2012 / 2013 Medicare Advantage Plan Information Click here to jump to the Chart Legend | ||||||||||||
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Plan Name | Monthly Premium |
Part A&B Maximum Out-Of |
Part D Deduct- ible |
(Donut Hole) Additional Gap Coverage |
Plan ID |
Cost-Sharing | Total Formulary Drugs | |||||
Cust. Service Rating |
Member Plan Exper. |
RxCost Info Rating |
Tier 1 |
Tier 2 |
Tier 3 |
Tier 4 |
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2012 ActiveSaver MSA (MSA) | $0.00 | n/a | No Rx Coverage | H9788 -004 -0 | This plan does NOT include Prescription Drug coverage. | |||||||
2013 ActiveSaver MSA (MSA) | $0.00 | n/a | No Rx Coverage | This plan does NOT include Prescription Drug coverage. | ||||||||
-- This plan not offered in 2012 -- |
H2773 -003 -0 | |||||||||||
-- | -- | -- | ||||||||||
2013 Advantage Health NY - SNP (HMO SNP) | $0.00 | n/a | $0 | No additional gap coverage, only the Donut Hole Discount | $2.00 | $25.00 | $55.00 | $55.00 | tbd | |||
-- This plan not offered in 2012 -- |
H2773 -002 -0 | |||||||||||
-- | -- | -- | ||||||||||
2013 Advantage Silver NY (HMO) | $0.00 | $3,400 | $0 | No additional gap coverage, only the Donut Hole Discount | $4.00 | $30.00 | $55.00 | $55.00 | tbd | |||
Plan Name | Monthly Premium |
Parts A&B MOOP |
Part D Deduct- ible |
Additional Gap Coverage |
Plan ID |
Cost-Sharing | Total Drugs | |||||
Cust. Serv. |
Plan Exper. |
Cost Info. |
Tier 1 |
Tier 2 |
Tier 3 |
Tier 4 |
||||||
-- This plan not offered in 2012 -- |
H6181 -009 -0 | |||||||||||
2013 Amerivantage Balance + Rx (HMO) | $0.00 | $3,400 | $0 | Some Generics | $0.00 | $4.00 | $35.00 | $35.00 | 2,941 2013 Formulary | |||
-- This plan not offered in 2012 -- |
H6181 -015 -0 | |||||||||||
2013 Amerivantage Classic Choice + Rx Plan (HMO-POS) | $0.00 | $6,700 | $0 | Some Generics | $3.00 | $3.00 | $40.00 | $40.00 | 2,941 2013 Formulary | |||
-- This plan not offered in 2012 -- |
H3347 -005 -0 | |||||||||||
2013 Elderplan Classic: Zero Premium (HMO) | $0.00 | $6,700 | $325 | No additional gap coverage, only the Donut Hole Discount | $4.00 | $30.00 | $90.00 | $90.00 | 3,056 2013 Formulary | |||
Plan Name | Monthly Premium |
Parts A&B MOOP |
Part D Deduct- ible |
Additional Gap Coverage |
Plan ID |
Cost-Sharing | Total Drugs | |||||
Cust. Serv. |
Plan Exper. |
Cost Info. |
Tier 1 |
Tier 2 |
Tier 3 |
Tier 4 |
||||||
2012 Fidelis Medicare Advantage without Rx (HMO-POS) | $0.00 | $6,700 | No Rx Coverage | H3328 -001 -0 | This plan does NOT include Prescription Drug coverage. | |||||||
2013 Fidelis Medicare Advantage without Rx (HMO-POS) | $0.00 | $6,700 | No Rx Coverage | This plan does NOT include Prescription Drug coverage. | ||||||||
2012 Healthfirst 65 Plus Plan (HMO) | $0.00 | $6,700 | $0 | No additional gap coverage, only the Donut Hole Discount | H3359 -001 -0 | $0.00 | $40.00 | $80.00 | $80.00 | 4,636 2012 Formulary | ||
2013 Healthfirst 65 Plus Plan (HMO) | $0.00 | $6,700 | $0 | No additional gap coverage, only the Donut Hole Discount | $0.00 | $40.00 | $80.00 | $80.00 | 4,885 2013 Formulary | |||
2012 Healthfirst Coordinated Benefits Plan (HMO) | $0.00 | $6,700 | No Rx Coverage | H3359 -027 -0 | This plan does NOT include Prescription Drug coverage. | |||||||
2013 Healthfirst Coordinated Benefits Plan (HMO) | $0.00 | $6,700 | No Rx Coverage | This plan does NOT include Prescription Drug coverage. | ||||||||
Plan Name | Monthly Premium |
Parts A&B MOOP |
Part D Deduct- ible |
Additional Gap Coverage |
Plan ID |
Cost-Sharing | Total Drugs | |||||
Cust. Serv. |
Plan Exper. |
Cost Info. |
Tier 1 |
Tier 2 |
Tier 3 |
Tier 4 |
||||||
-- This plan not offered in 2012 -- |
H3359 -032 -0 | |||||||||||
2013 Healthfirst Jade Benefits Plan (HMO) | $0.00 | $6,700 | $0 | Many Generics, Few Brands | $0.00 | $40.00 | $80.00 | $80.00 | 4,885 2013 Formulary | |||
2012 Liberty Health Advantage Preferred Choice (HMO) | $0.00 | $3,400 | $0 | All Generics | H3337 -001 -0 | $0.00 | $10.00 | $25.00 | $25.00 | 2,778 2012 Formulary | ||
2013 Liberty Health Advantage Preferred Choice (HMO) | $0.00 | $3,400 | $0 | All Generics | $0.00 | $10.00 | $25.00 | $25.00 | 2,863 2013 Formulary | |||
2012 UnitedHealthcare MedicareComplete Choice (Regional PPO) | $0.00 | $4,900 | $0 | No additional gap coverage, only the Donut Hole Discount | R5342 -001 -0 | $3.00 | $6.00 | $45.00 | $45.00 | 3,614 2012 Formulary | ||
2013 UnitedHealthcare MedicareComplete Choice (Regional PPO) | $0.00 | $4,900 | $0 | No additional gap coverage, only the Donut Hole Discount | $3.00 | $6.00 | $45.00 | $45.00 | 3,825 2013 Formulary | |||
Plan Name | Monthly Premium |
Parts A&B MOOP |
Part D Deduct- ible |
Additional Gap Coverage |
Plan ID |
Cost-Sharing | Total Drugs | |||||
Cust. Serv. |
Plan Exper. |
Cost Info. |
Tier 1 |
Tier 2 |
Tier 3 |
Tier 4 |
||||||
2012 UnitedHealthcare MedicareComplete Choice Essential (Regional PPO) | $0.00 | $3,900 | No Rx Coverage | R5342 -002 -0 | This plan does NOT include Prescription Drug coverage. | |||||||
2013 UnitedHealthcare MedicareComplete Choice Essential (Regional PPO) | $0.00 | $3,900 | No Rx Coverage | This plan does NOT include Prescription Drug coverage. | ||||||||
2012 GHI - VIP Essential (HMO) | $0.00 | $3,400 | $0 | No additional gap coverage, only the Donut Hole Discount | H3330 -032 -2 | $5.00 | $35.00 | 50% | 50% | 3,114 2012 Formulary | ||
2013 VIP Essential (HMO) | $0.00 | $3,400 | $0 | No additional gap coverage, only the Donut Hole Discount | $5.00 | $35.00 | 50% | 50% | 3,411 2013 Formulary | |||
-- This plan not offered in 2012 -- |
H5549 -004 -0 | |||||||||||
2013 VNSNY CHOICE Medicare Enhanced (HMO) | $0.00 | $3,400 | $0 | No additional gap coverage, only the Donut Hole Discount | $1.00 | $4.00 | $30.00 | $30.00 | 4,885 2013 Formulary | |||
Plan Name | Monthly Premium |
Parts A&B MOOP |
Part D Deduct- ible |
Additional Gap Coverage |
Plan ID |
Cost-Sharing | Total Drugs | |||||
Cust. Serv. |
Plan Exper. |
Cost Info. |
Tier 1 |
Tier 2 |
Tier 3 |
Tier 4 |
||||||
2012 WellCare Choice (HMO-POS) | $0.00 | $6,700 | $0 | No additional gap coverage, only the Donut Hole Discount | H3361 -106 -0 | $0.00 | $39.00 | $79.00 | $79.00 | 2,506 2012 Formulary | ||
2013 WellCare Choice (HMO-POS) | $0.00 | $6,700 | $0 | No additional gap coverage, only the Donut Hole Discount | $0.00 | $39.00 | $79.00 | $79.00 | 2,835 2013 Formulary | |||
2012 WellCare Rx (HMO) | $37.50 | $6,700 | $0 | No additional gap coverage, only the Donut Hole Discount | H3361 -130 -0 | $10.00 | $35.00 | $79.00 | $79.00 | 2,506 2012 Formulary | ||
2013 WellCare Rx (HMO) | $1.60 | $6,700 | $0 | No additional gap coverage, only the Donut Hole Discount | $8.00 | $35.00 | $79.00 | $79.00 | 2,835 2013 Formulary | |||
2012 WellCare Liberty (HMO SNP) | $39.80 | n/a | $320 | No additional gap coverage, only the Donut Hole Discount | H3361 -043 -0 | $0.00 | $38.00 | $90.00 | $90.00 | 2,506 2012 Formulary | ||
2013 WellCare Liberty (HMO SNP) | $20.60 | n/a | $325 | No additional gap coverage, only the Donut Hole Discount | $0.00 | $45.00 | $95.00 | $95.00 | 2,835 2013 Formulary | |||
Plan Name | Monthly Premium |
Parts A&B MOOP |
Part D Deduct- ible |
Additional Gap Coverage |
Plan ID |
Cost-Sharing | Total Drugs | |||||
Cust. Serv. |
Plan Exper. |
Cost Info. |
Tier 1 |
Tier 2 |
Tier 3 |
Tier 4 |
||||||
2012 Empire MediBlue Plus (HMO) | $0.00 | $3,400 | $0 | No additional gap coverage, only the Donut Hole Discount | H3370 -003 -0 | $8.00 | $35.00 | $85.00 | $85.00 | 4,453 2012 Formulary | ||
2013 Empire MediBlue Plus (HMO) | $30.00 | $3,400 | $75 | No additional gap coverage, only the Donut Hole Discount | $6.00 | $12.00 | $45.00 | $45.00 | 4,173 2013 Formulary | |||
2012 Healthfirst Increased Benefits Plan (HMO) | $39.80 | $6,700 | $320 | No additional gap coverage, only the Donut Hole Discount | H3359 -019 -0 | 25% | 25% | 25% | 25% | 4,636 2012 Formulary | ||
2013 Healthfirst Increased Benefits Plan (HMO) | $35.00 | $6,700 | $325 | No additional gap coverage, only the Donut Hole Discount | 25% | 25% | 25% | 25% | 4,885 2013 Formulary | |||
2012 UnitedHealthcare Nursing Home Plan (HMO SNP) | $36.30 | n/a | $320 | No additional gap coverage, only the Donut Hole Discount | H3379 -002 -0 | 25% | 25% | 25% | 25% | 3,614 2012 Formulary | ||
2013 UnitedHealthcare Nursing Home Plan (HMO SNP) | $35.00 | n/a | $325 | No additional gap coverage, only the Donut Hole Discount | 25% | 25% | 25% | 25% | 3,825 2013 Formulary | |||
Plan Name | Monthly Premium |
Parts A&B MOOP |
Part D Deduct- ible |
Additional Gap Coverage |
Plan ID |
Cost-Sharing | Total Drugs | |||||
Cust. Serv. |
Plan Exper. |
Cost Info. |
Tier 1 |
Tier 2 |
Tier 3 |
Tier 4 |
||||||
2012 Empire MediBlue Freedom I (PPO) | $0.00 | $4,500 | $60 | No additional gap coverage, only the Donut Hole Discount | H3342 -012 -0 | $9.00 | $45.00 | $85.00 | $85.00 | 4,453 2012 Formulary | ||
2013 Empire MediBlue Freedom I (PPO) | $38.00 | $4,500 | $75 | No additional gap coverage, only the Donut Hole Discount | $8.00 | $14.00 | $45.00 | $45.00 | 4,173 2013 Formulary | |||
-- This plan not offered in 2012 -- |
H5549 -002 -0 | |||||||||||
2013 VNSNY CHOICE Medicare Preferred (HMO SNP) | $40.10 | n/a | $325 | No additional gap coverage, only the Donut Hole Discount | 25% | 25% | 25% | 25% | 4,885 2013 Formulary | |||
-- This plan not offered in 2012 -- |
H3347 -003 -0 | |||||||||||
2013 Elderplan Advantage For Nursing Home Residents (HMO SNP) | $40.20 | n/a | $325 | No additional gap coverage, only the Donut Hole Discount | 25% | 3,054 2013 Formulary | ||||||
Plan Name | Monthly Premium |
Parts A&B MOOP |
Part D Deduct- ible |
Additional Gap Coverage |
Plan ID |
Cost-Sharing | Total Drugs | |||||
Cust. Serv. |
Plan Exper. |
Cost Info. |
Tier 1 |
Tier 2 |
Tier 3 |
Tier 4 |
||||||
2012 WellCare Access (HMO SNP) | $39.80 | n/a | $320 | No additional gap coverage, only the Donut Hole Discount | H3361 -109 -0 | $0.00 | $39.00 | $80.00 | $80.00 | 2,506 2012 Formulary | ||
2013 WellCare Access (HMO SNP) | $40.40 | n/a | $325 | No additional gap coverage, only the Donut Hole Discount | $0.00 | $45.00 | $95.00 | $95.00 | 2,835 2013 Formulary | |||
2012 UnitedHealthcare Dual Complete (HMO SNP) | $38.40 | n/a | $320 | No additional gap coverage, only the Donut Hole Discount | H3387 -010 -0 | 0% | 0% | 3,614 2012 Formulary | ||||
-- | ||||||||||||
2013 UnitedHealthcare Dual Complete (HMO SNP) | $41.20 | n/a | $325 | No additional gap coverage, only the Donut Hole Discount | 25% | 25% | 25% | 25% | 3,825 2013 Formulary | |||
2012 GuildNet Health Advantage (HMO-POS SNP) | $39.80 | n/a | $320 | No additional gap coverage, only the Donut Hole Discount | H6864 -002 -0 | 15% | 15% | 3,114 2012 Formulary | ||||
-- | -- | |||||||||||
2013 GuildNet Health Advantage (HMO-POS SNP) | $41.60 | n/a | $325 | No additional gap coverage, only the Donut Hole Discount | 25% | 25% | 25% | 25% | 3,411 2013 Formulary | |||
Plan Name | Monthly Premium |
Parts A&B MOOP |
Part D Deduct- ible |
Additional Gap Coverage |
Plan ID |
Cost-Sharing | Total Drugs | |||||
Cust. Serv. |
Plan Exper. |
Cost Info. |
Tier 1 |
Tier 2 |
Tier 3 |
Tier 4 |
||||||
-- This plan not offered in 2012 -- |
H3359 -035 -0 | |||||||||||
2013 Healthfirst AssuredCare (HMO SNP) | $43.00 | n/a | $325 | No additional gap coverage, only the Donut Hole Discount | 25% | 25% | 25% | 25% | 4,885 2013 Formulary | |||
-- This plan not offered in 2012 -- |
H3359 -034 -0 | |||||||||||
2013 Healthfirst CompleteCare (HMO SNP) | $43.00 | n/a | $325 | No additional gap coverage, only the Donut Hole Discount | 25% | 25% | 25% | 25% | 4,885 2013 Formulary | |||
2012 Healthfirst Life Improvement Plan (HMO SNP) | $39.80 | n/a | $320 | No additional gap coverage, only the Donut Hole Discount | H3359 -021 -0 | 15% | 15% | 4,636 2012 Formulary | ||||
2013 Healthfirst Life Improvement Plan (HMO SNP) | $43.00 | n/a | $325 | No additional gap coverage, only the Donut Hole Discount | 25% | 25% | 25% | 25% | 4,885 2013 Formulary | |||
Plan Name | Monthly Premium |
Parts A&B MOOP |
Part D Deduct- ible |
Additional Gap Coverage |
Plan ID |
Cost-Sharing | Total Drugs | |||||
Cust. Serv. |
Plan Exper. |
Cost Info. |
Tier 1 |
Tier 2 |
Tier 3 |
Tier 4 |
||||||
2012 Healthfirst Maximum Plan (HMO SNP) | $39.80 | n/a | $320 | No additional gap coverage, only the Donut Hole Discount | H3359 -033 -0 | 0% | 0% | 4,636 2012 Formulary | ||||
2013 Healthfirst Maximum Plan (HMO SNP) | $43.00 | n/a | $325 | No additional gap coverage, only the Donut Hole Discount | 25% | 25% | 25% | 25% | 4,885 2013 Formulary | |||
-- This plan not offered in 2012 -- |
H6181 -007 -0 | |||||||||||
2013 Amerivantage Specialty + Rx (HMO SNP) | $43.20 | n/a | $325 | Many Generics, Few Brands | $0.00 | $0.00 | 25% | 25% | 2,941 2013 Formulary | |||
2012 CCM Direct Complete Plan (HMO SNP) | $39.70 | n/a | $320 | No additional gap coverage, only the Donut Hole Discount | H5989 -002 -0 | 25% | 25% | 25% | 25% | 3,178 2012 Formulary | ||
-- | -- | |||||||||||
2013 CenterLight Direct Complete Plan (HMO SNP) | $43.20 | n/a | $325 | No additional gap coverage, only the Donut Hole Discount | $7.25 | $42.00 | $95.00 | $95.00 | 3,381 2013 Formulary | |||
Plan Name | Monthly Premium |
Parts A&B MOOP |
Part D Deduct- ible |
Additional Gap Coverage |
Plan ID |
Cost-Sharing | Total Drugs | |||||
Cust. Serv. |
Plan Exper. |
Cost Info. |
Tier 1 |
Tier 2 |
Tier 3 |
Tier 4 |
||||||
2012 CCM Direct Total Plan (HMO SNP) | $39.70 | n/a | $320 | No additional gap coverage, only the Donut Hole Discount | H5989 -008 -0 | 15% | 15% | 3,178 2012 Formulary | ||||
-- | -- | |||||||||||
2013 CenterLight Direct Total Plan (HMO SNP) | $43.20 | n/a | $185 | No additional gap coverage, only the Donut Hole Discount | $8.00 | $45.00 | $95.00 | $95.00 | 3,381 2013 Formulary | |||
2012 GHI - Dual Eligible (HMO SNP) | $39.80 | n/a | $320 | No additional gap coverage, only the Donut Hole Discount | H3330 -029 -0 | $4.00 | 25% | 30% | 30% | 3,114 2012 Formulary | ||
2013 Dual Eligible (HMO SNP) | $43.20 | n/a | $325 | No additional gap coverage, only the Donut Hole Discount | $4.00 | 25% | 30% | 30% | 3,411 2013 Formulary | |||
-- This plan not offered in 2012 -- |
H5528 -018 -0 | |||||||||||
2013 Dual Eligible (PPO SNP) | $43.20 | n/a | $325 | No additional gap coverage, only the Donut Hole Discount | $4.00 | 25% | 30% | 30% | 3,411 2013 Formulary | |||
Plan Name | Monthly Premium |
Parts A&B MOOP |
Part D Deduct- ible |
Additional Gap Coverage |
Plan ID |
Cost-Sharing | Total Drugs | |||||
Cust. Serv. |
Plan Exper. |
Cost Info. |
Tier 1 |
Tier 2 |
Tier 3 |
Tier 4 |
||||||
-- This plan not offered in 2012 -- |
H3347 -009 -0 | |||||||||||
2013 Elderplan Extra Help (HMO) | $43.20 | $6,700 | $325 | No additional gap coverage, only the Donut Hole Discount | 25% | 3,054 2013 Formulary | ||||||
-- This plan not offered in 2012 -- |
H3347 -002 -0 | |||||||||||
2013 Elderplan For Medicaid Beneficiaries (HMO SNP) | $43.20 | n/a | $325 | No additional gap coverage, only the Donut Hole Discount | 25% | 3,054 2013 Formulary | ||||||
-- This plan not offered in 2012 -- |
H3347 -008 -0 | |||||||||||
2013 Elderplan Medicaid Advantage (HMO SNP) | $43.20 | n/a | $325 | No additional gap coverage, only the Donut Hole Discount | 25% | 3,054 2013 Formulary | ||||||
Plan Name | Monthly Premium |
Parts A&B MOOP |
Part D Deduct- ible |
Additional Gap Coverage |
Plan ID |
Cost-Sharing | Total Drugs | |||||
Cust. Serv. |
Plan Exper. |
Cost Info. |
Tier 1 |
Tier 2 |
Tier 3 |
Tier 4 |
||||||
-- This plan not offered in 2012 -- |
H3347 -007 -0 | |||||||||||
2013 Elderplan Plus Long Term Care (HMO SNP) | $43.20 | n/a | $325 | No additional gap coverage, only the Donut Hole Discount | 25% | 3,054 2013 Formulary | ||||||
-- This plan not offered in 2012 -- |
H3328 -017 -0 | |||||||||||
2013 Fidelis Dual Advantage Flex (HMO SNP) | $43.20 | n/a | $320 | No additional gap coverage, only the Donut Hole Discount | $0.00 | $15.00 | $35.00 | $35.00 | 4,789 2013 Formulary | |||
-- This plan not offered in 2012 -- |
H3328 -018 -0 | |||||||||||
2013 Fidelis Long Term Care Advantage (HMO SNP) | $43.20 | n/a | $325 | No additional gap coverage, only the Donut Hole Discount | 25% | 25% | 25% | 25% | 4,789 2013 Formulary | |||
Plan Name | Monthly Premium |
Parts A&B MOOP |
Part D Deduct- ible |
Additional Gap Coverage |
Plan ID |
Cost-Sharing | Total Drugs | |||||
Cust. Serv. |
Plan Exper. |
Cost Info. |
Tier 1 |
Tier 2 |
Tier 3 |
Tier 4 |
||||||
2012 Fidelis Medicare Advantage Flex (HMO-POS) | $39.80 | $6,700 | $320 | No additional gap coverage, only the Donut Hole Discount | H3328 -003 -0 | $2.00 | $15.00 | $35.00 | $35.00 | 2,996 2012 Formulary | ||
2013 Fidelis Medicare Advantage Flex (HMO-POS) | $43.20 | $6,700 | $320 | No additional gap coverage, only the Donut Hole Discount | $0.00 | $15.00 | $35.00 | $35.00 | 4,789 2013 Formulary | |||
2012 GuildNet Gold (HMO-POS SNP) | $39.80 | n/a | $320 | No additional gap coverage, only the Donut Hole Discount | H6864 -001 -0 | $0.00 | $45.00 | $95.00 | $95.00 | 3,114 2012 Formulary | ||
-- | -- | |||||||||||
2013 GuildNet Gold (HMO-POS SNP) | $43.20 | n/a | $325 | No additional gap coverage, only the Donut Hole Discount | 25% | 25% | 25% | 25% | 3,411 2013 Formulary | |||
2012 Liberty Health Advantage Dual Power (HMO SNP) | $39.80 | n/a | $320 | No additional gap coverage, only the Donut Hole Discount | H3337 -003 -0 | 15% | 15% | 2,778 2012 Formulary | ||||
2013 Liberty Health Advantage Dual Power (HMO SNP) | $43.20 | n/a | $325 | No additional gap coverage, only the Donut Hole Discount | 25% | 25% | 25% | 25% | 2,863 2013 Formulary | |||
Plan Name | Monthly Premium |
Parts A&B MOOP |
Part D Deduct- ible |
Additional Gap Coverage |
Plan ID |
Cost-Sharing | Total Drugs | |||||
Cust. Serv. |
Plan Exper. |
Cost Info. |
Tier 1 |
Tier 2 |
Tier 3 |
Tier 4 |
||||||
2012 Empire MediBlue Select (HMO) | $21.00 | $3,000 | $0 | No additional gap coverage, only the Donut Hole Discount | H3370 -022 -0 | $7.00 | $35.00 | $80.00 | $80.00 | 4,453 2012 Formulary | ||
2013 Empire MediBlue Select (HMO) | $44.00 | $3,400 | $0 | No additional gap coverage, only the Donut Hole Discount | $6.00 | $10.00 | $45.00 | $45.00 | 4,173 2013 Formulary | |||
2012 GHI - VIP (HMO) | $21.00 | $3,400 | $0 | No additional gap coverage, only the Donut Hole Discount | H3330 -021 -2 | $5.00 | $35.00 | 50% | 50% | 3,114 2012 Formulary | ||
2013 VIP (HMO) | $44.50 | $3,400 | $0 | No additional gap coverage, only the Donut Hole Discount | $5.00 | $35.00 | 50% | 50% | 3,411 2013 Formulary | |||
2012 GHI - PPO I (PPO) | $39.00 | $3,400 | No Rx Coverage | H5528 -004 -0 | This plan does NOT include Prescription Drug coverage. | |||||||
2013 PPO I (PPO) | $49.00 | $3,400 | No Rx Coverage | This plan does NOT include Prescription Drug coverage. | ||||||||
Plan Name | Monthly Premium |
Parts A&B MOOP |
Part D Deduct- ible |
Additional Gap Coverage |
Plan ID |
Cost-Sharing | Total Drugs | |||||
Cust. Serv. |
Plan Exper. |
Cost Info. |
Tier 1 |
Tier 2 |
Tier 3 |
Tier 4 |
||||||
2012 GHI - PPO II (PPO) | $39.00 | $3,400 | $0 | No additional gap coverage, only the Donut Hole Discount | H5528 -005 -0 | $5.00 | $35.00 | 50% | 50% | 3,114 2012 Formulary | ||
2013 PPO II (PPO) | $52.50 | $3,400 | $0 | No additional gap coverage, only the Donut Hole Discount | $5.00 | $35.00 | $95.00 | $95.00 | 3,411 2013 Formulary | |||
-- This plan not offered in 2012 -- |
H2773 -001 -0 | |||||||||||
-- | -- | -- | ||||||||||
2013 Advantage Platinum NY (HMO) | $60.00 | $3,400 | $0 | Many Generics | $4.00 | $30.00 | $55.00 | $55.00 | tbd | |||
-- This plan not offered in 2012 -- |
H5549 -006 -0 | |||||||||||
2013 VNSNY CHOICE Medicare Maximum (HMO SNP) | $78.50 | n/a | $325 | No additional gap coverage, only the Donut Hole Discount | 25% | 25% | 25% | 25% | 4,885 2013 Formulary | |||
Plan Name | Monthly Premium |
Parts A&B MOOP |
Part D Deduct- ible |
Additional Gap Coverage |
Plan ID |
Cost-Sharing | Total Drugs | |||||
Cust. Serv. |
Plan Exper. |
Cost Info. |
Tier 1 |
Tier 2 |
Tier 3 |
Tier 4 |
||||||
-- This plan not offered in 2012 -- |
H5549 -003 -0 | |||||||||||
2013 VNSNY CHOICE Total (HMO SNP) | $95.00 | n/a | $325 | No additional gap coverage, only the Donut Hole Discount | 25% | 25% | 25% | 25% | 4,885 2013 Formulary | |||
2012 GHI - PPO III (PPO) | $99.00 | $3,400 | $0 | Many Generics | H5528 -008 -0 | $5.00 | $35.00 | 50% | 50% | 3,114 2012 Formulary | ||
2013 PPO III (PPO) | $112.50 | $3,400 | $0 | All Generics | $5.00 | $35.00 | $95.00 | $95.00 | 3,411 2013 Formulary | |||
2012 GHI - PPO High Option (PPO) | $180.00 | $3,400 | $0 | Many Generics | H5528 -020 -0 | $5.00 | $35.00 | 50% | 50% | 3,114 2012 Formulary | ||
2013 PPO High Option (PPO) | $218.50 | $3,400 | $0 | All Generics | $5.00 | $35.00 | $95.00 | $95.00 | 3,411 2013 Formulary | |||
Plan Name | Monthly Premium |
Parts A&B MOOP |
Part D Deduct- ible |
Additional Gap Coverage |
Plan ID |
Cost-Sharing | Total Drugs | |||||
Cust. Serv. |
Plan Exper. |
Cost Info. |
Tier 1 |
Tier 2 |
Tier 3 |
Tier 4 |
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2012 GHI - VIP High Option (HMO) | $180.00 | $3,400 | $0 | No additional gap coverage, only the Donut Hole Discount | H3330 -033 -2 | $5.00 | $35.00 | 50% | 50% | 3,114 2012 Formulary | ||
2013 VIP High Option (HMO) | $218.50 | $3,400 | $0 | No additional gap coverage, only the Donut Hole Discount | $5.00 | $35.00 | 50% | 50% | 3,411 2013 Formulary | |||
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