2012 Medicare Advantage Plan Information Click here to jump to the Chart Legend & Search Tips | |||||||||||
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Plan Name | County | Monthly Prem. (Parts C & D) |
Deduct- ible |
(Donut Hole) Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance 30-Day Supply |
MOOP for Part A & B Benefits | |||||
Cust. Service Rating |
Member Plan Exper. |
RxCost Info Rating |
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ActiveSaver MSA (MSA) - H9788-004-0 Benefit Details |
Queens | $0.00 | No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | n/a | ||||||
AARP MedicareComplete Essential (HMO) - H3307-018-0 Benefit Details |
Queens | $0.00 | No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $5,900 | ||||||
AARP MedicareComplete Mosaic (HMO) - H3307-015-0 Benefit Details |
Queens | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $4.00 Tier 3: $42.00 Tier 4: $85.00 Tier 5: 33% | $3,200 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
AARP MedicareComplete Plan 1 (HMO) - H3307-002-0 Benefit Details |
Queens | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $3.00 Tier 2: $6.00 Tier 3: $44.00 Tier 4: $88.00 Tier 5: 33% | $5,900 Browse Formulary | |||||
AARP MedicareComplete Plan 2 (HMO) - H3379-001-0 Benefit Details |
Queens | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $8.00 Tier 3: $45.00 Tier 4: $95.00 Tier 5: 33% | $4,950 Browse Formulary | |||||
Access Medicare Gold (HMO) - H4866-003-0 Benefit Details |
Queens | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $0.00 Tier 2: $30.00 Tier 3: $70.00 Tier 4: 30% | $3,400 Browse Formulary | |||||
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Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Amerivantage Balance + Rx (HMO) - H6181-009-0 Benefit Details |
Queens | $0.00 | $0 | Many Generics | Tier 1: $0.00 Tier 2: $0.00 Tier 3: $35.00 Tier 4: $80.00 Tier 5: 33% | $3,400 Browse Formulary | |||||
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ArchCare - Institutional SNP - NYC (HMO SNP) - H1777-007-0 Benefit Details |
Queens | $0.00 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% | n/a Browse Formulary | |||||
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Easy Choice Rewards (HMO) - H9285-001-0 Benefit Details |
Queens | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $0.00 Tier 2: $39.00 Tier 3: $79.00 Tier 4: 33% | $3,400 Browse Formulary | |||||
new | new | new | |||||||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Easy Choice Value (HMO) - H9285-002-0 Benefit Details |
Queens | $0.00 | $0 | Many Generics | Tier 1: $0.00 Tier 2: $39.00 Tier 3: $79.00 Tier 4: 33% | $3,400 Browse Formulary | |||||
new | new | new | |||||||||
Elderplan Classic: Zero Premium (HMO) - H3347-005-0 Benefit Details |
Queens | $0.00 | $0 | Many Generics | Tier 1: $4.00 Tier 2: $30.00 Tier 3: $80.00 Tier 4: 25% | $3,400 Browse Formulary | |||||
Elderplan Independence Choice (HMO-POS) - H3347-010-0 Benefit Details |
Queens | $0.00 | $0 | Many Generics | Tier 1: $4.00 Tier 2: $30.00 Tier 3: $80.00 Tier 4: 25% | $3,400 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Empire MediBlue Essential (HMO) - H3370-019-0 Benefit Details |
Queens | $0.00 | No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $3,400 | ||||||
Empire MediBlue Freedom I (PPO) - H3342-012-0 Benefit Details |
Queens | $0.00 | $60 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $9.00 Tier 2: $45.00 Tier 3: $85.00 Tier 4: 33% Tier 5: 33% Tier 6: $9.00 | $4,500 Browse Formulary | |||||
Empire MediBlue Plus (HMO) - H3370-001-0 Benefit Details |
Queens | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $35.00 Tier 3: $80.00 Tier 4: 33% Tier 5: 33% Tier 6: $5.00 | $2,800 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Fidelis Medicare Advantage without Rx (HMO-POS) - H3328-001-0 Benefit Details |
Queens | $0.00 | No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $6,700 | ||||||
GHI - PPO I (PPO) - H5528-001-0 Benefit Details |
Queens | $0.00 | No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $3,400 | ||||||
GHI - PPO II (PPO) - H5528-002-0 Benefit Details |
Queens | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $35.00 Tier 3: 50% Tier 4: 25% | $3,400 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
GHI - VIP (HMO) - H3330-021-1 Benefit Details |
Queens | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $35.00 Tier 3: 50% Tier 4: 25% | $3,400 Browse Formulary | |||||
GHI - VIP Essential (HMO) - H3330-032-1 Benefit Details |
Queens | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $35.00 Tier 3: 50% Tier 4: 25% | $3,400 Browse Formulary | |||||
Health Plus Advantage (HMO) - H6264-001-0 Benefit Details |
Queens | $0.00 | $0 | Many Generics | Tier 1: $3.00 Tier 2: $40.00 Tier 3: $65.00 Tier 4: 25% | $5,900 Browse Formulary | |||||
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Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Healthfirst 65 Plus Plan (HMO) - H3359-001-0 Benefit Details |
Queens | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $0.00 Tier 2: $40.00 Tier 3: $80.00 Tier 4: 33% | $6,700 Browse Formulary | |||||
Healthfirst Coordinated Benefits Plan (HMO) - H3359-027-0 Benefit Details |
Queens | $0.00 | No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $6,700 | ||||||
Healthfirst Jade Benefits Plan (HMO) - H3359-032-0 Benefit Details |
Queens | $0.00 | $0 | Many Generics | Tier 1: $0.00 Tier 2: $40.00 Tier 3: $80.00 Tier 4: 33% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Liberty Health Advantage Preferred Choice (HMO) - H3337-001-0 Benefit Details |
Queens | $0.00 | $0 | All Generics | Tier 1: $0.00 Tier 2: $10.00 Tier 3: $25.00 Tier 4: $50.00 Tier 5: 25% | $3,400 Browse Formulary | |||||
Touchstone Health Medicare Clear (HMO-POS) - H3327-022-0 Benefit Details |
Queens | $0.00 | No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $3,400 | ||||||
Touchstone Health Medicare Core (HMO) - H3327-037-0 Benefit Details |
Queens | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $8.00 Tier 2: $40.00 Tier 3: $80.00 Tier 4: 33% | $3,400 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Touchstone Health Medicare Freedom (HMO-POS) - H3327-038-0 Benefit Details |
Queens | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $40.00 Tier 3: $80.00 Tier 4: 33% | $3,400 Browse Formulary | |||||
Touchstone Health Medicare Power (HMO) - H3327-001-0 Benefit Details |
Queens | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $0.00 Tier 2: $40.00 Tier 3: $80.00 Tier 4: 33% | $3,400 Browse Formulary | |||||
UnitedHealthcare MedicareComplete Choice (Regional PPO) - R5342-001-0 Benefit Details |
Queens | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $3.00 Tier 2: $6.00 Tier 3: $45.00 Tier 4: $95.00 Tier 5: 33% | $4,900 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
UnitedHealthcare MedicareComplete Choice Essential (Regional PPO) - R5342-002-0 Benefit Details |
Queens | $0.00 | No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $3,900 | ||||||
VNSNY CHOICE Medicare Enhanced (HMO) - H5549-004-0 Benefit Details |
Queens | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $8.00 Tier 3: $30.00 Tier 4: $75.00 Tier 5: 25% | $3,400 Browse Formulary | |||||
WellCare Choice (HMO-POS) - H3361-106-0 Benefit Details |
Queens | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $0.00 Tier 2: $39.00 Tier 3: $79.00 Tier 4: 33% | $6,700 Browse Formulary | |||||
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Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
MetroPlus Medicare Partnership in Care Plan (HMO SNP) - H0423-002-0 Benefit Details |
Queens | $23.70 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% | n/a Browse Formulary | |||||
UnitedHealthcare Dual Complete RP (Regional PPO SNP) - R5342-003-0 Benefit Details |
Queens | $ for people who qualify for both Medicare and Medicaid. | $0 for people who qualify for both Medicare and Medicaid. | No additional gap coverage, only the Donut Hole Discount | Tier 1: 15% Tier 2: 15% | n/a Browse Formulary | |||||
MetroPlus Advantage Plan (HMO SNP) - H0423-001-0 Benefit Details |
Queens | $ for people who qualify for both Medicare and Medicaid. | $0 for people who qualify for both Medicare and Medicaid. | No additional gap coverage, only the Donut Hole Discount | Tier 1: 15% Tier 2: 15% | n/a Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Touchstone Health Medicare Prestige (HMO SNP) - H3327-026-0 Benefit Details |
Queens | $ for people who qualify for both Medicare and Medicaid. | $0 for people who qualify for both Medicare and Medicaid. | No additional gap coverage, only the Donut Hole Discount | Tier 1: 0% Tier 2: 0% | n/a Browse Formulary | |||||
Touchstone Health Medicare Total (HMO) - H3327-002-0 Benefit Details |
Queens | $35.40 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $0.00 Tier 2: $30.00 Tier 3: $70.00 Tier 4: 25% | $1,700 Browse Formulary | |||||
VNSNY CHOICE Medicare Preferred (HMO SNP) - H5549-002-0 Benefit Details |
Queens | $ for people who qualify for both Medicare and Medicaid. | $0 for people who qualify for both Medicare and Medicaid. | No additional gap coverage, only the Donut Hole Discount | Tier 1: 15% Tier 2: 15% | n/a Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
VNSNY CHOICE Total (HMO SNP) - H5549-003-0 Benefit Details |
Queens | $ for people who qualify for both Medicare and Medicaid. | $0 for people who qualify for both Medicare and Medicaid. | No additional gap coverage, only the Donut Hole Discount | Tier 1: 0% Tier 2: 0% | n/a Browse Formulary | |||||
Elderplan Extra Help (HMO) - H3347-009-0 Benefit Details |
Queens | $36.00 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,400 Browse Formulary | |||||
UnitedHealthcare Nursing Home Plan (HMO SNP) - H3379-002-0 Benefit Details |
Queens | $36.30 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% Tier 5: 25% | n/a Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Elderplan Advantage For Nursing Home Residents (HMO SNP) - H3347-003-0 Benefit Details |
Queens | $36.40 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | n/a Browse Formulary | |||||
Elderplan For Medicaid Beneficiaries (HMO SNP) - H3347-002-0 Benefit Details |
Queens | $ for people who qualify for both Medicare and Medicaid. | $0 for people who qualify for both Medicare and Medicaid. | No additional gap coverage, only the Donut Hole Discount | Tier 1: 15% Tier 2: 15% | n/a Browse Formulary | |||||
Elderplan Medicaid Advantage (HMO SNP) - H3347-008-0 Benefit Details |
Queens | $ for people who qualify for both Medicare and Medicaid. | $0 for people who qualify for both Medicare and Medicaid. | No additional gap coverage, only the Donut Hole Discount | Tier 1: 15% Tier 2: 15% | n/a Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Elderplan Plus Long Term Care (HMO SNP) - H3347-007-0 Benefit Details |
Queens | $ for people who qualify for both Medicare and Medicaid. | $0 for people who qualify for both Medicare and Medicaid. | No additional gap coverage, only the Donut Hole Discount | Tier 1: 15% Tier 2: 15% | n/a Browse Formulary | |||||
WellCare Rx (HMO) - H3361-130-0 Benefit Details |
Queens | $37.50 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $10.00 Tier 2: $35.00 Tier 3: $79.00 Tier 4: 33% | $6,700 Browse Formulary | |||||
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UnitedHealthcare Dual Complete (HMO SNP) - H3387-010-0 Benefit Details |
Queens | $ for people who qualify for both Medicare and Medicaid. | $0 for people who qualify for both Medicare and Medicaid. | No additional gap coverage, only the Donut Hole Discount | Tier 1: 0% Tier 2: 0% | n/a Browse Formulary | |||||
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Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
UnitedHealthcare Dual Complete LP (HMO SNP) - H3307-020-0 Benefit Details |
Queens | $ for people who qualify for both Medicare and Medicaid. | $0 for people who qualify for both Medicare and Medicaid. | No additional gap coverage, only the Donut Hole Discount | Tier 1: 15% Tier 2: 15% | n/a Browse Formulary | |||||
Access Medicare Platinum (HMO) - H4866-002-0 Benefit Details |
Queens | $39.70 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,400 Browse Formulary | |||||
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Access Medicare Silver (HMO) - H4866-004-0 Benefit Details |
Queens | $39.70 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $3,400 Browse Formulary | |||||
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Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Amerivantage Specialty + Rx (HMO SNP) - H6181-007-0 Benefit Details |
Queens | $ for people who qualify for both Medicare and Medicaid. | $0 for people who qualify for both Medicare and Medicaid. | Some Generics | Tier 1: $0.00 Tier 2: $0.00 Tier 3: 25% Tier 4: 25% Tier 5: 25% | n/a Browse Formulary | |||||
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CCM Direct Complete Plan (HMO SNP) - H5989-002-0 Benefit Details |
Queens | $39.70 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | n/a Browse Formulary | |||||
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CCM Direct Total Plan (HMO SNP) - H5989-008-0 Benefit Details |
Queens | $ for people who qualify for both Medicare and Medicaid. | $0 for people who qualify for both Medicare and Medicaid. | No additional gap coverage, only the Donut Hole Discount | Tier 1: 15% Tier 2: 15% | n/a Browse Formulary | |||||
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Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Affinity Medicare Solutions (HMO SNP) - H5991-002-0 Benefit Details |
Queens | $ for people who qualify for both Medicare and Medicaid. | $0 for people who qualify for both Medicare and Medicaid. | No additional gap coverage, only the Donut Hole Discount | Tier 1: 15% Tier 2: 15% | n/a Browse Formulary | |||||
Affinity Medicare Ultimate (HMO SNP) - H5991-001-0 Benefit Details |
Queens | $ for people who qualify for both Medicare and Medicaid. | $0 for people who qualify for both Medicare and Medicaid. | No additional gap coverage, only the Donut Hole Discount | Tier 1: 15% Tier 2: 15% | n/a Browse Formulary | |||||
Fidelis Dual Advantage (HMO SNP) - H3328-002-0 Benefit Details |
Queens | $ for people who qualify for both Medicare and Medicaid. | $0 for people who qualify for both Medicare and Medicaid. | No additional gap coverage, only the Donut Hole Discount | Tier 1: 15% Tier 2: 15% | n/a Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Fidelis Dual Advantage Flex (HMO SNP) - H3328-013-0 Benefit Details |
Queens | $ for people who qualify for both Medicare and Medicaid. | $0 for people who qualify for both Medicare and Medicaid. | No additional gap coverage, only the Donut Hole Discount | Tier 1: 0% Tier 2: 0% | n/a Browse Formulary | |||||
Fidelis Medicare Advantage Flex (HMO-POS) - H3328-003-0 Benefit Details |
Queens | $39.80 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $2.00 Tier 2: $15.00 Tier 3: $35.00 Tier 4: $95.00 Tier 5: 25% | $6,700 Browse Formulary | |||||
GHI - Dual Eligible (HMO SNP) - H3330-029-0 Benefit Details |
Queens | $ for people who qualify for both Medicare and Medicaid. | $0 for people who qualify for both Medicare and Medicaid. | No additional gap coverage, only the Donut Hole Discount | Tier 1: $4.00 Tier 2: 25% Tier 3: 30% Tier 4: 25% | n/a Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
GHI - Dual Eligible (PPO SNP) - H5528-018-0 Benefit Details |
Queens | $ for people who qualify for both Medicare and Medicaid. | $0 for people who qualify for both Medicare and Medicaid. | No additional gap coverage, only the Donut Hole Discount | Tier 1: $4.00 Tier 2: 25% Tier 3: 30% Tier 4: 25% | n/a Browse Formulary | |||||
GuildNet Gold (HMO-POS SNP) - H6864-001-0 Benefit Details |
Queens | $ for people who qualify for both Medicare and Medicaid. | $0 for people who qualify for both Medicare and Medicaid. | No additional gap coverage, only the Donut Hole Discount | Tier 1: $0.00 Tier 2: $45.00 Tier 3: $95.00 Tier 4: 25% | n/a Browse Formulary | |||||
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GuildNet Health Advantage (HMO-POS SNP) - H6864-002-0 Benefit Details |
Queens | $ for people who qualify for both Medicare and Medicaid. | $0 for people who qualify for both Medicare and Medicaid. | No additional gap coverage, only the Donut Hole Discount | Tier 1: 15% Tier 2: 15% | n/a Browse Formulary | |||||
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Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Health Plus Elite (HMO SNP) - H6264-002-0 Benefit Details |
Queens | $ for people who qualify for both Medicare and Medicaid. | $0 for people who qualify for both Medicare and Medicaid. | No additional gap coverage, only the Donut Hole Discount | Tier 1: 0% Tier 2: 0% | n/a Browse Formulary | |||||
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Healthfirst CompleteCare (HMO SNP) - H3359-034-0 Benefit Details |
Queens | $ for people who qualify for both Medicare and Medicaid. | $0 for people who qualify for both Medicare and Medicaid. | No additional gap coverage, only the Donut Hole Discount | Tier 1: 0% Tier 2: 0% | n/a Browse Formulary | |||||
Healthfirst Increased Benefits Plan (HMO) - H3359-019-0 Benefit Details |
Queens | $39.80 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Healthfirst Life Improvement Plan (HMO SNP) - H3359-021-0 Benefit Details |
Queens | $ for people who qualify for both Medicare and Medicaid. | $0 for people who qualify for both Medicare and Medicaid. | No additional gap coverage, only the Donut Hole Discount | Tier 1: 15% Tier 2: 15% | n/a Browse Formulary | |||||
Healthfirst Maximum Plan (HMO SNP) - H3359-033-0 Benefit Details |
Queens | $ for people who qualify for both Medicare and Medicaid. | $0 for people who qualify for both Medicare and Medicaid. | No additional gap coverage, only the Donut Hole Discount | Tier 1: 0% Tier 2: 0% | n/a Browse Formulary | |||||
Liberty Health Advantage Dual Power (HMO SNP) - H3337-003-0 Benefit Details |
Queens | $ for people who qualify for both Medicare and Medicaid. | $0 for people who qualify for both Medicare and Medicaid. | No additional gap coverage, only the Donut Hole Discount | Tier 1: 15% Tier 2: 15% | n/a Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
MetroPlus Select Plan (HMO SNP) - H0423-003-0 Benefit Details |
Queens | $ for people who qualify for both Medicare and Medicaid. | $0 for people who qualify for both Medicare and Medicaid. | No additional gap coverage, only the Donut Hole Discount | Tier 1: 0% Tier 2: 0% | n/a Browse Formulary | |||||
Senior Whole Health of New York (HMO SNP) - H5992-006-0 Benefit Details |
Queens | $ for people who qualify for both Medicare and Medicaid. | $0 for people who qualify for both Medicare and Medicaid. | No additional gap coverage, only the Donut Hole Discount | Tier 1: $0.00 Tier 2: $45.00 Tier 3: $95.00 | n/a Browse Formulary | |||||
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WellCare Access (HMO SNP) - H3361-109-0 Benefit Details |
Queens | $ for people who qualify for both Medicare and Medicaid. | $0 for people who qualify for both Medicare and Medicaid. | No additional gap coverage, only the Donut Hole Discount | Tier 1: $0.00 Tier 2: $39.00 Tier 3: $80.00 Tier 4: 25% | n/a Browse Formulary | |||||
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Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
WellCare Advocate Complete (HMO SNP) - H3361-105-0 Benefit Details |
Queens | $ for people who qualify for both Medicare and Medicaid. | $0 for people who qualify for both Medicare and Medicaid. | No additional gap coverage, only the Donut Hole Discount | Tier 1: $0.00 Tier 2: $37.00 Tier 3: $82.00 Tier 4: 25% | n/a Browse Formulary | |||||
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WellCare Liberty (HMO SNP) - H3361-043-0 Benefit Details |
Queens | $ for people who qualify for both Medicare and Medicaid. | $0 for people who qualify for both Medicare and Medicaid. | No additional gap coverage, only the Donut Hole Discount | Tier 1: $0.00 Tier 2: $38.00 Tier 3: $90.00 Tier 4: 25% | n/a Browse Formulary | |||||
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Empire MediBlue Freedom II (PPO) - H3342-013-0 Benefit Details |
Queens | $40.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $8.00 Tier 2: $45.00 Tier 3: $85.00 Tier 4: 33% Tier 5: 33% Tier 6: $8.00 | $3,400 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
Aetna Medicare Value Plan (HMO) - H3312-043-0 Benefit Details |
Queens | $50.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $33.00 Tier 3: $45.00 Tier 4: $95.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
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GHI - PPO III (PPO) - H5528-003-0 Benefit Details |
Queens | $51.00 | $0 | Many Generics | Tier 1: $5.00 Tier 2: $35.00 Tier 3: 50% Tier 4: 25% | $3,400 Browse Formulary | |||||
MetroPlus Platinum (HMO) - H0423-004-0 Benefit Details |
Queens | $51.30 | $320 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% | $6,700 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
VNSNY CHOICE Medicare Maximum (HMO SNP) - H5549-006-0 Benefit Details |
Queens | $ for people who qualify for both Medicare and Medicaid. | $0 for people who qualify for both Medicare and Medicaid. | No additional gap coverage, only the Donut Hole Discount | Tier 1: 0% Tier 2: 0% | n/a Browse Formulary | |||||
Aetna Medicare Standard Plan (HMO) - H3312-025-0 Benefit Details |
Queens | $80.00 | $0 | Many Generics | Tier 1: $3.00 Tier 2: $31.00 Tier 3: $45.00 Tier 4: $85.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
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Aetna Medicare Standard Plan (PPO) - H5521-040-0 Benefit Details |
Queens | $85.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $6.00 Tier 2: $33.00 Tier 3: $45.00 Tier 4: $95.00 Tier 5: 33% | $6,700 Browse Formulary | |||||
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Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
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Service | Exper. | Cost Info | |||||||||
GHI - PPO High Option (PPO) - H5528-019-0 Benefit Details |
Queens | $94.00 | $0 | Many Generics | Tier 1: $5.00 Tier 2: $35.00 Tier 3: 50% Tier 4: 25% | $3,400 Browse Formulary | |||||
Empire MediBlue Freedom III (PPO) - H3342-001-0 Benefit Details |
Queens | $103.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $3.00 Tier 2: $42.00 Tier 3: $80.00 Tier 4: 33% Tier 5: 33% Tier 6: $3.00 | $2,800 Browse Formulary | |||||
GHI - VIP High Option (HMO) - H3330-033-1 Benefit Details |
Queens | $154.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $5.00 Tier 2: $35.00 Tier 3: 50% Tier 4: 25% | $3,400 Browse Formulary | |||||
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