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) - H9788-003-0 Benefit Details |
Ulster | $0.00 | No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | n/a | ||||||
Empire MediBlue Essential (HMO) - H3370-019-0 Benefit Details |
Ulster | $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 |
Ulster | $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 | |||||
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 |
Ulster | $0.00 | No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $6,700 | ||||||
UnitedHealthcare MedicareComplete Choice (Regional PPO) - R5342-001-0 Benefit Details |
Ulster | $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 | |||||
UnitedHealthcare MedicareComplete Choice Essential (Regional PPO) - R5342-002-0 Benefit Details |
Ulster | $0.00 | No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $3,900 | ||||||
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 Advance (HMO) - H3361-059-0 Benefit Details |
Ulster | $0.00 | No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $6,700 | ||||||
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WellCare Value (HMO-POS) - H3361-099-0 Benefit Details |
Ulster | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $3.00 Tier 2: $39.00 Tier 3: $79.00 Tier 4: 33% | $6,700 Browse Formulary | |||||
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CDPHP Choice (HMO) - H3388-001-0 Benefit Details |
Ulster | $20.00 | No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $2,500 | ||||||
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 | |||||||||
CDPHP Value Rx (HMO) - H3388-004-0 Benefit Details |
Ulster | $25.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $0.00 Tier 2: $9.00 Tier 3: $45.00 Tier 4: $95.00 Tier 5: 33% | $3,300 Browse Formulary | |||||
UnitedHealthcare Dual Complete RP (Regional PPO SNP) - R5342-003-0 Benefit Details |
Ulster | $ 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 Liberty (HMO SNP) - H3361-098-0 Benefit Details |
Ulster | $ 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: $44.00 Tier 3: $95.00 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 Access (HMO SNP) - H3361-065-0 Benefit Details |
Ulster | $ 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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Empire MediBlue Select (HMO) - H3370-002-0 Benefit Details |
Ulster | $36.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $7.00 Tier 2: $35.00 Tier 3: $80.00 Tier 4: 33% Tier 5: 33% Tier 6: $7.00 | $3,400 Browse Formulary | |||||
Fidelis Dual Advantage (HMO SNP) - H3328-002-0 Benefit Details |
Ulster | $ 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 |
Ulster | $ 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 |
Ulster | $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 | |||||
Senior Whole Health of New York (HMO SNP) - H5992-005-0 Benefit Details |
Ulster | $ 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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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 Nursing Home Plan (HMO SNP) - H3379-022-0 Benefit Details |
Ulster | $39.80 | $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 | |||||
Empire MediBlue Freedom II (PPO) - H3342-014-0 Benefit Details |
Ulster | $47.00 | $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 | |||||
Today's Options Premier 400 (PFFS) - H2816-010-0 Benefit Details |
Ulster | $59.00 | No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $6,700 | ||||||
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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 | |||||||||
CDPHP Choice Rx (HMO) - H3388-002-0 Benefit Details |
Ulster | $75.00 | $0 | Many Generics | Tier 1: $0.00 Tier 2: $8.00 Tier 3: $40.00 Tier 4: $90.00 Tier 5: 30% | $2,500 Browse Formulary | |||||
CDPHP Classic (PPO) - H5042-004-0 Benefit Details |
Ulster | $95.00 | No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $2,500 | ||||||
Today's Options Premier Plus 450G (PFFS) - H2816-022-0 Benefit Details |
Ulster | $95.00 | $90 | No additional gap coverage, only the Donut Hole Discount | Tier 1: tbd | $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 | |||||||||
CDPHP Core Rx (PPO) - H5042-005-0 Benefit Details |
Ulster | $99.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: $0.00 Tier 2: $9.00 Tier 3: $45.00 Tier 4: $95.00 Tier 5: 33% | $3,300 Browse Formulary | |||||
Empire MediBlue Freedom III (PPO) - H3342-002-0 Benefit Details |
Ulster | $106.00 | $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 | |||||
Today's Options Premier 100 (PFFS) - H2816-026-0 Benefit Details |
Ulster | $110.00 | No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $3,400 | ||||||
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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 | |||||||||
Preferred Gold Rx (HMO-POS) - H9859-004-0 Benefit Details |
Ulster | $122.30 | $0 | Few Generics | Tier 1: $8.00 Tier 2: $35.00 Tier 3: $90.00 Tier 4: 33% Tier 5: $0.00 | $3,800 Browse Formulary | |||||
CDPHP Classic Rx (PPO) - H5042-001-0 Benefit Details |
Ulster | $145.00 | $0 | Many Generics | Tier 1: $0.00 Tier 2: $8.00 Tier 3: $40.00 Tier 4: $90.00 Tier 5: 30% | $2,500 Browse Formulary | |||||
Today's Options Premier Plus 150A (PFFS) - H2816-028-0 Benefit Details |
Ulster | $152.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Tier 1: tbd | $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 | |||||||||
CDPHP Prime Rx (PPO) - H5042-007-0 Benefit Details |
Ulster | $199.00 | $0 | Many Generics | Tier 1: $0.00 Tier 2: $5.00 Tier 3: $40.00 Tier 4: $75.00 Tier 5: 30% | $2,000 Browse Formulary | |||||
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