Plan Summary

Insurance Type
Medicare Advantage Plan (Part C w/ RX)
Insurance Provider
CMS Rating
Plan Type
Annual Drug Deductible

What To Know About This Plan

  • This plan has health and drug coverage

Plan Details

Costs and Other Important Information

Plan Year:
Optional Supplemental Benefits?
Choice of Doctors?
Plan Doctors Only
Prescription Drugs Covered?
Out-Of-Pocket Spending Limit
$4,100 In-Network
Other Deductibles?
In Network: No. Out of Network: No
Health Plan Deductible
Monthly Drug Plan Premium
Monthly Health Plan Premium


In Network
Out of Network
Doctor Office Visits
$15 maximum per visit
Not Applicable
Specialist Office Visit
$40 maximum per visit
Not Applicable
Outpatient Services
$150 maximum per visit
Not Applicable
Emergency Care
$65 maximum per visit
Not Applicable
Ambulance Services
$150 maximum
Not Applicable
Kidney Disease and Conditions
Not Applicable
Home Health Care
Not Applicable
Durable Medical Equipment
20% maximum per item
Not Applicable
Inpatient Hospital Care
$475 copay
Not Applicable
Skilled Nursing Facility (SNF)
Days 1-100: $50 copay per day
Not Applicable
Inpatient Mental Health Care
$475 copay
Not Applicable

Cost Sharing Information

Prescription Drug Copay/Coninsurance Details - Initial Coverage Limit

30 Day SupplyPreferred Retail PharmaciesNon-Preferred Retail PharmaciesMail-Order Pharmacies
Tier 1: Preferred Generic$3 copay$3 copayNot offered
Tier 2: Non-Preferred Generic$40 copay$40 copayNot offered
Tier 3: Preferred Brand Name$90 copay$90 copayNot offered
Tier 4: Non-Preferred Brand Name33% coinsurance33% coinsuranceNot offered
Tier 5: Specialty Tier
90 Day SupplyPreferred Retail PharmaciesNon-Preferred Retail PharmaciesMail-Order Pharmacies
Tier 1: Preferred Generic$7.5 copay$7.5 copay$7.5 copay
Tier 2: Non-Preferred Generic$100 copay$100 copay$100 copay
Tier 3: Preferred Brand Name$225 copay$225 copay$225 copay
Tier 4: Non-Preferred Brand Name33% coinsurance33% coinsurance33% coinsurance
Tier 5: Specialty Tier

CMS Ratings

Staying healthy - screenings, tests and vaccines

Breast cancer screening
Not Rated
Colorectal cancer screening
Cholesterol screening for patients with heart disease
Glaucoma testing
Annual flu vaccine
Pneumonia vaccine
Improving or maintaining physical health
Improving or maintaining mental health
Monitoring physical ability
Access to primary care doctor visits
Adult BMI assessment

Managing Chronic Conditions

Care for older adults – medication review
Not Rated
Care for older adults – functional status assessment
Not Rated
Care for older adults – Pain screening
Not Rated
Osteoporosis management in women who had a fracture
Diabetes care – eye exam
Diabetes care – kidney disease monitoring
Diabetes care – blood sugar controlled
Diabetes care – cholesterol controlled
Controlling blood pressure
Rheumatoid arthritis management
Improving bladder control
Reducing the risk of falling
Plan all-cause readmissions

Ratings of Plan Responsiveness and Care

Getting needed care
Getting appointments and care quickly
Customer service
Overall rating of health care quality
Overall rating of plan

Member Complaints, Problems Getting Services, and Choosing to Leave the Plan

Complaints about the health plan
Beneficiary access and performance problems
Members choosing to leave the plan
Plan makes timely decision about appeals
Reviewing appeals decisions
Call center – foreign language interpreter and TTY/TDD availability

Physician Finder

Physicians that accept Medicare Blue Choice Value (HMO) for New York


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Community Q&A

Do you have questions about this plan?

Get answers from the HealthPocket community.
2 question | 1 answer
Is Clozaril covered? or Clozapine, the generic form?
Asked on 10/24/2013 by Anonymous

1 answer

Know the Answer? Answer this Question
A: You can find out your total estimated annual cost of a plan with the above drugs by entering them in the quote page (click on 'Add Medications' button under 'My Medications'). However, you cannot tell if a specific drug is coverage.
Answered on 11/4/2013 by Duncan
what is the charge for xrays
Asked on 10/7/2013 by Anonymous

1 answer

Know the Answer? Answer this Question
A: For specific plan coverage questions, you should contact the carrier directly.
Answered on 10/9/2013 by Duncan

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