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Trinity Health Plan New York Glory No RX (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Trinity Health Plan New York Glory No RX (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Trinity Health Plan New York Glory No RX (HMO) in 2025, please refer to our full plan details page.
Trinity Health Plan New York Glory No RX (HMO) is a HMO plan offered by Trinity Health Corporation available for enrollment in 2025 to people living in Select Counties in New York. This plan received an overall rating of 4 out of 5 stars in 2025.
It's important to know that Trinity Health Plan New York Glory No RX (HMO) is a Medicare Advantage (MA) Plan without drug coverage. That means that this plan covers medical services but doesn't cover prescription drugs. If you are looking for a plan with prescription drug coverage, please search for other MA and PDP plans offered in your area.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Trinity Health Plan New York Glory No RX (HMO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Trinity Health Plan New York Glory No RX (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $60.00. You must continue to pay paying your reduced Part B Premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
Drugs are not covered by this plan, so a prescription drug deductible is not applicable.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $4800.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
Prescription drugs are not covered by Trinity Health Plan New York Glory No RX (HMO).
Additional Benefits
The Trinity Health Plan New York Glory No RX (HMO) plan offers comprehensive coverage with a variety of benefits. The plan covers inpatient hospital stays with a $275 copay for the first five days, and no copay for days 6-90. It also includes coverage for outpatient services, such as primary care visits with no copay, specialist visits with a $25 copay, and emergency services with a $110 copay. Additional benefits include hearing, vision, and dental services, with varying copays and coinsurance depending on the specific service. The plan also covers ambulance services, with copays for ground and air transportation, and offers coverage for services like home health, skilled nursing facilities, and various therapies with copays or coinsurance. Other benefits include coverage for acupuncture, over-the-counter items, and meal benefits.
Inpatient Hospital See details
The Trinity Health Plan New York Glory No RX (HMO) plan covers inpatient hospital stays, with a $275 copay for days 1-5 and no copay for days 6-90. Additional days for inpatient hospital-acute are covered with no copay, while non-Medicare-covered stays and upgrades for inpatient hospital-acute are not covered.
Outpatient Services See details
Outpatient Services include coverage for outpatient hospital services with a copay between $0 and $250, observation services with no copay, ambulatory surgical center services with a $250 copay, outpatient substance abuse services with a $25 copay for individual and group sessions, and outpatient blood services with no copay.
Partial Hospitalization See details
Partial Hospitalization is covered with a $50 copay.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Trinity Health Plan New York Glory No RX (HMO) plan. Medicare-covered ground ambulance services have a $150 copay, and air ambulance services have a $200 copay, with no coinsurance for either. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation are covered. Emergency Services and Worldwide Emergency Coverage have a $110 copay, Urgently Needed Services has a $25 copay, and Worldwide Emergency Transportation has a $150-$200 copay; all have no coinsurance.
Primary Care See details
Primary Care Physician Services have no copay, while Chiropractic Services have a $20 copay, but routine care is not covered. Occupational Therapy Services have a $25 copay, with no coinsurance. Specialist visits have a $25 copay, while Mental Health and Psychiatric Services have a $25 copay for individual and group sessions. Physical Therapy and Speech-Language Pathology Services have a $25 copay, with no coinsurance. Additional Telehealth Benefits have a copay between $0 and $25. Opioid Treatment Program Services have a $25 copay.
Preventive Services See details
Preventive Services include Medicare-covered preventive services, annual physical exams with no copay, and additional preventive services, some of which have a copay. Other services like Health Education, In-Home Safety Assessment, and others are not covered.
Hearing Services See details
Hearing Services include coverage for hearing exams with a $25 copay. Routine hearing exams are covered with no copay, and fitting/evaluation for hearing aids are covered with no copay. Prescription hearing aids (all types) are covered with a copay between $399 and $699, while prescription hearing aids for the inner ear, outer ear, and over the ear are not covered. OTC hearing aids are not covered.
Vision Services See details
The Trinity Health Plan New York Glory No RX (HMO) plan covers vision services, including eye exams with a copay between $0 and $25, and eyewear with a $0 copay. Eyewear has a combined maximum benefit of $200 per year, and upgrades are not covered.
Dental Services See details
Dental Services include Medicare Dental Services with a $25 copay, and Other Dental Services with no copay. Restorative Services and Oral and Maxillofacial Surgery are covered with a 50% coinsurance, while Endodontics and Periodontics have a 70% coinsurance. Prosthodontics (removable and fixed), and Orthodontics are offered as optional supplemental benefits. Maxillofacial Prosthetics, Implant Services, and Orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the Trinity Health Plan New York Glory No RX (HMO) plan and require prior authorization. Medicare Part B Insulin Drugs have a $35 copay, while Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered by the Trinity Health Plan New York Glory No RX (HMO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment benefits include Durable Medical Equipment (DME) with 20% coinsurance and Prosthetics/Medical Supplies with 20% coinsurance. Diabetic Equipment is also covered, with 20% coinsurance for Medicare-covered diabetic supplies, and a copay for Medicare-covered therapeutic shoes or inserts.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for all diagnostic services and radiological services. Diagnostic Procedures/Tests have a $25 copay, while Lab Services have no copay. Diagnostic Radiological Services have a $175 copay, and Therapeutic Radiological Services have 20% coinsurance. Outpatient X-Ray Services have no copay.
Home Health Services See details
Home Health Services are covered by the Trinity Health Plan New York Glory No RX (HMO) with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are not covered by the Trinity Health Plan New York Glory No RX (HMO) plan. The plan also does not cover Intensive Cardiac Rehabilitation Services, Pulmonary Rehabilitation Services, or SET for PAD Services.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Trinity Health Plan New York Glory No RX (HMO) plan. For days 1-20 and 56-100, there is no copay, while days 21-55 have a $214 copay. Additional days beyond Medicare-covered for SNF and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Under "Other Services," acupuncture is covered with a $20 copay per visit, while over-the-counter items have no copay and a maximum benefit of $75 every three months. Meal benefits also have no copay. However, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered.
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