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- 2012 SeniorCare plans
SeniorCare (Cost) HMO Plan H4564 Premiums
Premiums**
Medical Plans
|
Select
$35.00
|
Preferred
$97.00
|
Preferred Plus
$155.00
|
Medical Plans with optional Prescription Plans added (Additional monthly premium required for prescription plans.)
| With Value Rx ($50.10) | With Basic Rx ($40.00) | With Enhanced Rx ($98.70) | |
| Select | $85.10 | $75.00 | $133.70 |
| Preferred | $147.10 | $137.00 | $195.70 |
| Preferred Plus | $205.10 | $195.00 | $253.70 |
See the SeniorCare (Cost) Plan Summary of Benefits 
for complete details on the medical and prescription plans. The SeniorCare (Cost) Plan prescription plans are only available to SeniorCare (Cost) Plan members.
**Rates are per member with Medicare A & B. All Medicare beneficiaries may apply. For all plans, members must continue to pay Medicare Part B premiums if not otherwise paid for under Medicaid or by another third-party.
The benefit information provided is not comprehensive. Additional information should be requested before making a decision about your coverage.
You must receive all routine care from plan providers.
Rates are illustrative only.
Do not send money until after you have been accepted for coverage.
You must fill out an application to apply for SeniorCare (Cost) Plan coverage.
See Summary of Benefits for all benefit exclusions and limitations.
The above information is current as of October 2010.
"Medicare-Approved HMO"
H4564_WEB_SC_PREM_2011_REV_122010 CMS Approved 02/08/2011