2015 - Western PENNSYLVANIA Plans Plan Description Group Number Subgroup Plan Number Code Contract Number PBP WH Rx Option Rider Vision Dental Rider Rider Actual Rate Subgroup Name Subsidy Level Copay Category Copay Amounts PACE Rate - - - - HMO No Rx MCHMO1 500 GI3* H3907 002 D A098 VW E7 $0.00 No Rx HMO Deductible with Rx MCHMO1 MCHMO1 MCHMO1 MCHMO1 MCHMO1 MCHMO1 MCHMO1 MCHMO1 519 520 521 522 523 524 525 526 GI4* GI4* GI4* GI4* GI4* GI4* GI4* GI4* H3907 H3907 H3907 H3907 H3907 H3907 H3907 H3907 037 037 037 037 037 037 037 037 S/D D D D D S/D S/D S/D A098 A098 A098 A098 A098 A098 A098 A098 VW VW VW VW VW VW VW VW EQ EQ EQ EQ EQ EQ EQ EQ $18.00 $0.00 $0.00 $0.00 $0.00 $4.50 $9.00 $13.50 Standard Full Dual Institutional Full Dual Non-Institutional Low Income II Other Low Income Low Income III 100% Subsidy Low Income III 75% Subsidy Low Income III 50% Subsidy Low Income III 25% Subsidy 0 100 100 100 100 75 50 25 0 3 2 1 4 4 4 4 $10/$45/$95 $0.00 $1.20 / $3.60 $2.65 / $6.60 15% 15% 15% 15% $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 HMO Rx MCHMO1 MCHMO1 MCHMO1 MCHMO1 MCHMO1 MCHMO1 MCHMO1 MCHMO1 510 511 512 514 515 516 517 518 GI5* GI5* GI5* GI5* GI5* GI5* GI5* GI5* H3907 H3907 H3907 H3907 H3907 H3907 H3907 H3907 029 029 029 029 029 029 029 029 S/D S/D S/D S/D S/D S/D S/D S/D A100 A100 A100 A100 A100 A100 A100 A100 Z002 Z002 Z002 Z002 Z002 Z002 Z002 Z002 EQ EQ EQ EQ EQ EQ EQ EQ $78.00 $44.10 $44.10 $44.10 $44.10 $52.60 $61.00 $69.50 Standard Full Dual Institutional Full Dual Non-Institutional Low Income II Other Low Income Low Income III 100% Subsidy Low Income III 75% Subsidy Low Income III 50% Subsidy Low Income III 25% Subsidy 0 100 100 100 100 75 50 25 0 3 2 1 4 4 4 4 $8/$45/$95 $0.00 $1.20 / $3.60 $2.65 / $6.60 15% 15% 15% 15% $44.09 $44.09 $44.09 $44.09 $44.09 $44.09 $44.09 $44.09 MCHMO1 MCHMO1 MCHMO1 HMO Rx Enhanced MCHMO1 (PA) MCHMO1 MCHMO1 MCHMO1 MCHMO1 501 502 503 505 506 507 508 509 GI6* GI6* GI6* GI6* GI6* GI6* GI6* GI6* H3907 H3907 H3907 H3907 H3907 H3907 H3907 H3907 006 006 006 006 006 006 006 006 S/D S/D S/D S/D S/D S/D S/D S/D A101 A101 A101 A101 A101 A101 A101 A101 Z003 Z003 Z003 Z003 Z003 Z003 Z003 Z003 EQ EQ EQ EQ EQ EQ EQ EQ $223.00 $189.10 $189.10 $189.10 $189.10 $197.60 $206.00 $214.50 Standard Full Dual Institutional Full Dual Non-Institutional Low Income II Other Low Income Low Income III 100% Subsidy Low Income III 75% Subsidy Low Income III 50% Subsidy Low Income III 25% Subsidy 0 100 100 100 100 75 50 25 0 3 2 1 4 4 4 4 $8/$45/$95 $0.00 $1.20 / $3.60 $2.65 / $6.60 15% 15% 15% 15% $189.09 $189.09 $189.09 $189.09 $189.09 $189.09 $189.09 $189.09 PPO High Deductible w/ Rx (PA) MCPPO1 MCPPO1 MCPPO1 MCPPO1 MCPPO1 MCPPO1 MCPPO1 MCPPO1 710 711 712 713 714 715 716 717 H76 H76 H76 H76 H76 H76 H76 H76 H5533 H5533 H5533 H5533 H5533 H5533 H5533 H5533 003 003 003 003 003 003 003 003 S/D S/D S/D S/D S/D S/D S/D S/D A102 A102 A102 A102 A102 A102 A102 A102 Z001 Z001 Z001 Z001 Z001 Z001 Z001 Z001 EQ EQ EQ EQ EQ EQ EQ EQ $39.00 $5.10 $5.10 $5.10 $5.10 $13.60 $22.00 $30.50 Standard Full Dual Institutional Full Dual Non-Institutional Low Income II Other Low Income Low Income III 100% Subsidy Low Income III 75% Subsidy Low Income III 50% Subsidy Low Income III 25% Subsidy 0 100 100 100 100 75 50 25 0 3 2 1 4 4 4 4 $10/$45/$95 $0.00 $1.20 / $3.60 $2.65 / $6.60 15% 15% 15% 15% $5.09 $5.09 $5.09 $5.09 $5.09 $5.09 $5.09 $5.09 PPO Rx Enhanced MCPPO1 MCPPO1 MCPPO1 MCPPO1 MCPPO1 MCPPO1 MCPPO1 MCPPO1 726 727 728 729 730 731 732 733 H77 H77 H77 H77 H77 H77 H77 H77 H5533 H5533 H5533 H5533 H5533 H5533 H5533 H5533 005 005 005 005 005 005 005 005 S/D S/D S/D S/D S/D S/D S/D S/D A103 A103 A103 A103 A103 A103 A103 A103 Z003 Z003 Z003 Z003 Z003 Z003 Z003 Z003 EQ EQ EQ EQ EQ EQ EQ EQ $139.00 $105.10 $105.10 $105.10 $105.10 $113.60 $122.00 $130.50 Standard Full Dual Institutional Full Dual Non-Institutional Low Income II Other Low Income Low Income III 100% Subsidy Low Income III 75% Subsidy Low Income III 50% Subsidy Low Income III 25% Subsidy 0 100 100 100 100 75 50 25 0 3 2 1 4 4 4 4 $10/$45/$95 $0.00 $1.20 / $3.60 $2.65 / $6.60 15% 15% 15% 15% $105.09 $105.09 $105.09 $105.09 $105.09 $105.09 $105.09 $105.09 * The plan code is the letter G, the letter I, and then a number. Please ensure this is coded correctly. 2015 - Lancaster Plans Subgroup Number 527 Plan Code GI3* Contract Number H3907 MCHMO1 MCHMO1 MCHMO1 HMO Deductible with Rx - MCHMO1 Lancaster MCHMO1 MCHMO1 MCHMO1 MCHMO1 528 529 530 531 532 533 534 535 GI4* GI4* GI4* GI4* GI4* GI4* GI4* GI4* H3907 H3907 H3907 H3907 H3907 H3907 H3907 H3907 039 039 039 039 039 039 039 039 D D D D D D D D MCPPO1 MCPPO1 MCPPO1 PPO High Deductible w/ Rx MCPPO1 (Lancaster) MCPPO1 MCPPO1 MCPPO1 MCPPO1 734 735 736 737 738 739 740 741 H76 H76 H76 H76 H76 H76 H76 H76 H5533 H5533 H5533 H5533 H5533 H5533 H5533 H5533 006 006 006 006 006 006 006 006 S/D S/D S/D S/D S/D S/D S/D S/D Plan Description HMO No Rx - Lancaster Group Number MCHMO1 PBP 038 WH Rx Rider Option D A104 Vision Rider VW Dental Rider E7 $0.00 No Rx A105 A105 A105 A105 A105 A105 A105 A105 VW VW VW VW VW VW VW VW EQ EQ EQ EQ EQ EQ EQ EQ $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 Standard Full Dual Institutional Full Dual Non-Institutional Low Income II Other Low Income Low Income III 100% Subsidy Low Income III 75% Subsidy Low Income III 50% Subsidy Low Income III 25% Subsidy 0 100 100 100 100 75 50 25 0 3 2 1 4 4 4 4 $10/$45/$95 $0.00 $1.20 / $3.60 $2.65 / $6.60 15% 15% 15% 15% $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 A106 A106 A106 A106 A106 A106 A106 A106 Z001 Z001 Z001 Z001 Z001 Z001 Z001 Z001 EQ EQ EQ EQ EQ EQ EQ EQ $39.00 $5.10 $5.10 $5.10 $5.10 $13.60 $22.00 $30.50 Standard Full Dual Institutional Full Dual Non-Institutional Low Income II Other Low Income Low Income III 100% Subsidy Low Income III 75% Subsidy Low Income III 50% Subsidy Low Income III 25% Subsidy 0 100 100 100 100 75 50 25 0 3 2 1 4 4 4 4 $10/$45/$95 $0.00 $1.20 / $3.60 $2.65 / $6.60 15% 15% 15% 15% $5.09 $5.09 $5.09 $5.09 $5.09 $5.09 $5.09 $5.09 * The plan code is the letter G, the letter I, and then a number. Please ensure this is coded correctly. Actual Rate Subgroup Name Subsidy Level - Copay Copay Amounts Category - PACE Rate - 2015 - SNP Plans Group Subgroup Contract Plan Code Number Number Number PBP WH Option Rx Rider Vision Rider Dental Rider Actual Rate Subgroup Name UPMC Community Care MCSNC1 MCSNC1 MCSNC1 MCSNC1 MCSNC1 MCSNC1 MCSNC1 MCSNC1 500 501 502 503 504 505 506 508 GDC GDC GDC GDC GDC GDC GDC GDC H4279 H4279 H4279 H4279 H4279 H4279 H4279 H4279 002 002 002 002 002 002 002 002 D D S/D D S/D S/D S/D D A140 A140 A140 A140 A140 A140 A140 A140 8Y 8Y 8Y 8Y 8Y 8Y 8Y 8Y EL EL EL EL EL EL EL EL $0.00 $0.00 $33.90 $0.00 $8.50 $16.90 $25.40 $0.00 UPMC for Life Options MCSNI1 MCSNI1 MCSNI1 MCSNI1 MCSNI1 MCSNI1 MCSNI1 MCSNI1 500 501 502 503 504 505 506 508 GOI GOI GOI GOI GOI GOI GOI GOI H3907 H3907 H3907 H3907 H3907 H3907 H3907 H3907 032 032 032 032 032 032 032 032 D D S/D D S/D S/D S/D D A139 A139 A139 A139 A139 A139 A139 A139 8Y 8Y 8Y 8Y 8Y 8Y 8Y 8Y V002 V002 V002 V002 V002 V002 V002 V002 UPMC for You Advantage MCSND1 MCSND1 MCSND1 MCSND1 MCSND1 MCSND1 MCSND1 MCSND1 500 501 502 503 504 505 506 508 GVA GVA GVA GVA GVA GVA GVA GVA H4279 H4279 H4279 H4279 H4279 H4279 H4279 H4279 001 001 001 001 001 001 001 001 D D S/D D S/D S/D S/D D A137 A137 A137 A137 A137 A137 A137 A137 V001 V001 V001 V001 V001 V001 V001 V001 UPMC for You AdvantageGrace MCSNDG MCSNDG MCSNDG MCSNDG MCSNDG MCSNDG MCSNDG MCSNDG 500 501 502 503 504 505 506 508 GVD GVD GVD GVD GVD GVD GVD GVD H4279 H4279 H4279 H4279 H4279 H4279 H4279 H4279 001 001 001 001 001 001 001 001 D D S/D D S/D S/D S/D D A138 A138 A138 A138 A138 A138 A138 A138 V001 V001 V001 V001 V001 V001 V001 V001 Plan Description Subsidy Level Copay Category Copay Amounts PACE Rate Standard Institutionalized No or Partial MA No or Partial MA-LIS No or Partial MA-LIS No or Partial MA-LIS No or Partial MA-LIS MA/LIS 100 100 0 100 75 50 25 100 2 3 0 4 4 4 4 1 $1.20/$3.60 $0.00 25% 15% 15% 15% 15% $2.65/$6.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $33.90 $0.00 $8.50 $16.90 $25.40 $0.00 Standard Institutionalized No or Partial MA No or Partial MA-LIS No or Partial MA-LIS No or Partial MA-LIS No or Partial MA-LIS MA/LIS 100 100 0 100 75 50 25 100 2 3 0 4 4 4 4 1 $1.20/$3.60 $0.00 25% 15% 15% 15% 15% $2.65/$6.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 EP EP EP EP EP EP EP EP $0.00 $0.00 $33.90 $0.00 $8.50 $16.90 $25.40 $0.00 Standard Institutionalized No or Partial MA No or Partial MA-LIS No or Partial MA-LIS No or Partial MA-LIS No or Partial MA-LIS MA/LIS 100 100 0 100 75 50 25 100 2 3 0 4 4 4 4 1 $1.20/$3.60 $0.00 $7/$35/$80/25%/$4 15% 15% 15% 15% $2.65/$6.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 EP EP EP EP EP EP EP EP $0.00 $0.00 $33.90 $0.00 $8.50 $16.90 $25.40 $0.00 Standard Institutionalized No or Partial MA No or Partial MA-LIS No or Partial MA-LIS No or Partial MA-LIS No or Partial MA-LIS MA/LIS 100 100 0 100 75 50 25 100 2 3 0 4 4 4 4 1 $1.20/$3.60 $0.00 $7/$35/$80/25%/$4 15% 15% 15% 15% $2.65/$6.60 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00
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