Insurance Company HumanaChoicePPO PPO R5826- 009 Regional PPO $46.00 $24.77 $0 • 99 • Boone Humana Insurance Company Humana Gold Choice PFFS H1804-137 PFFS $0.00 $0.00 $0 • 99 • Boone Humana Insurance Company HumanaChoicePPO PPO R5826- 023 Regional PPO $0.00 - Boone Humana Insurance Company HumanaChoicePPO PPO R5826- 037 Regional PPO $35.00 $14.24 $250 99 • Boone Humana Insurance Company HumanaChoicePPO PPO R5826- 009 Regional PPO $46.00 $24.77 $0 • 99 • Boone OSF Care Preferred OSF Care Preferred Local PPO $68.00 - Boone OSF Care Preferred OSF Care Preferred Basic Rx Local PPO $98.00 $30.48 $250 •Apache Health Net Health Net Preferred Regional PPO $41.00 - Apache Health Net Health Net Preferred Plus Regional PPO $57.00 $15.09 $0 • 100 • Apache Humana Insurance Company Humana Gold Choice PFFS H1804-005 PFFS $0.00 $0.00 $0 • 99 • Apache Humana Insurance Company Humana Gold Choice PFFS H1804-147 PFFS $14.51 $14.51 $0 • 99 • Apache Humana Insurance Company HumanaChoicePPO PPO R5826- 028 Regional PPO $16.00 - Apache Humana Insurance Company HumanaChoicePPO PPO R5826- 042 Regional PPO $58.00 $11.15 $250 99 • Apache Humana Insurance Company HumanaChoicePPO PPO R5826- 014 Regional PPO $67.00 $20.47 $0 • 99 • Apache SecureHorizons Direct SecureHorizons Direct Plan 4 PFFS $25.00 - Apache SecureHorizons Direct SecureHorizons Direct Premier Plan 200 PFFS $85.00 - Cochise Health Net Health Net Preferred Regional PPO $41.00 - Cochise Health Net Health Net Preferred Plus Regional PPO $57.00 $15.09 $0 • 100 • Cochise Humana Insurance Company Humana Gold Choice PFFS H1804-005 PFFS $0.00 $0.00 $0 • 99 • Cochise Humana Insurance Company HumanaChoicePPO PPO R5826- 028 Regional PPO $16.00 - Cochise Humana Insurance Company HumanaChoicePPO PPO R5826- 042 Regional PPO $58.00 $11.15 $250 99 • Cochise Humana Insurance Company HumanaChoicePPO PPO R5826- 014 Regional PPO $67.00 $20.47 $0 • 99 • Cochise SecureHorizons Direct SecureHorizons Direct Plan 2 PFFS $0.00 - Cochise SecureHorizons Direct SecureHorizons Direct Premier Plan 200 PFFS $85.00 - Cochise Sterling Option I Sterling Option I PFFS $9.00 - Cochise Today's Option Today's Options Basic PFFS $14.95 - Cochise Today's Option Today's Options Premier PFFS $26.95 - Cochise UnitedHealthcare Of Arizona Inc UnitedHealthcare Medicare Complete Rx Local HMO $0.00 $0.00 $0 • 100 • Cochise UnitedHealthcare Of Arizona Inc UnitedHealthcare Medicare Complete Local HMO $0.00 - Coconino Desert Canyon Community Care Desert Canyon Community Care - Plus Local HMO $0.00 $0.00 $0 • G 98 • Coconino Desert Canyon Community Care Desert Canyon Community Care - Basic Local HMO $0.00 Carson City Humana Insurance Company Humana Gold Choice PFFS H1804-150 PFFS $59.00 $9.90 $250 99 • Carson City Humana Insurance Company Humana Gold Choice PFFS H1804-083 PFFS $65.00 $16.99 $0 • 99 • Carson City Sierra Nevada Spectrum Sierra Nevada Spectrum Regional PPO $0.00 $0.00 $0 • 78 • Carson City Sierra Spectrum Sierra Spectrum Local PPO $39.00 $28.64 $0 • 78 • Carson City Sterling Option I Sterling Option I PFFS $9.00 - Churchill Humana Insurance Company Humana Gold Choice PFFS H1804-150 PFFS $59.00 $9.90 $250 99 • Churchill Humana Insurance Company Humana Gold Choice PFFS H1804-083 PFFS $65.00 $16.99 $0 • 99 • Churchill SecureHorizons Direct SecureHorizons Direct Plan 4 PFFS $25.00 - Churchill SecureHorizons Direct SecureHorizons Direct Premier Plan 100 PFFS $95.00 - Churchill Sierra Nevada Spectrum Sierra Nevada Spectrum Regional PPO $0.00 $0.00 $0 • 78 • Churchill Sierra Spectrum Sierra Spectrum Local PPO $39.00 $28.64 $0 • 78 • Clark Humana Insurance Company Humana Gold Choice PFFS H1804-150 PFFS $59.00 $9.90 $250 99 • Clark Humana Insurance Company Humana Gold Choice PFFS H1804-083 PFFS $65.00 $16.99 $0 • 99 • Clark Secure Horizons Medicare Advantage Plan Secure Horizons Classic Plan Local HMO $0.00 $0.00 $0 • 82 • Clark Secure Horizons Medicare Advantage Plan Secure Horizons Medical Plan Local HMO $0.00 - Clark Secure Horizons Medicare Advantage Plan Secure Horizons Classic Enhanced Plan Local HMO $45.00 $23.00 $0 • G 82 • Clark Senior Dimensions Senior Dimensions Southern Nevada Plan Demo $0.00 $0.00 $0 • G/B 99 • Clark Senior Dimensions Senior Dimensions Southern Nevada Plan Local HMO $0.00 $0.00 $0 • G/B 99 • Clark Sierra Nevada Spectrum Sierra Nevada Spectrum Regional PPO $0.00 $0.00 $0 • 78 • Clark Sierra Spectrum Sierra Spectrum Local PPO $39.00 $28.64 $0 • 78 • Clark Sterling Option I Sterling Option I PFFS $9.00 - Douglas Humana Insurance Company Humana Gold Choice PFFS H1804-150 PFFS $59.00 $9.90 $250 99 • Douglas Humana Insurance Company Humana Gold Choice PFFS H1804-083 PFFS $65.00 $16.99 $0 • 99 • Douglas Sierra Nevada Spectrum Sierra Nevada Spectrum Regional PPO $0.00 $0.00 $0 • |
