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 |
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 | Preferred Generic: $2.00 Non-Preferred Generic: $4.00 Preferred Brand: $44.00 Non-Preferred Brand: $92.00 Specialty Tier: 33% | $3,500 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 | |||||||||
AARP MedicareComplete Plan 1 (HMO) - H3307-002-0 Benefit Details |
Queens | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $3.00 Non-Preferred Generic: $6.00 Preferred Brand: $44.00 Non-Preferred Brand: $92.00 Specialty Tier: 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 | Preferred Generic: $0.00 Non-Preferred Generic: $8.00 Preferred Brand: $45.00 Non-Preferred Brand: $95.00 Specialty Tier: 33% | $3,900 Browse Formulary | |||||
Access Medicare Gold (HMO) - H4866-003-0 Benefit Details |
Queens | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic: $0.00 Preferred Brand: $30.00 Non-Preferred Brand: $70.00 Specialty Tier: 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 | |||||||||
Advantage Health NY - SNP (HMO SNP) - H2773-003-0 Benefit Details |
Queens | $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 - Queens (HMO) - H2773-013-0 Benefit Details |
Queens | $0.00 | $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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Amerivantage Balance + Rx (HMO) - H6181-009-0 Benefit Details |
Queens | $0.00 | $0 | Some Generics | Preferred Generic: $0.00 Non-Preferred Generic: $4.00 Preferred Brand: $35.00 Non-Preferred Brand: $80.00 Specialty Tier: 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 | |||||||||
Amerivantage Classic Choice + Rx Plan (HMO-POS) - H6181-015-0 Benefit Details |
Queens | $0.00 | $0 | Some Generics | Preferred Generic: $3.00 Non-Preferred Generic: $3.00 Preferred Brand: $40.00 Non-Preferred Brand: $65.00 Specialty Tier: 25% | $6,700 Browse Formulary | |||||
Easy Choice Diamond Rewards (HMO SNP) - H9285-003-0 Benefit Details |
Queens | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Preferred Brand: $20.00 Non-Preferred Brand: $69.00 Specialty Tier: 33% | n/a Browse Formulary | |||||
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Easy Choice Diamond Rewards COPD (HMO SNP) - H9285-004-0 Benefit Details |
Queens | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Preferred Brand: $20.00 Non-Preferred Brand: $69.00 Specialty Tier: 33% | 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 | |||||||||
Easy Choice Rewards (HMO) - H9285-001-0 Benefit Details |
Queens | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $0.00 Preferred Brand: $39.00 Non-Preferred Brand: $79.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
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Easy Choice Value (HMO) - H9285-002-0 Benefit Details |
Queens | $0.00 | $0 | Many Generics | Preferred Generic: $0.00 Preferred Brand: $20.00 Non-Preferred Brand: $69.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
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Elderplan Classic: Zero Premium (HMO) - H3347-005-0 Benefit Details |
Queens | $0.00 | $325 | No additional gap coverage, only the Donut Hole Discount | Generic: $4.00 Preferred Brand: $30.00 Non-Preferred Brand: $90.00 Specialty Tier: 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 | |||||||||
Empire MediBlue Essential (HMO) - H3370-019-0 Benefit Details |
Queens | $0.00 | No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $4,000 | ||||||
Empire MediBlue Plus (HMO) - H3370-001-0 Benefit Details |
Queens | $0.00 | $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: $95.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Fidelis Medicare $0 Premium (HMO) - H3328-019-0 Benefit Details |
Queens | $0.00 | $0 | 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: 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 | |||||||||
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 | ||||||
Healthfirst 65 Plus Plan (HMO) - H3359-001-0 Benefit Details |
Queens | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic: $0.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 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 | ||||||
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 Jade Benefits Plan (HMO) - H3359-032-0 Benefit Details |
Queens | $0.00 | $0 | Many Generics, Few Brands | Generic: $0.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $6,700 Browse Formulary | |||||
Liberty Health Advantage Preferred Choice (HMO) - H3337-001-0 Benefit Details |
Queens | $0.00 | $0 | All Generics | Preferred Generic: $0.00 Non-Preferred Generic: $10.00 Preferred Brand: $25.00 Non-Preferred Brand: $50.00 Specialty Tier: 25% | $3,400 Browse Formulary | |||||
PPO I (PPO) - H5528-001-0 Benefit Details |
Queens | $0.00 | 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 | |||||||||
PPO II (PPO) - H5528-002-0 Benefit Details |
Queens | $0.00 | $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 | |||||
Touchstone Health Medicare Clear (HMO-POS) - H3327-039-0 Benefit Details |
Queens | $0.00 | No Rx Coverage | This Plan does NOT include Prescription Drug coverage. | $3,400 | ||||||
Touchstone Health Medicare Freedom (HMO-POS) - H3327-038-0 Benefit Details |
Queens | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic: $6.00 Preferred Brand: $40.00 Non-Preferred Brand: $80.00 Specialty Tier: 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 Power (HMO) - H3327-001-0 Benefit Details |
Queens | $0.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic: $0.00 Preferred Brand: $45.00 Non-Preferred Brand: $80.00 Specialty Tier: 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 | 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 |
Queens | $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 | |||||||||
VIP (HMO) - H3330-021-1 Benefit Details |
Queens | $0.00 | $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 Essential (HMO) - H3330-032-1 Benefit Details |
Queens | $0.00 | $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 | |||||
VNSNY CHOICE Medicare Enhanced (HMO) - H5549-004-0 Benefit Details |
Queens | $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 | |||||
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 Choice (HMO-POS) - H3361-106-0 Benefit Details |
Queens | $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 |
Queens | $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 | |||||
WellCare Liberty (HMO SNP) - H3361-043-0 Benefit Details |
Queens | $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 | |||||
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 | $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 | |||||
MetroPlus Platinum (HMO) - H0423-004-0 Benefit Details |
Queens | $34.70 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% | $6,700 Browse Formulary | |||||
Healthfirst Increased Benefits Plan (HMO) - H3359-019-0 Benefit Details |
Queens | $35.00 | $325 | 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 | |||||||||
UnitedHealthcare Nursing Home Plan (HMO SNP) - H3379-002-0 Benefit Details |
Queens | $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 | |||||
Touchstone Health Medicare Total (HMO) - H3327-002-0 Benefit Details |
Queens | $38.60 | $0 | No additional gap coverage, only the Donut Hole Discount | Generic: $0.00 Preferred Brand: $30.00 Non-Preferred Brand: $80.00 Specialty Tier: 33% | $1,700 Browse Formulary | |||||
HHH Choices Gold (HMO SNP) - H3635-001-0 Benefit Details |
Queens | $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% | n/a 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 | |||||||||
VNSNY CHOICE Medicare Preferred (HMO SNP) - H5549-002-0 Benefit Details |
Queens | $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 | |||||
Elderplan Advantage For Nursing Home Residents (HMO SNP) - H3347-003-0 Benefit Details |
Queens | $40.20 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% | n/a Browse Formulary | |||||
WellCare Access (HMO SNP) - H3361-109-0 Benefit Details |
Queens | $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 | |||||
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 | $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 | |||||
UnitedHealthcare Dual Complete (HMO SNP) - H3387-010-0 Benefit Details |
Queens | $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 | |||||
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GuildNet Health Advantage (HMO-POS SNP) - H6864-002-0 Benefit Details |
Queens | $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 | |||||||||
MetroPlus Advantage Plan (HMO SNP) - H0423-001-0 Benefit Details |
Queens | $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% | n/a Browse Formulary | |||||
UnitedHealthcare Dual Complete LP (HMO SNP) - H3307-020-0 Benefit Details |
Queens | $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 | |||||
Healthfirst AssuredCare (HMO SNP) - H3359-035-0 Benefit Details |
Queens | $43.00 | $325 | 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 | |||||
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 CompleteCare (HMO SNP) - H3359-034-0 Benefit Details |
Queens | $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 | |||||
Healthfirst Life Improvement Plan (HMO SNP) - H3359-021-0 Benefit Details |
Queens | $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 | |||||
Healthfirst Maximum Plan (HMO SNP) - H3359-033-0 Benefit Details |
Queens | $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 | |||||
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 | $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% | n/a Browse Formulary | |||||
Access Medicare Pearl (HMO SNP) - H4866-005-0 Benefit Details |
Queens | $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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Access Medicare Platinum (HMO) - H4866-002-0 Benefit Details |
Queens | $43.20 | $325 | 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 | |||||||||
Access Medicare Silver (HMO SNP) - H4866-006-0 Benefit Details |
Queens | $43.20 | $325 | 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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Affinity Medicare Solutions (HMO SNP) - H5991-002-0 Benefit Details |
Queens | $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% | n/a Browse Formulary | |||||
Affinity Medicare Ultimate (HMO SNP) - H5991-001-0 Benefit Details |
Queens | $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% Brand: 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 | |||||||||
Amerivantage Specialty + Rx (HMO SNP) - H6181-007-0 Benefit Details |
Queens | $0.00 for people who qualify for both Medicare and Medicaid. | $0 for people who qualify for both Medicare and Medicaid. | Many Generics, Few Brands | Preferred Generic: $0.00 Non-Preferred Generic: $0.00 Preferred Brand: 25% Non-Preferred Brand: 25% Specialty Tier: 25% | n/a Browse Formulary | |||||
ArchCare - Inst and IE SNP - All Counties (HMO SNP) - H1777-007-0 Benefit Details |
Queens | $43.20 | $325 | 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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CenterLight Direct Complete Plan (HMO SNP) - H5989-002-0 Benefit Details |
Queens | $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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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 Total Plan (HMO SNP) - H5989-008-0 Benefit Details |
Queens | $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 |
Queens | $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 | |||||
Dual Eligible (PPO SNP) - H5528-018-0 Benefit Details |
Queens | $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 | |||||||||
Elderplan Extra Help (HMO) - H3347-009-0 Benefit Details |
Queens | $43.20 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% | $6,700 Browse Formulary | |||||
Elderplan For Medicaid Beneficiaries (HMO SNP) - H3347-002-0 Benefit Details |
Queens | $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% | n/a Browse Formulary | |||||
Elderplan Medicaid Advantage (HMO SNP) - H3347-008-0 Benefit Details |
Queens | $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% | 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 | $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% | n/a Browse Formulary | |||||
Fidelis Dual Advantage (HMO SNP) - H3328-002-0 Benefit Details |
Queens | $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: $70.00 Specialty Tier: 25% | n/a Browse Formulary | |||||
Fidelis Dual Advantage Flex (HMO SNP) - H3328-017-0 Benefit Details |
Queens | $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 | |||||
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 Long Term Care Advantage (HMO SNP) - H3328-018-0 Benefit Details |
Queens | $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 | |||||
Fidelis Medicaid Advantage Plus (HMO SNP) - H3328-016-0 Benefit Details |
Queens | $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: $91.00 Specialty Tier: 25% | n/a Browse Formulary | |||||
Fidelis Medicare Advantage Flex (HMO-POS) - H3328-003-0 Benefit Details |
Queens | $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 | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
GuildNet Gold (HMO-POS SNP) - H6864-001-0 Benefit Details |
Queens | $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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Liberty Health Advantage Dual Power (HMO SNP) - H3337-003-0 Benefit Details |
Queens | $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 | |||||
Senior Whole Health of New York (HMO SNP) - H5992-006-0 Benefit Details |
Queens | $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 Brand: $45.00 | 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 |
|||||
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 | Preferred Generic: $6.00 Non-Preferred Generic: $33.00 Preferred Brand: $45.00 Non-Preferred Brand: $95.00 Specialty Tier: 33% | $6,700 Browse Formulary | |||||
PPO III (PPO) - H5528-003-0 Benefit Details |
Queens | $54.50 | $0 | All Generics | Preferred Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Brand: $95.00 Specialty Tier: 25% | $3,400 Browse Formulary | |||||
Advantage Platinum NY (HMO) - H2773-001-0 Benefit Details |
Queens | $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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Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
MetroPlus Medicare Partnership in Care Plan (HMO SNP) - H0423-002-0 Benefit Details |
Queens | $67.10 | $325 | No additional gap coverage, only the Donut Hole Discount | Tier 1: 25% Tier 2: 25% | n/a Browse Formulary | |||||
VNSNY CHOICE Medicare Maximum (HMO SNP) - H5549-006-0 Benefit Details |
Queens | $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 | |||||
Aetna Medicare Standard Plan (HMO) - H3312-025-0 Benefit Details |
Queens | $80.00 | $0 | Some Generics | Preferred Generic: $6.00 Non-Preferred Generic: $33.00 Preferred Brand: $45.00 Non-Preferred Brand: $95.00 Specialty Tier: 33% | $3,400 Browse Formulary | |||||
Plan Name | County | Monthly Prem. |
Deduct- ible |
Additional Gap Coverage |
Preferred Pharmacy Copay/ Coinsurance |
MOOP for A & B |
|||||
Service | Exper. | Cost Info | |||||||||
Aetna Medicare Standard Plan (PPO) - H5521-040-0 Benefit Details |
Queens | $85.00 | $0 | No additional gap coverage, only the Donut Hole Discount | Preferred Generic: $6.00 Non-Preferred Generic: $33.00 Preferred Brand: $45.00 Non-Preferred Brand: $95.00 Specialty Tier: 33% | $6,700 Browse Formulary | |||||
VNSNY CHOICE Total (HMO SNP) - H5549-003-0 Benefit Details |
Queens | $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 | |||||
PPO High Option (PPO) - H5528-019-0 Benefit Details |
Queens | $132.50 | $0 | All Generics | Preferred Generic: $5.00 Preferred Brand: $35.00 Non-Preferred Brand: $95.00 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 |
|||||
Service | Exper. | Cost Info | |||||||||
VIP High Option (HMO) - H3330-033-1 Benefit Details |
Queens | $157.50 | $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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