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| MAPD's: Preventive Services In-Network $0 Chemotherapy & Medicare Part B Drugs 20% Durable Medical Equipment/Oxygen 20% PLAN NAME |
Monthly Plan Premium | Monthly Premium with (LIS) Extra Help | Annual Drug Tier 3-5 Deductible $0 with Extra Help | Copay & Coinsurance - Cost for IN-NETWORK Providers - Prior Authorization and Limits may apply General Information only | |||||||||||||||||
| Doctor Primary/ Specialist | Therapy PT, OT & ST |
Lab Services | Diagnostic Tests & Procedures | Diagnostic Radiology (like MRI) | Outpatient Therapy Mental Health Group / Individual | Hospital Outpatient | Hospital Inpatient |
Skilled Nursing Facility $0 days 1-20 |
Maximum Out of Pocket Spending Limit | ||||||||||||
| Aetna Medicare Credit Plan (PPO) | $0 | $0 | $350 | $15/$45 | $40 | $10 | $45 | $450 | $40/$40 | $45-395 | $395/day 1-5 | $188/day 21-100 | $7,550 | ||||||||
| Aetna Medicare Discover Value Plan (PPO) | $25 | $0 | $300 | $0/$30 | $40 | $0 | $30 | $225 | $40/$40 | $30-325 | $325/day 1-6 | $188/day 21-100 | $7,550 | ||||||||
| Aetna Medicare Premier Plan (PPO) | $0 | $0 | $250 | $0/$35 | $35 | $0 | $35 | $200 | $35/$35 | $35-335 | $335/day 1-6 | $188/day 21-100 | $7,550 | ||||||||
| Aetna Medicare Value Plan (HMO) | $0 | $0 | $0 | $0/$25 | $30 | $0 | $25 | $200 | $30/$30 | $25-325 | $300/day 1-6 | $188/day 21-100 | $7,550 | ||||||||
| CDPHP $0 Medicare Rx (HMO) 5* | $0 | $0 | $300 | $0-40 | $40 | 0-20% | 20% | $195 | $40/$40 | $365 | $360/day 1-5 | $184/day 21-100 | $7,500 | ||||||||
| CDPHP Basic RX (HMO) 5* | $31 | $0 | $0 | $0-45 | $40 | $0-45 | $45 | $140 | $40/$40 | $330 | $335/day 1-6 | $150/day 21-100 | $6,700 | ||||||||
| CDPHP Choice Rx (HMO) 5* | $131 | $88 | $0 | $0-30 | $30 | $0-30 | $30 | $100 | $30/$30 | $200 | $260/day 1-6 | $120/day 21-100 | $5,000 | ||||||||
| CDPHP Flex Rx (PPO) 5* | $42 | $8 | $0 | $0-40 | $40 | $0-40 | $40 | $135 | $40/$40 | $325 | $310/day 1-6 | $145/day 21-100 | $5,500 | ||||||||
| CDPHP Value Rx (HMO) 5* | $60.80 | $23.00 | $0 | $0-35 | $35 | $0-35 | $35 | $130 | $35/$35 | $300 | $295/day 1-6 | $140/day 21-100 | $5,800 | ||||||||
| CDPHP Vital Rx (PPO) 5* | $0 | $0 | $350 | $0-50 | $40 | $0-20% | 20% | $220 | $40/$40 | $395 | $460/day 1-4 | $184.day 21-100 | $7,500 | ||||||||
| Empire MediBlue Access (PPO) | $90 | $50.10 | $310 | $10/$50 | $40 | $0-20 | $0-80 | $50-150 | $40/$40 | 20% | $372/day 1-5 | $188/day 21-100 | $6,200 | ||||||||
| Empire MediBlue Plus (HMO) | $42 | $3.30 | $325 | $0/$40 | $40 | $0 | $0-$60 | $80-100 | $40/$40 | $0-300 | $325/day 1-5 | $188/day 21/100 | $5,000 | ||||||||
| Excellus- Medicare BluePlus (PPO) | $116 | $73.60 | $480 All Tiers | $5/$50 | $40 | $20 | $20 | 20% | 20%/20% | 20% | $360/day 1-5 | $188/day 21-100 | $6,000 | ||||||||
| MVP Medicare Secure Plus with Part D (HMO-POS) | $90 | $48 | $0 | $0/$40 | $20 | $0 | $10 | $40-150 | $40/$40 | $300 | $350/day 1-5 | $188/day 21-100 | $7,550 | ||||||||
| MVP Medicare WellSelect with Part D (PPO) | $0 | $0 | $300 | $0/$45 | $30 | $0 | $20 | $60-150 | $40/$40 | $350 | $385/day 1-5 | $188/day 21-100 | $7,550 | ||||||||
| UVM Health Advantage Preferred (PPO) | $130 | $90.60 | $0 | $0/$25 | $15 | $0 | $25 | $20-125 | $15/$25 | $175 | $350/day 1-2 | $150/day 21-48 | $5,000 | ||||||||
| UVM Health Advantage Secure (PPO) | $50 | $11.10 | $150 | $0/$30 | $20 | $0 | $30 | $25-125 | $15/$25 | $200 | $400/day 1-2 | $150/day 21-48 | $5,000 | ||||||||
| UVM Health Advantage Select (PPO) | $0 | $0 | $250 | $0/$35 | $20 | $0 | $35 | $25-160 | $15/$25 | $285 | $450/day 1-2 | $188/day 21-55 | $6,700 v | ||||||||
| UnitedHealthcare Medicare Advantage Choice Plan 1 (Regional PPO) | $16 | $0 | $300 | $0/$40 | $40 | $0 | $35 | $175 | $15/$25 | $0-375 | $375/day 1-5 | $188/day 21-59 | $7,200 | ||||||||
| UnitedHealthcare Medicare Advantage Choice Plan 3 (Regional PPO) | $46 | $11.80 | $250 | $0/$40 | $40 | $0 | $35 | $160 | $15/$25 | $0-340 | $360/day 1-5 | $188/day 21-57 | $6,900 | ||||||||
| UnitedHealthcare Medicare Advantage Choice Plan 4 (Regional PPO) | $84 | $41.60 | $150 | $0/$30 | $30 | $0 | $30 | $175 | $15/$25 | $0-325 | $315/day 1-5 | $188/day 21-56 | $6,700 | ||||||||
| Wellcare Fidelis Assist (HMO-POS) | $17.10 | $0 | $480 | $0/$30 | $30 | $0 | $0-20 | $0-390 | $25/$25 | $390 or 20% | $390/day 1-5 | $184/day 21-100 | $7,550 | ||||||||
| Wellcare Fidelis No Premium (HMO) | $0 | $0 | $0 | $10/$45 | $40 | $0 | $0-20 | $0-403 | $25/$25 | $403 or 20% | $403/day 1-5 | $184/day 21-100 | $7,550 | ||||||||
This Product is funded in part by The Administration for Community Living, New York State and Clinton County Office for the Aging NY Connects.
General information only - See plan Summary of Benefits and Evidence of Coverage for more details