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2020 Medicare Advantage Prescription Drug Plan List
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County Organization Name
Plan Name Contract ID
Plan ID
Plan Type Special Needs Plan
Special Needs Plan
Type
Benefit Type Part C Premium2
Part D Basic Premium3
Part D Premium Obligation with Full
Premium Assistance6
Baker Moda Health Plan, Inc.
Moda Health PPORX (PPO)
H3813 6 Local PPO No Enhanced Alternative
$77.60 $61.40 $28.80
Benton UnitedHealthcare UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP)
H0710 36 Local PPO Yes Institutional Defined Standard Benefit
$0.00 $29.70 $0.00
Benton UnitedHealthcare UnitedHealthcare Assisted Living Plan 2 (PPO I-SNP)
H0710 37 Local PPO Yes Institutional Enhanced Alternative
$0.00 $15.10 $0.00
Benton UnitedHealthcare UnitedHealthcare Assisted Living Plan 1 (PPO I-SNP)
H2228 17 Local PPO Yes Institutional Enhanced Alternative
$0.00 $14.20 $0.00
Benton UnitedHealthcare AARP Medicare Advantage Plan 1 (HMO)
H3805 7 HMO No Enhanced Alternative
$30.80 $24.20 $0.00
Benton UnitedHealthcare AARP Medicare Advantage Plan 2 (HMO)
H3805 23 HMO No Enhanced Alternative
$0.00 $0.00 $0.00
Benton Samaritan Advantage Health Plan
Samaritan Advantage Premier Plan (HMO)
H3811 2 HMO No Enhanced Alternative
$25.00 $30.00 $0.00
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Benton Samaritan Advantage Health Plan
Samaritan Advantage Special Needs Plan (HMO D-SNP)
H3811 3 HMO Yes Dual-Eligible
Defined Standard Benefit
$0.00 $32.60 $0.00
Benton Samaritan Advantage Health Plan
Samaritan Advantage Premier Plan Plus (HMO)
H3811 9 HMO No Enhanced Alternative
$85.00 $44.00 $11.40
Benton Moda Health Plan, Inc.
Moda Health NW PPORX (PPO)
H3813 11 Local PPO No Enhanced Alternative
$44.20 $59.80 $27.20
Benton Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Classic (PPO)
H3817 8 Local PPO No Enhanced Alternative
$33.00 $42.00 $9.40
Benton Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Enhanced (PPO)
H3817 9 Local PPO No Enhanced Alternative
$137.70 $56.30 $23.70
Benton Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Primary (PPO)
H3817 11 Local PPO No Enhanced Alternative
$0.00 $15.00 $0.00
Benton Health Net Life Insurance Company
Health Net Violet 1 (PPO)
H5439 11 Local PPO No Enhanced Alternative
$69.50 $50.50 $17.90
Benton Health Net Life Insurance Company
Health Net Violet 2 (PPO)
H5439 14 Local PPO No Enhanced Alternative
$0.00 $24.00 $0.00
Benton Health Net Health Plan of Oregon, Inc.
Health Net Ruby (HMO)
H6815 3 HMO No Enhanced Alternative
$0.00 $0.00 $0.00
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2020 Medicare Advantage Prescription Drug Plan List
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Benton Kaiser Permanente
Kaiser Permanente Senior Advantage (HMO)
H9003 1 HMO No Enhanced Alternative
$57.20 $47.00 $37.20
Benton Kaiser Permanente
Kaiser Permanente Senior Advantage Basic (HMO)
H9003 6 HMO No Enhanced Alternative
$8.70 $35.30 $2.70
Benton Providence Medicare Advantage Plans
Providence Medicare Enrich + RX (HMO)
H9047 45 HMO No Basic Alternative
$96.60 $51.40 $18.80
Clackamas UnitedHealthcare UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP)
H0710 36 Local PPO Yes Institutional Defined Standard Benefit
$0.00 $29.70 $0.00
Clackamas UnitedHealthcare UnitedHealthcare Assisted Living Plan 2 (PPO I-SNP)
H0710 37 Local PPO Yes Institutional Enhanced Alternative
$0.00 $15.10 $0.00
Clackamas Humana Humana Gold Plus H1036-153 (HMO)
H1036 153 HMO No Enhanced Alternative
$0.00 $0.00 $0.00
Clackamas AgeRight Advantage
AgeRight Advantage Health Plan (HMO I-SNP)
H1372 1 HMO Yes Institutional Defined Standard Benefit
$0.00 $32.60 $0.00
Clackamas Aetna Medicare Aetna Medicare Elite Plan (HMO)
H2056 3 HMO No Enhanced Alternative
$0.00 $0.00 $0.00
Clackamas Aetna Medicare Aetna Medicare Value Plan (HMO)
H2056 4 HMO No Enhanced Alternative
$0.00 $0.00 $0.00
Clackamas UnitedHealthcare UnitedHealthcare Nursing Home Plan 1 (PPO I-SNP)
H2228 16 Local PPO Yes Institutional Defined Standard Benefit
$0.00 $29.80 $0.00
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Clackamas UnitedHealthcare UnitedHealthcare Assisted Living Plan 1 (PPO I-SNP)
H2228 17 Local PPO Yes Institutional Enhanced Alternative
$0.00 $14.20 $0.00
Clackamas UnitedHealthcare AARP Medicare Advantage Choice (PPO)
H2228 29 Local PPO No Enhanced Alternative
$4.10 $27.90 $0.00
Clackamas UnitedHealthcare AARP Medicare Advantage Walgreens (PPO)
H2228 84 Local PPO No Enhanced Alternative
$0.00 $0.00 $0.00
Clackamas UnitedHealthcare AARP Medicare Advantage Plan 1 (HMO)
H3805 1 HMO No Enhanced Alternative
$39.50 $32.50 $0.00
Clackamas UnitedHealthcare AARP Medicare Advantage Plan 2 (HMO)
H3805 22 HMO No Enhanced Alternative
$0.00 $0.00 $0.00
Clackamas Providence ElderPlace Portland
Providence ElderPlace Portland (dual eligible) (PACE)
H3809 1 National PACE No $224.50 $0.00
Clackamas Providence ElderPlace Portland
Providence ElderPlace Portland (private pay) (PACE)
H3809 2 National PACE No $171.60 $693.90
Clackamas Moda Health Plan, Inc.
Moda Health PPORX Enhanced (PPO)
H3813 9 Local PPO No Enhanced Alternative
$107.30 $71.50 $55.10
Clackamas Moda Health Plan, Inc.
Moda Health Metro PPORX (PPO)
H3813 13 Local PPO No Enhanced Alternative
$53.90 $45.10 $12.50
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Clackamas Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Classic (PPO)
H3817 8 Local PPO No Enhanced Alternative
$5.00 $42.00 $9.40
Clackamas Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Enhanced (PPO)
H3817 9 Local PPO No Enhanced Alternative
$117.70 $56.30 $23.70
Clackamas Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Primary (PPO)
H3817 11 Local PPO No Enhanced Alternative
$0.00 $0.00 $0.00
Clackamas PacificSource Medicare
PacificSource Medicare MyCare Rx 39 (HMO)
H3864 39 HMO No Enhanced Alternative
$36.40 $31.60 $0.00
Clackamas PacificSource Medicare
PacificSource Medicare MyCare Rx 40 (HMO)
H3864 40 HMO No Enhanced Alternative
$0.00 $0.00 $0.00
Clackamas Humana HumanaChoice H5216-048 (PPO)
H5216 48 Local PPO No Basic Alternative
$166.40 $33.60 $0.90
Clackamas Health Net Life Insurance Company
Health Net Violet 1 (PPO)
H5439 11 Local PPO No Enhanced Alternative
$69.50 $50.50 $17.90
Clackamas Health Net Life Insurance Company
Health Net Violet 2 (PPO)
H5439 14 Local PPO No Enhanced Alternative
$0.00 $19.00 $0.00
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Clackamas CareOregon Advantage
CareOregon Advantage Plus (HMO-POS D-SNP)
H5859 1 HMOPOS Yes Dual-Eligible
Enhanced Alternative
$0.00 $32.60 $0.00
Clackamas Regence BlueCross BlueShield of Oregon
Regence BlueAdvantage HMO (HMO)
H6237 7 HMO No Enhanced Alternative
$0.00 $0.00 $0.00
Clackamas Regence BlueCross BlueShield of Oregon
Regence BlueAdvantage HMO Plus (HMO)
H6237 8 HMO No Enhanced Alternative
$9.10 $24.90 $0.00
Clackamas Health Net Health Plan of Oregon, Inc.
Health Net Ruby (HMO)
H6815 3 HMO No Enhanced Alternative
$0.00 $0.00 $0.00
Clackamas Kaiser Permanente
Kaiser Permanente Senior Advantage (HMO)
H9003 1 HMO No Enhanced Alternative
$57.20 $47.00 $37.20
Clackamas Kaiser Permanente
Kaiser Permanente Senior Advantage Basic (HMO)
H9003 6 HMO No Enhanced Alternative
$8.70 $35.30 $2.70
Clackamas Providence Medicare Advantage Plans
Providence Medicare Prime + RX (HMO)
H9047 37 HMO No Enhanced Alternative
$0.00 $0.00 $0.00
Clackamas Providence Medicare Advantage Plans
Providence Medicare Dual Plus (HMO D-SNP)
H9047 43 HMO Yes Dual-Eligible
Defined Standard Benefit
$0.00 $32.60 $0.00
Clackamas Providence Medicare Advantage Plans
Providence Medicare Extra + RX (HMO)
H9047 55 HMO No Enhanced Alternative
$121.30 $51.70 $19.10
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Clackamas Providence Medicare Advantage Plans
Providence Medicare Choice + RX (HMO-POS)
H9047 56 HMOPOS No Enhanced Alternative
$31.50 $56.50 $23.90
Clackamas Providence Medicare Advantage Plans
Providence Medicare Bridge 1 + RX (HMO)
H9047 59 HMO No Enhanced Alternative
$0.00 $35.00 $2.40
Clackamas Aetna Medicare Aetna Medicare Choice Plan (PPO)
H9431 5 Local PPO No Enhanced Alternative
$0.00 $17.00 $0.00
Clackamas Aetna Medicare Aetna Medicare Select Plan (PPO)
H9431 8 Local PPO No Enhanced Alternative
$24.90 $21.10 $0.00
Clatsop Providence ElderPlace Portland
Providence ElderPlace Portland (dual eligible) (PACE)
H3809 1 National PACE No $224.50 $0.00
Clatsop Providence ElderPlace Portland
Providence ElderPlace Portland (private pay) (PACE)
H3809 2 National PACE No $171.60 $693.90
Clatsop Moda Health Plan, Inc.
Moda Health NW PPORX (PPO)
H3813 11 Local PPO No Enhanced Alternative
$44.20 $59.80 $27.20
Columbia Moda Health Plan, Inc.
Moda Health NW PPORX (PPO)
H3813 11 Local PPO No Enhanced Alternative
$44.20 $59.80 $27.20
Columbia Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Classic (PPO)
H3817 8 Local PPO No Enhanced Alternative
$33.00 $42.00 $9.40
Columbia Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Enhanced (PPO)
H3817 9 Local PPO No Enhanced Alternative
$137.70 $56.30 $23.70
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Columbia Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Primary (PPO)
H3817 11 Local PPO No Enhanced Alternative
$0.00 $15.00 $0.00
Columbia Humana HumanaChoice H5216-048 (PPO)
H5216 48 Local PPO No Basic Alternative
$166.40 $33.60 $0.90
Columbia CareOregon Advantage
CareOregon Advantage Plus (HMO-POS D-SNP)
H5859 1 HMOPOS Yes Dual-Eligible
Enhanced Alternative
$0.00 $32.60 $0.00
Columbia Kaiser Permanente
Kaiser Permanente Senior Advantage (HMO)
H9003 1 HMO No Enhanced Alternative
$57.20 $47.00 $37.20
Columbia Kaiser Permanente
Kaiser Permanente Senior Advantage Basic (HMO)
H9003 6 HMO No Enhanced Alternative
$8.70 $35.30 $2.70
Columbia Providence Medicare Advantage Plans
Providence Medicare Timber + RX (HMO)
H9047 54 HMO No Enhanced Alternative
$0.00 $0.00 $0.00
Columbia Providence Medicare Advantage Plans
Providence Medicare Extra + RX (HMO)
H9047 55 HMO No Enhanced Alternative
$121.30 $51.70 $19.10
Columbia Providence Medicare Advantage Plans
Providence Medicare Choice + RX (HMO-POS)
H9047 56 HMOPOS No Enhanced Alternative
$31.50 $56.50 $23.90
Columbia Providence Medicare Advantage Plans
Providence Medicare Bridge 2 + RX (HMO)
H9047 60 HMO No Enhanced Alternative
$0.00 $40.00 $7.40
Coos Moda Health Plan, Inc.
Moda Health Southern PPORX (PPO)
H3813 12 Local PPO No Enhanced Alternative
$37.50 $61.50 $28.90
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Coos Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Classic (PPO)
H3817 8 Local PPO No Enhanced Alternative
$33.00 $42.00 $9.40
Coos Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Enhanced (PPO)
H3817 9 Local PPO No Enhanced Alternative
$137.70 $56.30 $23.70
Coos Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Primary (PPO)
H3817 11 Local PPO No Enhanced Alternative
$0.00 $15.00 $0.00
Coos PacificSource Medicare
PacificSource Medicare Essentials Rx 41 (HMO)
H3864 41 HMO No Enhanced Alternative
$30.60 $38.40 $5.80
Coos PacificSource Medicare
PacificSource Medicare Explorer Rx 7 (PPO)
H4754 7 Local PPO No Enhanced Alternative
$79.60 $30.80 $18.60
Coos Health Net Health Plan of Oregon, Inc.
Health Net Ruby (HMO)
H6815 6 HMO No Enhanced Alternative
$55.00 $29.00 $0.00
Crook Moda Health Plan, Inc.
Moda Health Central PPORX (PPO)
H3813 10 Local PPO No Enhanced Alternative
$45.10 $64.80 $32.20
Crook PacificSource Medicare
PacificSource Medicare Essentials Rx 6 (HMO)
H3864 6 HMO No Enhanced Alternative
$145.40 $47.40 $39.00
Crook PacificSource Medicare
PacificSource Medicare Essentials Choice Rx 14 (HMO-POS)
H3864 14 HMOPOS No Enhanced Alternative
$59.00 $40.00 $7.40
Crook PacificSource Medicare
PacificSource Medicare Essentials Rx 27 (HMO)
H3864 27 HMO No Enhanced Alternative
$4.30 $50.70 $18.10
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Crook Humana HumanaChoice H5216-044 (PPO)
H5216 44 Local PPO No Enhanced Alternative
$13.80 $24.20 $0.00
Crook Humana HumanaChoice H5216-047 (PPO)
H5216 47 Local PPO No Enhanced Alternative
$61.80 $29.90 $9.30
Crook Humana HumanaChoice H5216-048 (PPO)
H5216 48 Local PPO No Basic Alternative
$166.40 $33.60 $0.90
Crook Health Net Health Plan of Oregon, Inc.
Health Net Ruby (HMO)
H6815 6 HMO No Enhanced Alternative
$55.00 $29.00 $0.00
Crook Providence Medicare Advantage Plans
Providence Medicare Latitude + RX (HMO-POS)
H9047 38 HMOPOS No Enhanced Alternative
$125.20 $55.00 $38.20
Crook Providence Medicare Advantage Plans
Providence Medicare Compass + RX (HMO-POS)
H9047 39 HMOPOS No Enhanced Alternative
$58.50 $40.50 $7.90
Curry Moda Health Plan, Inc.
Moda Health Southern PPORX (PPO)
H3813 12 Local PPO No Enhanced Alternative
$37.50 $61.50 $28.90
Curry Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Classic (PPO)
H3817 8 Local PPO No Enhanced Alternative
$33.00 $42.00 $9.40
Curry Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Enhanced (PPO)
H3817 9 Local PPO No Enhanced Alternative
$137.70 $56.30 $23.70
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Curry Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Primary (PPO)
H3817 11 Local PPO No Enhanced Alternative
$0.00 $15.00 $0.00
Curry PacificSource Medicare
PacificSource Medicare Essentials Rx 41 (HMO)
H3864 41 HMO No Enhanced Alternative
$30.60 $38.40 $5.80
Curry PacificSource Medicare
PacificSource Medicare Explorer Rx 7 (PPO)
H4754 7 Local PPO No Enhanced Alternative
$79.60 $30.80 $18.60
Deschutes Humana Humana Gold Plus H1036-219 (HMO)
H1036 219 HMO No Enhanced Alternative
$58.00 $0.00 $0.00
Deschutes Moda Health Plan, Inc.
Moda Health Central PPORX (PPO)
H3813 10 Local PPO No Enhanced Alternative
$45.10 $64.80 $32.20
Deschutes PacificSource Medicare
PacificSource Medicare Essentials Rx 6 (HMO)
H3864 6 HMO No Enhanced Alternative
$145.40 $47.40 $39.00
Deschutes PacificSource Medicare
PacificSource Medicare Essentials Choice Rx 14 (HMO-POS)
H3864 14 HMOPOS No Enhanced Alternative
$59.00 $40.00 $7.40
Deschutes PacificSource Medicare
PacificSource Medicare Essentials Rx 27 (HMO)
H3864 27 HMO No Enhanced Alternative
$4.30 $50.70 $18.10
Deschutes Humana HumanaChoice H5216-044 (PPO)
H5216 44 Local PPO No Enhanced Alternative
$13.80 $24.20 $0.00
Deschutes Humana HumanaChoice H5216-047 (PPO)
H5216 47 Local PPO No Enhanced Alternative
$61.80 $29.90 $9.30
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Deschutes Humana HumanaChoice H5216-048 (PPO)
H5216 48 Local PPO No Basic Alternative
$166.40 $33.60 $0.90
Deschutes Regence BlueCross BlueShield of Oregon
Regence BlueAdvantage HMO (HMO)
H6237 7 HMO No Enhanced Alternative
$27.00 $22.00 $0.00
Deschutes Regence BlueCross BlueShield of Oregon
Regence BlueAdvantage HMO Plus (HMO)
H6237 8 HMO No Enhanced Alternative
$63.10 $24.90 $0.00
Deschutes Health Net Health Plan of Oregon, Inc.
Health Net Ruby (HMO)
H6815 6 HMO No Enhanced Alternative
$55.00 $29.00 $0.00
Deschutes Providence Medicare Advantage Plans
Providence Medicare Latitude + RX (HMO-POS)
H9047 38 HMOPOS No Enhanced Alternative
$125.20 $55.00 $38.20
Deschutes Providence Medicare Advantage Plans
Providence Medicare Compass + RX (HMO-POS)
H9047 39 HMOPOS No Enhanced Alternative
$58.50 $40.50 $7.90
Douglas AllCare Advantage
AllCare Advantage Gold Plus Rx (HMO)
H3810 3 HMO No Enhanced Alternative
$55.90 $48.30 $50.50
Douglas AllCare Advantage
AllCare Advantage Preferred Rx (HMO)
H3810 20 HMO No Defined Standard Benefit
$0.00 $32.60 $0.00
Douglas AllCare Advantage
AllCare Advantage Focus Rx (HMO)
H3810 22 HMO No Enhanced Alternative
$0.00 $39.00 $6.40
Douglas Moda Health Plan, Inc.
Moda Health Southern PPORX (PPO)
H3813 12 Local PPO No Enhanced Alternative
$37.50 $61.50 $28.90
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Douglas ATRIO Health Plans
ATRIO Special Needs Plan (HMO D-SNP)
H3814 7 HMO Yes Dual-Eligible
Defined Standard Benefit
$0.00 $32.60 $0.00
Douglas Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Classic (PPO)
H3817 8 Local PPO No Enhanced Alternative
$33.00 $42.00 $9.40
Douglas Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Enhanced (PPO)
H3817 9 Local PPO No Enhanced Alternative
$137.70 $56.30 $23.70
Douglas Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Primary (PPO)
H3817 11 Local PPO No Enhanced Alternative
$0.00 $15.00 $0.00
Douglas Health Net Life Insurance Company
Health Net Violet 1 (PPO)
H5439 13 Local PPO No Enhanced Alternative
$69.40 $35.60 $3.00
Douglas Health Net Life Insurance Company
Health Net Violet 3 (PPO)
H5439 15 Local PPO No Enhanced Alternative
$0.00 $0.00 $0.00
Douglas Health Net Life Insurance Company
Health Net Violet 2 (PPO)
H5439 16 Local PPO No Enhanced Alternative
$0.00 $25.00 $0.00
Douglas ATRIO Health Plans
ATRIO Bronze Rx (Umpqua) (PPO)
H6743 7 Local PPO No Enhanced Alternative
$0.00 $0.00 $0.00
Douglas ATRIO Health Plans
ATRIO Silver Rx (PPO)
H6743 20 Local PPO No Enhanced Alternative
$67.00 $53.60 $29.40
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Douglas ATRIO Health Plans
ATRIO Gold Rx (PPO)
H6743 21 Local PPO No Enhanced Alternative
$110.10 $59.50 $56.30
Douglas Health Net Health Plan of Oregon, Inc.
Health Net Ruby (HMO)
H6815 5 HMO No Enhanced Alternative
$3.50 $25.50 $0.00
Gilliam Moda Health Plan, Inc.
Moda Health PPORX (PPO)
H3813 6 Local PPO No Enhanced Alternative
$77.60 $61.40 $28.80
Grant Moda Health Plan, Inc.
Moda Health PPORX (PPO)
H3813 6 Local PPO No Enhanced Alternative
$77.60 $61.40 $28.80
Grant PacificSource Medicare
PacificSource Medicare Essentials Rx 6 (HMO)
H3864 6 HMO No Enhanced Alternative
$145.40 $47.40 $39.00
Grant PacificSource Medicare
PacificSource Medicare Essentials Choice Rx 14 (HMO-POS)
H3864 14 HMOPOS No Enhanced Alternative
$59.00 $40.00 $7.40
Grant PacificSource Medicare
PacificSource Medicare Essentials Rx 27 (HMO)
H3864 27 HMO No Enhanced Alternative
$4.30 $50.70 $18.10
Harney Moda Health Plan, Inc.
Moda Health PPORX (PPO)
H3813 6 Local PPO No Enhanced Alternative
$77.60 $61.40 $28.80
Hood River Moda Health Plan, Inc.
Moda Health Central PPORX (PPO)
H3813 10 Local PPO No Enhanced Alternative
$45.10 $64.80 $32.20
Hood River PacificSource Medicare
PacificSource Medicare Essentials Rx 6 (HMO)
H3864 6 HMO No Enhanced Alternative
$145.40 $47.40 $39.00
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Hood River PacificSource Medicare
PacificSource Medicare Essentials Choice Rx 14 (HMO-POS)
H3864 14 HMOPOS No Enhanced Alternative
$59.00 $40.00 $7.40
Hood River PacificSource Medicare
PacificSource Medicare Essentials Rx 27 (HMO)
H3864 27 HMO No Enhanced Alternative
$4.30 $50.70 $18.10
Hood River Humana HumanaChoice H5216-048 (PPO)
H5216 48 Local PPO No Basic Alternative
$166.40 $33.60 $0.90
Hood River Providence Medicare Advantage Plans
Providence Medicare Latitude + RX (HMO-POS)
H9047 38 HMOPOS No Enhanced Alternative
$125.20 $55.00 $38.20
Hood River Providence Medicare Advantage Plans
Providence Medicare Compass + RX (HMO-POS)
H9047 39 HMOPOS No Enhanced Alternative
$58.50 $40.50 $7.90
Jackson AllCare Advantage
AllCare Advantage Gold Plus Rx (HMO)
H3810 3 HMO No Enhanced Alternative
$55.90 $48.30 $50.50
Jackson AllCare Advantage
AllCare Advantage Preferred Rx (HMO)
H3810 20 HMO No Defined Standard Benefit
$0.00 $32.60 $0.00
Jackson AllCare Advantage
AllCare Advantage Focus Rx (HMO)
H3810 22 HMO No Enhanced Alternative
$0.00 $39.00 $6.40
Jackson Moda Health Plan, Inc.
Moda Health PPORX Enhanced (PPO)
H3813 7 Local PPO No Enhanced Alternative
$101.70 $75.40 $60.70
Jackson Moda Health Plan, Inc.
Moda Health Southern PPORX (PPO)
H3813 12 Local PPO No Enhanced Alternative
$37.50 $61.50 $28.90
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Jackson Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Classic (PPO)
H3817 8 Local PPO No Enhanced Alternative
$33.00 $42.00 $9.40
Jackson Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Enhanced (PPO)
H3817 9 Local PPO No Enhanced Alternative
$137.70 $56.30 $23.70
Jackson Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Primary (PPO)
H3817 11 Local PPO No Enhanced Alternative
$0.00 $15.00 $0.00
Jackson Health Net Life Insurance Company
Health Net Violet 1 (PPO)
H5439 13 Local PPO No Enhanced Alternative
$69.40 $35.60 $3.00
Jackson Health Net Life Insurance Company
Health Net Violet 2 (PPO)
H5439 16 Local PPO No Enhanced Alternative
$0.00 $25.00 $0.00
Jackson CareOregon Advantage
CareOregon Advantage Plus (HMO-POS D-SNP)
H5859 1 HMOPOS Yes Dual-Eligible
Enhanced Alternative
$0.00 $32.60 $0.00
Jackson ATRIO Health Plans
ATRIO Bronze Rx (Rogue) (PPO)
H6743 18 Local PPO No Enhanced Alternative
$0.00 $0.00 $0.00
Jackson ATRIO Health Plans
ATRIO Silver Rx (PPO)
H6743 20 Local PPO No Enhanced Alternative
$45.40 $53.60 $21.00
Jackson Health Net Health Plan of Oregon, Inc.
Health Net Ruby (HMO)
H6815 5 HMO No Enhanced Alternative
$3.50 $25.50 $0.00
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Jackson Aetna Medicare Aetna Medicare Choice Plan (PPO)
H9431 4 Local PPO No Enhanced Alternative
$19.70 $20.30 $0.00
Jackson Aetna Medicare Aetna Medicare Select Plan (PPO)
H9431 7 Local PPO No Enhanced Alternative
$54.40 $19.60 $0.00
Jefferson Humana Humana Gold Plus H1036-219 (HMO)
H1036 219 HMO No Enhanced Alternative
$58.00 $0.00 $0.00
Jefferson Moda Health Plan, Inc.
Moda Health Central PPORX (PPO)
H3813 10 Local PPO No Enhanced Alternative
$45.10 $64.80 $32.20
Jefferson PacificSource Medicare
PacificSource Medicare Essentials Rx 6 (HMO)
H3864 6 HMO No Enhanced Alternative
$145.40 $47.40 $39.00
Jefferson PacificSource Medicare
PacificSource Medicare Essentials Choice Rx 14 (HMO-POS)
H3864 14 HMOPOS No Enhanced Alternative
$59.00 $40.00 $7.40
Jefferson PacificSource Medicare
PacificSource Medicare Essentials Rx 27 (HMO)
H3864 27 HMO No Enhanced Alternative
$4.30 $50.70 $18.10
Jefferson Humana HumanaChoice H5216-044 (PPO)
H5216 44 Local PPO No Enhanced Alternative
$13.80 $24.20 $0.00
Jefferson Humana HumanaChoice H5216-047 (PPO)
H5216 47 Local PPO No Enhanced Alternative
$61.80 $29.90 $9.30
Jefferson Humana HumanaChoice H5216-048 (PPO)
H5216 48 Local PPO No Basic Alternative
$166.40 $33.60 $0.90
Page 18
2020 Medicare Advantage Prescription Drug Plan List
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Jefferson Health Net Health Plan of Oregon, Inc.
Health Net Ruby (HMO)
H6815 6 HMO No Enhanced Alternative
$55.00 $29.00 $0.00
Jefferson Providence Medicare Advantage Plans
Providence Medicare Latitude + RX (HMO-POS)
H9047 38 HMOPOS No Enhanced Alternative
$125.20 $55.00 $38.20
Jefferson Providence Medicare Advantage Plans
Providence Medicare Compass + RX (HMO-POS)
H9047 39 HMOPOS No Enhanced Alternative
$58.50 $40.50 $7.90
Josephine AllCare Advantage
AllCare Advantage Gold Plus Rx (HMO)
H3810 3 HMO No Enhanced Alternative
$55.90 $48.30 $50.50
Josephine AllCare Advantage
AllCare Advantage Preferred Rx (HMO)
H3810 20 HMO No Defined Standard Benefit
$0.00 $32.60 $0.00
Josephine AllCare Advantage
AllCare Advantage Focus Rx (HMO)
H3810 22 HMO No Enhanced Alternative
$0.00 $39.00 $6.40
Josephine Moda Health Plan, Inc.
Moda Health PPORX Enhanced (PPO)
H3813 7 Local PPO No Enhanced Alternative
$101.70 $75.40 $60.70
Josephine Moda Health Plan, Inc.
Moda Health Southern PPORX (PPO)
H3813 12 Local PPO No Enhanced Alternative
$37.50 $61.50 $28.90
Josephine Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Classic (PPO)
H3817 8 Local PPO No Enhanced Alternative
$33.00 $42.00 $9.40
Page 19
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Josephine Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Enhanced (PPO)
H3817 9 Local PPO No Enhanced Alternative
$137.70 $56.30 $23.70
Josephine Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Primary (PPO)
H3817 11 Local PPO No Enhanced Alternative
$0.00 $15.00 $0.00
Josephine Health Net Life Insurance Company
Health Net Violet 1 (PPO)
H5439 13 Local PPO No Enhanced Alternative
$69.40 $35.60 $3.00
Josephine Health Net Life Insurance Company
Health Net Violet 3 (PPO)
H5439 15 Local PPO No Enhanced Alternative
$0.00 $0.00 $0.00
Josephine Health Net Life Insurance Company
Health Net Violet 2 (PPO)
H5439 16 Local PPO No Enhanced Alternative
$0.00 $25.00 $0.00
Josephine ATRIO Health Plans
ATRIO Bronze Rx (Rogue) (PPO)
H6743 18 Local PPO No Enhanced Alternative
$0.00 $23.00 $0.00
Josephine ATRIO Health Plans
ATRIO Silver Rx (PPO)
H6743 20 Local PPO No Enhanced Alternative
$75.40 $53.60 $21.00
Josephine Health Net Health Plan of Oregon, Inc.
Health Net Ruby (HMO)
H6815 5 HMO No Enhanced Alternative
$3.50 $25.50 $0.00
Josephine Aetna Medicare Aetna Medicare Choice Plan (PPO)
H9431 4 Local PPO No Enhanced Alternative
$19.70 $20.30 $0.00
Page 20
2020 Medicare Advantage Prescription Drug Plan List
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Josephine Aetna Medicare Aetna Medicare Select Plan (PPO)
H9431 7 Local PPO No Enhanced Alternative
$54.40 $19.60 $0.00
Klamath AgeRight Advantage
AgeRight Advantage Health Plan (HMO I-SNP)
H1372 1 HMO Yes Institutional Defined Standard Benefit
$0.00 $32.60 $0.00
Klamath Moda Health Plan, Inc.
Moda Health Southern PPORX (PPO)
H3813 12 Local PPO No Enhanced Alternative
$37.50 $61.50 $28.90
Klamath ATRIO Health Plans
ATRIO Special Needs Plan (HMO D-SNP)
H3814 7 HMO Yes Dual-Eligible
Defined Standard Benefit
$0.00 $32.60 $0.00
Klamath PacificSource Medicare
PacificSource Medicare Essentials Rx 6 (HMO)
H3864 6 HMO No Enhanced Alternative
$145.40 $47.40 $39.00
Klamath PacificSource Medicare
PacificSource Medicare Essentials Choice Rx 14 (HMO-POS)
H3864 14 HMOPOS No Enhanced Alternative
$59.00 $40.00 $7.40
Klamath PacificSource Medicare
PacificSource Medicare Essentials Rx 27 (HMO)
H3864 27 HMO No Enhanced Alternative
$4.30 $50.70 $18.10
Klamath ATRIO Health Plans
ATRIO Bronze Rx (Basin) (PPO)
H6743 1 Local PPO No Enhanced Alternative
$0.00 $0.00 $0.00
Klamath ATRIO Health Plans
ATRIO Silver Rx (PPO)
H6743 20 Local PPO No Enhanced Alternative
$45.40 $53.60 $21.00
Klamath ATRIO Health Plans
ATRIO Gold Rx (PPO)
H6743 21 Local PPO No Enhanced Alternative
$101.40 $59.50 $65.00
Page 21
2020 Medicare Advantage Prescription Drug Plan List
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Lake Moda Health Plan, Inc.
Moda Health PPORX (PPO)
H3813 6 Local PPO No Enhanced Alternative
$77.60 $61.40 $28.80
Lane UnitedHealthcare UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP)
H0710 36 Local PPO Yes Institutional Defined Standard Benefit
$0.00 $29.70 $0.00
Lane AgeRight Advantage
AgeRight Advantage Health Plan (HMO I-SNP)
H1372 1 HMO Yes Institutional Defined Standard Benefit
$0.00 $32.60 $0.00
Lane Trillium Medicare Advantage
Trillium Advantage Dual (HMO D-SNP)
H2174 1 HMO Yes Dual-Eligible
Defined Standard Benefit
$0.00 $32.60 $0.00
Lane UnitedHealthcare UnitedHealthcare Nursing Home Plan 1 (PPO I-SNP)
H2228 16 Local PPO Yes Institutional Defined Standard Benefit
$0.00 $29.80 $0.00
Lane UnitedHealthcare AARP Medicare Advantage Choice (PPO)
H2228 29 Local PPO No Enhanced Alternative
$4.10 $27.90 $0.00
Lane UnitedHealthcare AARP Medicare Advantage Walgreens (PPO)
H2228 84 Local PPO No Enhanced Alternative
$0.00 $0.00 $0.00
Lane UnitedHealthcare UnitedHealthcare Assisted Living Plan (HMO I-SNP)
H3113 8 HMO Yes Institutional Enhanced Alternative
$0.00 $9.20 $0.00
Lane UnitedHealthcare AARP Medicare Advantage Plan 1 (HMO)
H3805 7 HMO No Enhanced Alternative
$30.80 $24.20 $0.00
Page 22
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Lane UnitedHealthcare AARP Medicare Advantage Plan 2 (HMO)
H3805 23 HMO No Enhanced Alternative
$0.00 $0.00 $0.00
Lane Moda Health Plan, Inc.
Moda Health NW PPORX (PPO)
H3813 11 Local PPO No Enhanced Alternative
$44.20 $59.80 $27.20
Lane Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Classic (PPO)
H3817 8 Local PPO No Enhanced Alternative
$5.00 $42.00 $9.40
Lane Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Enhanced (PPO)
H3817 9 Local PPO No Enhanced Alternative
$117.70 $56.30 $23.70
Lane Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Primary (PPO)
H3817 11 Local PPO No Enhanced Alternative
$0.00 $0.00 $0.00
Lane PacificSource Medicare
PacificSource Medicare Essentials Rx 36 (HMO)
H3864 36 HMO No Enhanced Alternative
$0.00 $29.00 $0.00
Lane PacificSource Medicare
PacificSource Medicare Essentials Rx 41 (HMO)
H3864 41 HMO No Enhanced Alternative
$30.60 $38.40 $5.80
Lane PacificSource Medicare
PacificSource Medicare Explorer Rx 4 (PPO)
H4754 4 Local PPO No Enhanced Alternative
$29.30 $79.70 $47.10
Lane Health Net Life Insurance Company
Health Net Violet 1 (PPO)
H5439 11 Local PPO No Enhanced Alternative
$69.50 $50.50 $17.90
Page 23
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Lane Health Net Life Insurance Company
Health Net Violet 2 (PPO)
H5439 14 Local PPO No Enhanced Alternative
$0.00 $19.00 $0.00
Lane Health Net Life Insurance Company
Health Net Violet 4 (PPO)
H5439 17 Local PPO No Enhanced Alternative
$0.00 $0.00 $0.00
Lane Regence BlueCross BlueShield of Oregon
Regence BlueAdvantage HMO (HMO)
H6237 7 HMO No Enhanced Alternative
$0.00 $0.00 $0.00
Lane Regence BlueCross BlueShield of Oregon
Regence BlueAdvantage HMO Plus (HMO)
H6237 8 HMO No Enhanced Alternative
$23.10 $24.90 $0.00
Lane Health Net Health Plan of Oregon, Inc.
Health Net Ruby (HMO)
H6815 3 HMO No Enhanced Alternative
$0.00 $0.00 $0.00
Lane Providence Medicare Advantage Plans
Providence Medicare Timber + RX (HMO)
H9047 54 HMO No Enhanced Alternative
$0.00 $0.00 $0.00
Lane Providence Medicare Advantage Plans
Providence Medicare Extra + RX (HMO)
H9047 55 HMO No Enhanced Alternative
$121.30 $51.70 $19.10
Lane Providence Medicare Advantage Plans
Providence Medicare Choice + RX (HMO-POS)
H9047 56 HMOPOS No Enhanced Alternative
$31.50 $56.50 $23.90
Lane Providence Medicare Advantage Plans
Providence Medicare Bridge 2 + RX (HMO)
H9047 60 HMO No Enhanced Alternative
$0.00 $40.00 $7.40
Page 24
2020 Medicare Advantage Prescription Drug Plan List
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Lincoln Samaritan Advantage Health Plan
Samaritan Advantage Premier Plan (HMO)
H3811 2 HMO No Enhanced Alternative
$25.00 $30.00 $0.00
Lincoln Samaritan Advantage Health Plan
Samaritan Advantage Special Needs Plan (HMO D-SNP)
H3811 3 HMO Yes Dual-Eligible
Defined Standard Benefit
$0.00 $32.60 $0.00
Lincoln Samaritan Advantage Health Plan
Samaritan Advantage Premier Plan Plus (HMO)
H3811 9 HMO No Enhanced Alternative
$85.00 $44.00 $11.40
Lincoln Moda Health Plan, Inc.
Moda Health NW PPORX (PPO)
H3813 11 Local PPO No Enhanced Alternative
$44.20 $59.80 $27.20
Lincoln Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Classic (PPO)
H3817 8 Local PPO No Enhanced Alternative
$33.00 $42.00 $9.40
Lincoln Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Primary (PPO)
H3817 11 Local PPO No Enhanced Alternative
$0.00 $15.00 $0.00
Lincoln Humana HumanaChoice H5216-048 (PPO)
H5216 48 Local PPO No Basic Alternative
$166.40 $33.60 $0.90
Linn UnitedHealthcare UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP)
H0710 36 Local PPO Yes Institutional Defined Standard Benefit
$0.00 $29.70 $0.00
Linn UnitedHealthcare UnitedHealthcare Assisted Living Plan 2 (PPO I-SNP)
H0710 37 Local PPO Yes Institutional Enhanced Alternative
$0.00 $15.10 $0.00
Page 25
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Linn UnitedHealthcare UnitedHealthcare Nursing Home Plan 1 (PPO I-SNP)
H2228 16 Local PPO Yes Institutional Defined Standard Benefit
$0.00 $29.80 $0.00
Linn UnitedHealthcare UnitedHealthcare Assisted Living Plan 1 (PPO I-SNP)
H2228 17 Local PPO Yes Institutional Enhanced Alternative
$0.00 $14.20 $0.00
Linn UnitedHealthcare AARP Medicare Advantage Plan 1 (HMO)
H3805 7 HMO No Enhanced Alternative
$30.80 $24.20 $0.00
Linn UnitedHealthcare AARP Medicare Advantage Plan 2 (HMO)
H3805 23 HMO No Enhanced Alternative
$3.30 $15.70 $0.00
Linn Samaritan Advantage Health Plan
Samaritan Advantage Premier Plan (HMO)
H3811 2 HMO No Enhanced Alternative
$25.00 $30.00 $0.00
Linn Samaritan Advantage Health Plan
Samaritan Advantage Special Needs Plan (HMO D-SNP)
H3811 3 HMO Yes Dual-Eligible
Defined Standard Benefit
$0.00 $32.60 $0.00
Linn Samaritan Advantage Health Plan
Samaritan Advantage Premier Plan Plus (HMO)
H3811 9 HMO No Enhanced Alternative
$85.00 $44.00 $11.40
Linn Moda Health Plan, Inc.
Moda Health NW PPORX (PPO)
H3813 11 Local PPO No Enhanced Alternative
$44.20 $59.80 $27.20
Linn Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Classic (PPO)
H3817 8 Local PPO No Enhanced Alternative
$33.00 $42.00 $9.40
Linn Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Enhanced (PPO)
H3817 9 Local PPO No Enhanced Alternative
$137.70 $56.30 $23.70
Page 26
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Linn Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Primary (PPO)
H3817 11 Local PPO No Enhanced Alternative
$0.00 $15.00 $0.00
Linn Humana HumanaChoice H5216-048 (PPO)
H5216 48 Local PPO No Basic Alternative
$166.40 $33.60 $0.90
Linn Health Net Life Insurance Company
Health Net Violet 1 (PPO)
H5439 11 Local PPO No Enhanced Alternative
$69.50 $50.50 $17.90
Linn Health Net Life Insurance Company
Health Net Violet 2 (PPO)
H5439 14 Local PPO No Enhanced Alternative
$0.00 $24.00 $0.00
Linn Health Net Health Plan of Oregon, Inc.
Health Net Ruby (HMO)
H6815 3 HMO No Enhanced Alternative
$0.00 $0.00 $0.00
Linn Kaiser Permanente
Kaiser Permanente Senior Advantage (HMO)
H9003 1 HMO No Enhanced Alternative
$57.20 $47.00 $37.20
Linn Kaiser Permanente
Kaiser Permanente Senior Advantage Basic (HMO)
H9003 6 HMO No Enhanced Alternative
$8.70 $35.30 $2.70
Linn Providence Medicare Advantage Plans
Providence Medicare Enrich + RX (HMO)
H9047 45 HMO No Basic Alternative
$96.60 $51.40 $18.80
Malheur Moda Health Plan, Inc.
Moda Health PPORX (PPO)
H3813 6 Local PPO No Enhanced Alternative
$77.60 $61.40 $28.80
Malheur Humana HumanaChoice H5216-044 (PPO)
H5216 44 Local PPO No Enhanced Alternative
$13.80 $24.20 $0.00
Page 27
2020 Medicare Advantage Prescription Drug Plan List
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Malheur Humana HumanaChoice H5216-132 (PPO)
H5216 132 Local PPO No Enhanced Alternative
$0.00 $0.00 $0.00
Marion UnitedHealthcare UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP)
H0710 36 Local PPO Yes Institutional Defined Standard Benefit
$0.00 $29.70 $0.00
Marion UnitedHealthcare UnitedHealthcare Assisted Living Plan 2 (PPO I-SNP)
H0710 37 Local PPO Yes Institutional Enhanced Alternative
$0.00 $15.10 $0.00
Marion UnitedHealthcare UnitedHealthcare Assisted Living Plan 1 (PPO I-SNP)
H2228 17 Local PPO Yes Institutional Enhanced Alternative
$0.00 $14.20 $0.00
Marion UnitedHealthcare AARP Medicare Advantage Choice (PPO)
H2228 29 Local PPO No Enhanced Alternative
$4.10 $27.90 $0.00
Marion UnitedHealthcare AARP Medicare Advantage Plan 1 (HMO)
H3805 1 HMO No Enhanced Alternative
$39.50 $32.50 $0.00
Marion UnitedHealthcare AARP Medicare Advantage Plan 2 (HMO)
H3805 22 HMO No Enhanced Alternative
$0.00 $0.00 $0.00
Marion Moda Health Plan, Inc.
Moda Health NW PPORX (PPO)
H3813 11 Local PPO No Enhanced Alternative
$44.20 $59.80 $27.20
Marion Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Classic (PPO)
H3817 8 Local PPO No Enhanced Alternative
$33.00 $42.00 $9.40
Marion Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Enhanced (PPO)
H3817 9 Local PPO No Enhanced Alternative
$137.70 $56.30 $23.70
Page 28
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Marion Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Primary (PPO)
H3817 11 Local PPO No Enhanced Alternative
$0.00 $15.00 $0.00
Marion Health Net Life Insurance Company
Health Net Violet 1 (PPO)
H5439 11 Local PPO No Enhanced Alternative
$69.50 $50.50 $17.90
Marion Health Net Life Insurance Company
Health Net Violet 2 (PPO)
H5439 14 Local PPO No Enhanced Alternative
$0.00 $32.00 $0.00
Marion ATRIO Health Plans
ATRIO Special Needs Plan (Willamette) (HMO D-SNP)
H5995 1 HMO Yes Dual-Eligible
Defined Standard Benefit
$0.00 $32.60 $0.00
Marion Health Net Health Plan of Oregon, Inc.
Health Net Ruby (HMO)
H6815 3 HMO No Enhanced Alternative
$0.00 $0.00 $0.00
Marion ATRIO Health Plans
ATRIO Gold Rx (Willamette) (PPO)
H7006 1 Local PPO No Enhanced Alternative
$127.50 $62.50 $29.90
Marion ATRIO Health Plans
ATRIO Silver Rx (Willamette) (PPO)
H7006 3 Local PPO No Enhanced Alternative
$21.80 $53.20 $20.60
Marion Kaiser Permanente
Kaiser Permanente Senior Advantage (HMO)
H9003 1 HMO No Enhanced Alternative
$57.20 $47.00 $37.20
Marion Kaiser Permanente
Kaiser Permanente Senior Advantage Basic (HMO)
H9003 6 HMO No Enhanced Alternative
$8.70 $35.30 $2.70
Page 29
2020 Medicare Advantage Prescription Drug Plan List
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Marion Providence Medicare Advantage Plans
Providence Medicare Timber + RX (HMO)
H9047 54 HMO No Enhanced Alternative
$0.00 $0.00 $0.00
Marion Providence Medicare Advantage Plans
Providence Medicare Extra + RX (HMO)
H9047 55 HMO No Enhanced Alternative
$121.30 $51.70 $19.10
Marion Providence Medicare Advantage Plans
Providence Medicare Choice + RX (HMO-POS)
H9047 56 HMOPOS No Enhanced Alternative
$31.50 $56.50 $23.90
Marion Providence Medicare Advantage Plans
Providence Medicare Bridge 2 + RX (HMO)
H9047 60 HMO No Enhanced Alternative
$0.00 $40.00 $7.40
Morrow Moda Health Plan, Inc.
Moda Health PPORX (PPO)
H3813 6 Local PPO No Enhanced Alternative
$77.60 $61.40 $28.80
Multnomah UnitedHealthcare UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP)
H0710 36 Local PPO Yes Institutional Defined Standard Benefit
$0.00 $29.70 $0.00
Multnomah UnitedHealthcare UnitedHealthcare Assisted Living Plan 2 (PPO I-SNP)
H0710 37 Local PPO Yes Institutional Enhanced Alternative
$0.00 $15.10 $0.00
Multnomah Humana Humana Gold Plus H1036-153 (HMO)
H1036 153 HMO No Enhanced Alternative
$0.00 $0.00 $0.00
Multnomah AgeRight Advantage
AgeRight Advantage Health Plan (HMO I-SNP)
H1372 1 HMO Yes Institutional Defined Standard Benefit
$0.00 $32.60 $0.00
Multnomah Aetna Medicare Aetna Medicare Elite Plan (HMO)
H2056 3 HMO No Enhanced Alternative
$0.00 $0.00 $0.00
Page 30
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Multnomah Aetna Medicare Aetna Medicare Value Plan (HMO)
H2056 4 HMO No Enhanced Alternative
$0.00 $0.00 $0.00
Multnomah UnitedHealthcare UnitedHealthcare Nursing Home Plan 1 (PPO I-SNP)
H2228 16 Local PPO Yes Institutional Defined Standard Benefit
$0.00 $29.80 $0.00
Multnomah UnitedHealthcare UnitedHealthcare Assisted Living Plan 1 (PPO I-SNP)
H2228 17 Local PPO Yes Institutional Enhanced Alternative
$0.00 $14.20 $0.00
Multnomah UnitedHealthcare AARP Medicare Advantage Choice (PPO)
H2228 29 Local PPO No Enhanced Alternative
$4.10 $27.90 $0.00
Multnomah UnitedHealthcare AARP Medicare Advantage Walgreens (PPO)
H2228 84 Local PPO No Enhanced Alternative
$0.00 $0.00 $0.00
Multnomah UnitedHealthcare AARP Medicare Advantage Plan 1 (HMO)
H3805 1 HMO No Enhanced Alternative
$39.50 $32.50 $0.00
Multnomah UnitedHealthcare AARP Medicare Advantage Plan 2 (HMO)
H3805 22 HMO No Enhanced Alternative
$0.00 $0.00 $0.00
Multnomah Providence ElderPlace Portland
Providence ElderPlace Portland (dual eligible) (PACE)
H3809 1 National PACE No $224.50 $0.00
Multnomah Providence ElderPlace Portland
Providence ElderPlace Portland (private pay) (PACE)
H3809 2 National PACE No $171.60 $693.90
Multnomah Moda Health Plan, Inc.
Moda Health PPORX Enhanced (PPO)
H3813 9 Local PPO No Enhanced Alternative
$107.30 $71.50 $55.10
Page 31
2020 Medicare Advantage Prescription Drug Plan List
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Multnomah Moda Health Plan, Inc.
Moda Health Metro PPORX (PPO)
H3813 13 Local PPO No Enhanced Alternative
$53.90 $45.10 $12.50
Multnomah Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Classic (PPO)
H3817 8 Local PPO No Enhanced Alternative
$5.00 $42.00 $9.40
Multnomah Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Enhanced (PPO)
H3817 9 Local PPO No Enhanced Alternative
$117.70 $56.30 $23.70
Multnomah Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Primary (PPO)
H3817 11 Local PPO No Enhanced Alternative
$0.00 $0.00 $0.00
Multnomah PacificSource Medicare
PacificSource Medicare MyCare Rx 39 (HMO)
H3864 39 HMO No Enhanced Alternative
$36.40 $31.60 $0.00
Multnomah PacificSource Medicare
PacificSource Medicare MyCare Rx 40 (HMO)
H3864 40 HMO No Enhanced Alternative
$0.00 $0.00 $0.00
Multnomah Humana HumanaChoice H5216-048 (PPO)
H5216 48 Local PPO No Basic Alternative
$166.40 $33.60 $0.90
Multnomah Health Net Life Insurance Company
Health Net Violet 1 (PPO)
H5439 11 Local PPO No Enhanced Alternative
$69.50 $50.50 $17.90
Multnomah Health Net Life Insurance Company
Health Net Violet 2 (PPO)
H5439 14 Local PPO No Enhanced Alternative
$0.00 $19.00 $0.00
Multnomah CareOregon Advantage
CareOregon Advantage Plus (HMO-POS D-SNP)
H5859 1 HMOPOS Yes Dual-Eligible
Enhanced Alternative
$0.00 $32.60 $0.00
Page 32
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Multnomah Regence BlueCross BlueShield of Oregon
Regence BlueAdvantage HMO (HMO)
H6237 7 HMO No Enhanced Alternative
$0.00 $0.00 $0.00
Multnomah Regence BlueCross BlueShield of Oregon
Regence BlueAdvantage HMO Plus (HMO)
H6237 8 HMO No Enhanced Alternative
$9.10 $24.90 $0.00
Multnomah Health Net Health Plan of Oregon, Inc.
Health Net Ruby (HMO)
H6815 3 HMO No Enhanced Alternative
$0.00 $0.00 $0.00
Multnomah Kaiser Permanente
Kaiser Permanente Senior Advantage (HMO)
H9003 1 HMO No Enhanced Alternative
$57.20 $47.00 $37.20
Multnomah Kaiser Permanente
Kaiser Permanente Senior Advantage Basic (HMO)
H9003 6 HMO No Enhanced Alternative
$8.70 $35.30 $2.70
Multnomah Providence Medicare Advantage Plans
Providence Medicare Prime + RX (HMO)
H9047 37 HMO No Enhanced Alternative
$0.00 $0.00 $0.00
Multnomah Providence Medicare Advantage Plans
Providence Medicare Dual Plus (HMO D-SNP)
H9047 43 HMO Yes Dual-Eligible
Defined Standard Benefit
$0.00 $32.60 $0.00
Multnomah Providence Medicare Advantage Plans
Providence Medicare Extra + RX (HMO)
H9047 55 HMO No Enhanced Alternative
$121.30 $51.70 $19.10
Page 33
2020 Medicare Advantage Prescription Drug Plan List
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Multnomah Providence Medicare Advantage Plans
Providence Medicare Choice + RX (HMO-POS)
H9047 56 HMOPOS No Enhanced Alternative
$31.50 $56.50 $23.90
Multnomah Providence Medicare Advantage Plans
Providence Medicare Bridge 1 + RX (HMO)
H9047 59 HMO No Enhanced Alternative
$0.00 $35.00 $2.40
Multnomah Aetna Medicare Aetna Medicare Choice Plan (PPO)
H9431 5 Local PPO No Enhanced Alternative
$0.00 $17.00 $0.00
Multnomah Aetna Medicare Aetna Medicare Select Plan (PPO)
H9431 8 Local PPO No Enhanced Alternative
$24.90 $21.10 $0.00
Polk UnitedHealthcare AARP Medicare Advantage Plan 1 (HMO)
H3805 1 HMO No Enhanced Alternative
$39.50 $32.50 $0.00
Polk UnitedHealthcare AARP Medicare Advantage Plan 2 (HMO)
H3805 22 HMO No Enhanced Alternative
$0.00 $0.00 $0.00
Polk Moda Health Plan, Inc.
Moda Health NW PPORX (PPO)
H3813 11 Local PPO No Enhanced Alternative
$44.20 $59.80 $27.20
Polk Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Classic (PPO)
H3817 8 Local PPO No Enhanced Alternative
$33.00 $42.00 $9.40
Polk Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Enhanced (PPO)
H3817 9 Local PPO No Enhanced Alternative
$137.70 $56.30 $23.70
Page 34
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Polk Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Primary (PPO)
H3817 11 Local PPO No Enhanced Alternative
$0.00 $15.00 $0.00
Polk Health Net Life Insurance Company
Health Net Violet 1 (PPO)
H5439 11 Local PPO No Enhanced Alternative
$69.50 $50.50 $17.90
Polk Health Net Life Insurance Company
Health Net Violet 2 (PPO)
H5439 14 Local PPO No Enhanced Alternative
$0.00 $32.00 $0.00
Polk ATRIO Health Plans
ATRIO Special Needs Plan (Willamette) (HMO D-SNP)
H5995 1 HMO Yes Dual-Eligible
Defined Standard Benefit
$0.00 $32.60 $0.00
Polk Health Net Health Plan of Oregon, Inc.
Health Net Ruby (HMO)
H6815 3 HMO No Enhanced Alternative
$0.00 $0.00 $0.00
Polk ATRIO Health Plans
ATRIO Gold Rx (Willamette) (PPO)
H7006 1 Local PPO No Enhanced Alternative
$127.50 $62.50 $29.90
Polk ATRIO Health Plans
ATRIO Silver Rx (Willamette) (PPO)
H7006 3 Local PPO No Enhanced Alternative
$21.80 $53.20 $20.60
Polk Kaiser Permanente
Kaiser Permanente Senior Advantage (HMO)
H9003 1 HMO No Enhanced Alternative
$57.20 $47.00 $37.20
Polk Kaiser Permanente
Kaiser Permanente Senior Advantage Basic (HMO)
H9003 6 HMO No Enhanced Alternative
$8.70 $35.30 $2.70
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Polk Providence Medicare Advantage Plans
Providence Medicare Timber + RX (HMO)
H9047 54 HMO No Enhanced Alternative
$0.00 $0.00 $0.00
Polk Providence Medicare Advantage Plans
Providence Medicare Extra + RX (HMO)
H9047 55 HMO No Enhanced Alternative
$121.30 $51.70 $19.10
Polk Providence Medicare Advantage Plans
Providence Medicare Choice + RX (HMO-POS)
H9047 56 HMOPOS No Enhanced Alternative
$31.50 $56.50 $23.90
Polk Providence Medicare Advantage Plans
Providence Medicare Bridge 2 + RX (HMO)
H9047 60 HMO No Enhanced Alternative
$0.00 $40.00 $7.40
Sherman Moda Health Plan, Inc.
Moda Health PPORX (PPO)
H3813 6 Local PPO No Enhanced Alternative
$77.60 $61.40 $28.80
Sherman PacificSource Medicare
PacificSource Medicare Essentials Rx 6 (HMO)
H3864 6 HMO No Enhanced Alternative
$145.40 $47.40 $39.00
Sherman PacificSource Medicare
PacificSource Medicare Essentials Choice Rx 14 (HMO-POS)
H3864 14 HMOPOS No Enhanced Alternative
$59.00 $40.00 $7.40
Sherman PacificSource Medicare
PacificSource Medicare Essentials Rx 27 (HMO)
H3864 27 HMO No Enhanced Alternative
$4.30 $50.70 $18.10
Tillamook Providence ElderPlace Portland
Providence ElderPlace Portland (dual eligible) (PACE)
H3809 1 National PACE No $224.50 $0.00
Tillamook Providence ElderPlace Portland
Providence ElderPlace Portland (private pay) (PACE)
H3809 2 National PACE No $171.60 $693.90
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Tillamook Moda Health Plan, Inc.
Moda Health NW PPORX (PPO)
H3813 11 Local PPO No Enhanced Alternative
$44.20 $59.80 $27.20
Tillamook CareOregon Advantage
CareOregon Advantage Plus (HMO-POS D-SNP)
H5859 1 HMOPOS Yes Dual-Eligible
Enhanced Alternative
$0.00 $32.60 $0.00
Umatilla Moda Health Plan, Inc.
Moda Health PPORX (PPO)
H3813 6 Local PPO No Enhanced Alternative
$77.60 $61.40 $28.80
Union Moda Health Plan, Inc.
Moda Health PPORX (PPO)
H3813 6 Local PPO No Enhanced Alternative
$77.60 $61.40 $28.80
Wallowa Moda Health Plan, Inc.
Moda Health PPORX (PPO)
H3813 6 Local PPO No Enhanced Alternative
$77.60 $61.40 $28.80
Wasco Moda Health Plan, Inc.
Moda Health Central PPORX (PPO)
H3813 10 Local PPO No Enhanced Alternative
$45.10 $64.80 $32.20
Wasco PacificSource Medicare
PacificSource Medicare Essentials Rx 6 (HMO)
H3864 6 HMO No Enhanced Alternative
$145.40 $47.40 $39.00
Wasco PacificSource Medicare
PacificSource Medicare Essentials Choice Rx 14 (HMO-POS)
H3864 14 HMOPOS No Enhanced Alternative
$59.00 $40.00 $7.40
Wasco PacificSource Medicare
PacificSource Medicare Essentials Rx 27 (HMO)
H3864 27 HMO No Enhanced Alternative
$4.30 $50.70 $18.10
Washington UnitedHealthcare UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP)
H0710 36 Local PPO Yes Institutional Defined Standard Benefit
$0.00 $29.70 $0.00
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Washington UnitedHealthcare UnitedHealthcare Assisted Living Plan 2 (PPO I-SNP)
H0710 37 Local PPO Yes Institutional Enhanced Alternative
$0.00 $15.10 $0.00
Washington Humana Humana Gold Plus H1036-153 (HMO)
H1036 153 HMO No Enhanced Alternative
$0.00 $0.00 $0.00
Washington AgeRight Advantage
AgeRight Advantage Health Plan (HMO I-SNP)
H1372 1 HMO Yes Institutional Defined Standard Benefit
$0.00 $32.60 $0.00
Washington Aetna Medicare Aetna Medicare Elite Plan (HMO)
H2056 3 HMO No Enhanced Alternative
$0.00 $0.00 $0.00
Washington Aetna Medicare Aetna Medicare Value Plan (HMO)
H2056 4 HMO No Enhanced Alternative
$0.00 $0.00 $0.00
Washington UnitedHealthcare UnitedHealthcare Nursing Home Plan 1 (PPO I-SNP)
H2228 16 Local PPO Yes Institutional Defined Standard Benefit
$0.00 $29.80 $0.00
Washington UnitedHealthcare UnitedHealthcare Assisted Living Plan 1 (PPO I-SNP)
H2228 17 Local PPO Yes Institutional Enhanced Alternative
$0.00 $14.20 $0.00
Washington UnitedHealthcare AARP Medicare Advantage Choice (PPO)
H2228 29 Local PPO No Enhanced Alternative
$4.10 $27.90 $0.00
Washington UnitedHealthcare AARP Medicare Advantage Walgreens (PPO)
H2228 84 Local PPO No Enhanced Alternative
$0.00 $0.00 $0.00
Washington UnitedHealthcare AARP Medicare Advantage Plan 1 (HMO)
H3805 1 HMO No Enhanced Alternative
$39.50 $32.50 $0.00
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Washington UnitedHealthcare AARP Medicare Advantage Plan 2 (HMO)
H3805 22 HMO No Enhanced Alternative
$0.00 $0.00 $0.00
Washington Providence ElderPlace Portland
Providence ElderPlace Portland (dual eligible) (PACE)
H3809 1 National PACE No $224.50 $0.00
Washington Providence ElderPlace Portland
Providence ElderPlace Portland (private pay) (PACE)
H3809 2 National PACE No $171.60 $693.90
Washington Moda Health Plan, Inc.
Moda Health PPORX Enhanced (PPO)
H3813 9 Local PPO No Enhanced Alternative
$107.30 $71.50 $55.10
Washington Moda Health Plan, Inc.
Moda Health Metro PPORX (PPO)
H3813 13 Local PPO No Enhanced Alternative
$53.90 $45.10 $12.50
Washington Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Classic (PPO)
H3817 8 Local PPO No Enhanced Alternative
$5.00 $42.00 $9.40
Washington Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Enhanced (PPO)
H3817 9 Local PPO No Enhanced Alternative
$117.70 $56.30 $23.70
Washington Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Primary (PPO)
H3817 11 Local PPO No Enhanced Alternative
$0.00 $0.00 $0.00
Washington PacificSource Medicare
PacificSource Medicare MyCare Rx 39 (HMO)
H3864 39 HMO No Enhanced Alternative
$36.40 $31.60 $0.00
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Washington PacificSource Medicare
PacificSource Medicare MyCare Rx 40 (HMO)
H3864 40 HMO No Enhanced Alternative
$0.00 $0.00 $0.00
Washington Humana HumanaChoice H5216-048 (PPO)
H5216 48 Local PPO No Basic Alternative
$166.40 $33.60 $0.90
Washington Health Net Life Insurance Company
Health Net Violet 1 (PPO)
H5439 11 Local PPO No Enhanced Alternative
$69.50 $50.50 $17.90
Washington Health Net Life Insurance Company
Health Net Violet 2 (PPO)
H5439 14 Local PPO No Enhanced Alternative
$0.00 $19.00 $0.00
Washington CareOregon Advantage
CareOregon Advantage Plus (HMO-POS D-SNP)
H5859 1 HMOPOS Yes Dual-Eligible
Enhanced Alternative
$0.00 $32.60 $0.00
Washington Regence BlueCross BlueShield of Oregon
Regence BlueAdvantage HMO (HMO)
H6237 7 HMO No Enhanced Alternative
$0.00 $0.00 $0.00
Washington Regence BlueCross BlueShield of Oregon
Regence BlueAdvantage HMO Plus (HMO)
H6237 8 HMO No Enhanced Alternative
$9.10 $24.90 $0.00
Washington Health Net Health Plan of Oregon, Inc.
Health Net Ruby (HMO)
H6815 3 HMO No Enhanced Alternative
$0.00 $0.00 $0.00
Washington Kaiser Permanente
Kaiser Permanente Senior Advantage (HMO)
H9003 1 HMO No Enhanced Alternative
$57.20 $47.00 $37.20
Washington Kaiser Permanente
Kaiser Permanente Senior Advantage Basic (HMO)
H9003 6 HMO No Enhanced Alternative
$8.70 $35.30 $2.70
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Washington Providence Medicare Advantage Plans
Providence Medicare Prime + RX (HMO)
H9047 37 HMO No Enhanced Alternative
$0.00 $0.00 $0.00
Washington Providence Medicare Advantage Plans
Providence Medicare Dual Plus (HMO D-SNP)
H9047 43 HMO Yes Dual-Eligible
Defined Standard Benefit
$0.00 $32.60 $0.00
Washington Providence Medicare Advantage Plans
Providence Medicare Extra + RX (HMO)
H9047 55 HMO No Enhanced Alternative
$121.30 $51.70 $19.10
Washington Providence Medicare Advantage Plans
Providence Medicare Choice + RX (HMO-POS)
H9047 56 HMOPOS No Enhanced Alternative
$31.50 $56.50 $23.90
Washington Providence Medicare Advantage Plans
Providence Medicare Bridge 1 + RX (HMO)
H9047 59 HMO No Enhanced Alternative
$0.00 $35.00 $2.40
Washington Aetna Medicare Aetna Medicare Choice Plan (PPO)
H9431 5 Local PPO No Enhanced Alternative
$0.00 $17.00 $0.00
Washington Aetna Medicare Aetna Medicare Select Plan (PPO)
H9431 8 Local PPO No Enhanced Alternative
$24.90 $21.10 $0.00
Wheeler Moda Health Plan, Inc.
Moda Health PPORX (PPO)
H3813 6 Local PPO No Enhanced Alternative
$77.60 $61.40 $28.80
Wheeler PacificSource Medicare
PacificSource Medicare Essentials Rx 6 (HMO)
H3864 6 HMO No Enhanced Alternative
$145.40 $47.40 $39.00
Wheeler PacificSource Medicare
PacificSource Medicare Essentials Choice Rx 14 (HMO-POS)
H3864 14 HMOPOS No Enhanced Alternative
$59.00 $40.00 $7.40
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Wheeler PacificSource Medicare
PacificSource Medicare Essentials Rx 27 (HMO)
H3864 27 HMO No Enhanced Alternative
$4.30 $50.70 $18.10
Wheeler Providence Medicare Advantage Plans
Providence Medicare Latitude + RX (HMO-POS)
H9047 38 HMOPOS No Enhanced Alternative
$125.20 $55.00 $38.20
Wheeler Providence Medicare Advantage Plans
Providence Medicare Compass + RX (HMO-POS)
H9047 39 HMOPOS No Enhanced Alternative
$58.50 $40.50 $7.90
Yamhill UnitedHealthcare UnitedHealthcare Nursing Home Plan 2 (PPO I-SNP)
H0710 36 Local PPO Yes Institutional Defined Standard Benefit
$0.00 $29.70 $0.00
Yamhill UnitedHealthcare UnitedHealthcare Assisted Living Plan 2 (PPO I-SNP)
H0710 37 Local PPO Yes Institutional Enhanced Alternative
$0.00 $15.10 $0.00
Yamhill AgeRight Advantage
AgeRight Advantage Health Plan (HMO I-SNP)
H1372 1 HMO Yes Institutional Defined Standard Benefit
$0.00 $32.60 $0.00
Yamhill Aetna Medicare Aetna Medicare Elite Plan (HMO)
H2056 3 HMO No Enhanced Alternative
$0.00 $0.00 $0.00
Yamhill Aetna Medicare Aetna Medicare Value Plan (HMO)
H2056 4 HMO No Enhanced Alternative
$0.00 $0.00 $0.00
Yamhill UnitedHealthcare UnitedHealthcare Assisted Living Plan 1 (PPO I-SNP)
H2228 17 Local PPO Yes Institutional Enhanced Alternative
$0.00 $14.20 $0.00
Yamhill UnitedHealthcare AARP Medicare Advantage Choice (PPO)
H2228 29 Local PPO No Enhanced Alternative
$4.10 $27.90 $0.00
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Yamhill UnitedHealthcare AARP Medicare Advantage Plan 1 (HMO)
H3805 1 HMO No Enhanced Alternative
$39.50 $32.50 $0.00
Yamhill UnitedHealthcare AARP Medicare Advantage Plan 2 (HMO)
H3805 22 HMO No Enhanced Alternative
$0.00 $0.00 $0.00
Yamhill Moda Health Plan, Inc.
Moda Health NW PPORX (PPO)
H3813 11 Local PPO No Enhanced Alternative
$44.20 $59.80 $27.20
Yamhill Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Classic (PPO)
H3817 8 Local PPO No Enhanced Alternative
$33.00 $42.00 $9.40
Yamhill Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Enhanced (PPO)
H3817 9 Local PPO No Enhanced Alternative
$137.70 $56.30 $23.70
Yamhill Regence BlueCross BlueShield of Oregon
Regence MedAdvantage + Rx Primary (PPO)
H3817 11 Local PPO No Enhanced Alternative
$0.00 $15.00 $0.00
Yamhill Health Net Life Insurance Company
Health Net Violet 1 (PPO)
H5439 11 Local PPO No Enhanced Alternative
$69.50 $50.50 $17.90
Yamhill Health Net Life Insurance Company
Health Net Violet 2 (PPO)
H5439 14 Local PPO No Enhanced Alternative
$0.00 $24.00 $0.00
Yamhill Health Net Health Plan of Oregon, Inc.
Health Net Ruby (HMO)
H6815 3 HMO No Enhanced Alternative
$0.00 $0.00 $0.00
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Yamhill Kaiser Permanente
Kaiser Permanente Senior Advantage (HMO)
H9003 1 HMO No Enhanced Alternative
$57.20 $47.00 $37.20
Yamhill Kaiser Permanente
Kaiser Permanente Senior Advantage Basic (HMO)
H9003 6 HMO No Enhanced Alternative
$8.70 $35.30 $2.70
Yamhill Providence Medicare Advantage Plans
Providence Medicare Prime + RX (HMO)
H9047 37 HMO No Enhanced Alternative
$0.00 $0.00 $0.00
Yamhill Providence Medicare Advantage Plans
Providence Medicare Extra + RX (HMO)
H9047 55 HMO No Enhanced Alternative
$121.30 $51.70 $19.10
Yamhill Providence Medicare Advantage Plans
Providence Medicare Choice + RX (HMO-POS)
H9047 56 HMOPOS No Enhanced Alternative
$31.50 $56.50 $23.90
Yamhill Providence Medicare Advantage Plans
Providence Medicare Bridge 1 + RX (HMO)
H9047 59 HMO No Enhanced Alternative
$0.00 $35.00 $2.40
Yamhill Aetna Medicare Aetna Medicare Choice Plan (PPO)
H9431 5 Local PPO No Enhanced Alternative
$0.00 $17.00 $0.00
Yamhill Aetna Medicare Aetna Medicare Select Plan (PPO)
H9431 8 Local PPO No Enhanced Alternative
$24.90 $21.10 $0.00
