2013 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 |
Suffolk | $0.00 | No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | n/a | ||||||
Advantage Health NY - SNP (HMO SNP) - H2773-003-0 Benefit Details |
Suffolk | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $2.00 Preferred Brand: $25.00 Non-Preferred Brand: $55.00 Specialty Tier: 33% | n/a Browse Formulary | |||||
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Advantage Silver NY (HMO) - H2773-002-0 Benefit Details |
Suffolk | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $4.00 Preferred Brand: $30.00 Non-Preferred Brand: $55.00 Specialty Tier: 33% | $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 | |||||||||
Fidelis Medicare Advantage without Rx (HMO-POS) - H3328-001-0 Benefit Details |
Suffolk | $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 |
Suffolk | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $45.00 Non-Preferred Brand: $95.00 Specialty Tier: 33% | $4,900 Browse Formulary | |||||
UnitedHealthcare MedicareComplete Choice Essential (Regional PPO) - R5342-002-0 Benefit Details |
Suffolk | $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 | |||||||||
VNSNY CHOICE Medicare Enhanced (HMO) - H5549-004-0 Benefit Details |
Suffolk | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $1.00 Non-Preferred Generic: $4.00 Preferred Brand: $30.00 Non-Preferred Brand: $90.00 Specialty Tier: 25% | $3,400 Browse Formulary | |||||
WellCare Choice (HMO-POS) - H3361-106-0 Benefit Details |
Suffolk | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic: $0.00 Preferred Brand: $39.00 Non-Preferred Brand: $79.00 Specialty Tier: 33% | $6,700 Browse Formulary | |||||
WellCare Rx (HMO) - H3361-130-0 Benefit Details |
Suffolk | $1.60 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic: $8.00 Preferred Brand: $35.00 Non-Preferred Brand: $79.00 Specialty Tier: 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 | |||||||||
WellCare Liberty (HMO SNP) - H3361-043-0 Benefit Details |
Suffolk | $0.00 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 | Generic: $0.00 Preferred Brand: $45.00 Non-Preferred Brand: $95.00 Specialty Tier: 25% | n/a Browse Formulary | |||||
UnitedHealthcare Nursing Home Plan (HMO SNP) - H3379-002-0 Benefit Details |
Suffolk | $35.00 | $325 | 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 I (PPO) - H3342-012-0 Benefit Details |
Suffolk | $38.00 | $75 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $8.00 Non-Preferred Generic: $14.00 Preferred Brand: $45.00 Non-Preferred Brand: $95.00 Injectable Drugs: $95.00 Specialty Tier: 33% | $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 | |||||||||
VNSNY CHOICE Medicare Preferred (HMO SNP) - H5549-002-0 Benefit Details |
Suffolk | $0.00 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: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% Tier 5: 25% | n/a Browse Formulary | |||||
WellCare Access (HMO SNP) - H3361-109-0 Benefit Details |
Suffolk | $0.00 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 | Generic: $0.00 Preferred Brand: $45.00 Non-Preferred Brand: $95.00 Specialty Tier: 25% | n/a Browse Formulary | |||||
GuildNet Health Advantage (HMO-POS SNP) - H6864-002-0 Benefit Details |
Suffolk | $0.00 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: 25% Tier 2: 25% Tier 3: 25% 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 | |||||||||
CenterLight Direct Complete Plan (HMO SNP) - H5989-002-0 Benefit Details |
Suffolk | $43.20 | $325 | No additional gap coverage, only the Donut Hole Discount | Generic: $7.25 Preferred Brand: $42.00 Non-Preferred Brand: $95.00 Specialty Tier: 25% | n/a Browse Formulary | |||||
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CenterLight Direct Total Plan (HMO SNP) - H5989-008-0 Benefit Details |
Suffolk | $0.00 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 | Generic: $8.00 Preferred Brand: $45.00 Non-Preferred Brand: $95.00 Specialty Tier: 28% | n/a Browse Formulary | |||||
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Dual Eligible (HMO SNP) - H3330-029-0 Benefit Details |
Suffolk | $0.00 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 | Preferred Generic: $4.00 Preferred Brand: 25% Non-Preferred Brand: 30% Specialty Tier: 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 | |||||||||
Dual Eligible (PPO SNP) - H5528-018-0 Benefit Details |
Suffolk | $0.00 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 | Preferred Generic: $4.00 Preferred Brand: 25% Non-Preferred Brand: 30% Specialty Tier: 25% | n/a Browse Formulary | |||||
Fidelis Dual Advantage Flex (HMO SNP) - H3328-017-0 Benefit Details |
Suffolk | $0.00 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 | Preferred Generic: $0.00 Non-Preferred Generic: $15.00 Preferred Brand: $35.00 Non-Preferred Brand: $95.00 Specialty Tier: 25% | n/a Browse Formulary | |||||
Fidelis Long Term Care Advantage (HMO SNP) - H3328-018-0 Benefit Details |
Suffolk | $43.20 | $325 | 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 | |||||||||
Fidelis Medicare Advantage Flex (HMO-POS) - H3328-003-0 Benefit Details |
Suffolk | $43.20 | $320 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Non-Preferred Generic: $15.00 Preferred Brand: $35.00 Non-Preferred Brand: $75.00 Specialty Tier: 25% | $6,700 Browse Formulary | |||||
GuildNet Gold (HMO-POS SNP) - H6864-001-0 Benefit Details |
Suffolk | $0.00 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: 25% Tier 2: 25% Tier 3: 25% Tier 4: 25% | n/a Browse Formulary | |||||
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PPO I (PPO) - H5528-009-0 Benefit Details |
Suffolk | $57.00 | No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $3,400 | ||||||
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 | |||||||||
Advantage Platinum NY (HMO) - H2773-001-0 Benefit Details |
Suffolk | $60.00 | $0 | Many Generics | Preferred Generic: $4.00 Preferred Brand: $30.00 Non-Preferred Brand: $55.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
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PPO II (PPO) - H5528-010-0 Benefit Details |
Suffolk | $68.50 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Brand: $95.00 Specialty Tier: 25% | $3,400 Browse Formulary | |||||
VNSNY CHOICE Medicare Maximum (HMO SNP) - H5549-006-0 Benefit Details |
Suffolk | $0.00 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: 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 | |||||||||
Empire MediBlue Freedom II (PPO) - H3342-015-0 Benefit Details |
Suffolk | $83.00 | $75 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $7.00 Non-Preferred Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Brand: $95.00 Injectable Drugs: $95.00 Specialty Tier: 33% | $3,900 Browse Formulary | |||||
Empire MediBlue Plus (HMO) - H3370-004-0 Benefit Details |
Suffolk | $83.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Non-Preferred Generic: $10.00 Preferred Brand: $45.00 Non-Preferred Brand: $95.00 Injectable Drugs: 33% Specialty Tier: 33% | $4,000 Browse Formulary | |||||
VNSNY CHOICE Total (HMO SNP) - H5549-003-0 Benefit Details |
Suffolk | $0.00 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: 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 | |||||||||
PPO III (PPO) - H5528-011-0 Benefit Details |
Suffolk | $123.50 | $0 | All Generics | Preferred Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Brand: $95.00 Specialty Tier: 25% | $3,400 Browse Formulary | |||||
VIP Essential (HMO) - H3330-032-3 Benefit Details |
Suffolk | $126.50 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Brand: 50% Specialty Tier: 25% | $3,400 Browse Formulary | |||||
VIP (HMO) - H3330-021-3 Benefit Details |
Suffolk | $141.50 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Brand: 50% Specialty Tier: 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 | |||||||||
PPO High Option (PPO) - H5528-021-0 Benefit Details |
Suffolk | $249.50 | $0 | All Generics | Preferred Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Brand: $95.00 Specialty Tier: 25% | $3,400 Browse Formulary | |||||
VIP High Option (HMO) - H3330-033-3 Benefit Details |
Suffolk | $309.50 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Brand: 50% Specialty Tier: 25% | $3,400 Browse Formulary | |||||
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