Plan ID: H4961-006

What You Need to Know:

  • Balance (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 .
  • The plan includes an out-of-pocket maximum of $2,850 per year (in-network).
  • Balance (PPO) includes a Part D prescription drug plan for prescription medication coverage. The annual deductible is .
  • This plan's Part D Initial Coverage Limit is $0.

$0

Monthly Premium

Medicare Plan Features
Monthly Premium: $0
Part C Premium: $0
Monthly Premium: Part C Premium: Part D Drug Premium: Part D Supplemental Premium: Total Part D Premium: Drug Deductible: Tiers with No Deductible:
$0 $0 $0 $0 $0 $0 0.0
Gap Coverage: Yes
Benchmark: not below the regional benchmark
Type of Medicare Health: Enhanced Alternative
Health Plan Type: Local PPO
Similar Plan: H4961-001
Special Needs Type: NULL
Chronic Condition: NULL
Additional Gap Coverage: Yes, some additional gap coverage.
Maximum Out-of-Pocket Limit for Parts A & B (Moop): $2,850
Annual Deductible: NULL
Annual Initial Coverage Limit ICL: $4,130
Number of Members enrolled in this plan in Stanislaus, California: Plans Summary Star Rating: Customer Service Rating: Drug Cost Rating:
62 members New plan - No summary rating as of yet. New plan - not yet rated. New plan - not yet rated.
Plan Offers Mail Order: Yes
Plan Health Benefits
Total # of Formulary Drugs: 3,466 drugs
Number of Members Enrolled in this Plan in Stanislaus, California: NULL
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
$0.00 $0.00 $0.00 $0.00
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
$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00
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)
330 $0.00 932 $3.00 776 $40.00 481 $93.00 749 33%

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AllCare Preferred Plan (HMO) (2023)Local HMO$2,900$0
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Health Net Green (HMO) (2023)Local HMO *$3,400$-
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Health Net Sapphire (HMO) (2023)Local HMO$3,450$445
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SCAN Classic (HMO) (2023)Local HMO$3,400$0
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Imperial Traditional (HMO) (2023)Local HMO$2,999$0
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Blue Shield Inspire (HMO) (2023)Local HMO$3,400$0
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SCAN Plus (HMO) (2023)Local HMO$7,550$445
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Imperial Traditional Plus (HMO) (2023)Local HMO$2,999$445
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Aetna Medicare Elite Plan (PPO) (2023)Local PPO$7,550$0
5
Humana Gold Plus H5619-032 (HMO) (2023)Local HMO$3,450$0
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AARP Medicare Advantage SecureHorizons Focus (HMO) (2023)Local HMO$3,400$0
4
Blue Shield Coordinated Choice Plan (HMO) (2023)Local HMO$6,700$445
3
Blue Shield AdvantageOptimum Plan (HMO) (2023)Local HMO$3,400$0
3
AARP Medicare Advantage SecureHorizons Plan 1 (HMO) (2023)Local HMO$3,400$100
4
AARP Medicare Advantage SecureHorizons Plan 2 (HMO) (2023)Local HMO$4,900$100
4
Kaiser Permanente Senior Advantage Basic Stanis (HMO) (2023)Local HMO$5,900$0
5
Anthem MediBlue Value (HMO) (2023)Local HMO$3,400$0
5
Anthem MediBlue StartSmart Plus (HMO) (2023)Local HMO$3,450$0
5
Kaiser Permanente Senior Advantage Enhanced Stanis (HMO) (2023)Local HMO$3,400$0
5
Health Net Ruby (HMO) (2023)Local HMO$3,450$0
4
Medicare Advantage Plans by Alignment Health Plan
CalPlus (HMO) (2023)Local HMO$4,900$445
5
My Choice (PPO) (2023)Local PPO$4,200$0
New plan - not yet rated.
My Choice (HMO) (2023)Local HMO$4,900$0
5
AllCare Preferred Plan (HMO) (2023)Local HMO$2,900$0
5

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