A non-government entity
Village Care of New York, Inc.
Plan ID: H2168-2-0
Plan Summary PageVillageCareMAX Medicare Total Advantage Plan (HMO D-SNP)
2026 VillageCareMAX Medicare Total Advantage Plan (HMO D-SNP) H2168 — 002 — 0 is a Medicare Advantage plan with drug coverage. It has received a 3.5-out-of-5 star rating from CMS for 2026.
Learn more about VillageCareMAX Medicare Total Advantage Plan (HMO D-SNP) H2168 - 002 - 0, including the health and drug services it covers, by reading our easy-to-use guide. Or contact a licensed insurance agent for help now.
3.5 / 5 stars for 2026
$58.80 /mo
Monthly premium
$615.00
Drug deductible
$9250.00
Out-of-pocket maximum (Out-of-Network)
Enroll online
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Get personalized help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week!
About This Plan
The VillageCareMAX Medicare Total Advantage Plan (HMO D-SNP) offers comprehensive medical coverage featuring no copay for inpatient hospital stays, skilled nursing facility care, and home health services, though a deductible or prior authorization may be required. For outpatient services, primary care visits, emergency care, and diagnostic testing, members will generally pay no copay alongside a 20% coinsurance. Key supplemental benefits like preventive care, over-the-counter items, and select dental and hearing services are also covered with no copay and no coinsurance, including up to $625 per ear annually for prescription hearing aids. Vision care includes no copays for exams alongside a $350 annual eyewear allowance, while durable medical equipment and dialysis services require no copay and a 20% coinsurance.
The VillageCareMAX Medicare Total Advantage Plan (HMO D-SNP) features an annual prescription drug deductible of $615. For cost-effective medications, the plan offers no copay for Tier 6 select care drugs at standard pharmacies and through standard mail order. Additionally, Tier 1 preferred generics and Tier 2 generics are highly affordable, with standard pharmacy copays starting at just $2.00 and $5.00 for a one-month supply. For brand-name and specialty medications, costs are structured as coinsurance at standard pharmacies. Tier 3 preferred brands require a 23% coinsurance, while Tier 4 non-preferred drugs and Tier 5 specialty drugs both carry a 25% coinsurance. Standard mail order options are also available for three-month supplies on most tiers to help you conveniently manage your healthcare expenses.
Plan data sourced from the official CMS 2026 public benefit files. Reviewed by Walt Whitney. How we source and review plan information.
Plan Overview
2026 VillageCareMAX Medicare Total Advantage Plan (HMO D-SNP) H2168 — 002 — 0 is a HMO D-SNP offered in NYC boroughs, Nassau, Westchester, Putnam by Village Care of New York, Inc.. It has a monthly premium of $58.80.
Important:
2026 VillageCareMAX Medicare Total Advantage Plan (HMO D-SNP) H2168 — 002 — 0 is a Dual-Eligible Special Needs Type plan. You can only enroll in this plan if you meet specific criteria.
Premium Breakdown
Monthly plan premium
$58.80
Standard Part B premium
$202.90
Note:
The standard Medicare Part B premium for 2026 is $202.90. Your actual Part B premium may differ based on income (IRMAA), late enrollment penalties, Medicaid assistance, disability status, or other factors. Most people enrolled in Medicare Part B are required to pay this premium.
Special needs plan type
Yes
Out-of-pocket maximum (In-Network)
N/A
Out-of-pocket maximum (Out-of-Network)
$9250.00
Out-of-pocket maximum (Combined)
N/A
Conditions Covered
None
Plan Organization:
Village Care of New York, Inc.
Plan Type:
HMO D-SNP
Location:
NYC boroughs, Nassau, Westchester, Putnam
Drugs Covered:
Yes
Drug Formulary:
Pharmacies:
Doctors Link:
Deductibles
The amount you must pay each year before your plan starts to pay for covered services or drugs.
Drug deductible
$615
Note:
This plan does not charge an annual deductible for all drugs. The $615.00 annual deductible only applies to drugs in certain tiers.
Sign up for VillageCareMAX Medicare Total Advantage Plan (HMO D-SNP)
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
Drug Coverage
VillageCareMAX Medicare Total Advantage Plan (HMO D-SNP) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
Drug Benefit Type
Enhanced Alternative
Prescription drug deductible
$615.00
Part D Premium Reduction
This plan's premium may be reduced for you if you qualify for the low-income subsidy (also known as LIS or "Extra help"). The following is what you'll pay for with LIS.
Part D | LIS Full |
|---|---|
$58.80 | $58.80 |
Initial Coverage Phase
After you pay your $615.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $2100.00. Once you reach that amount, you will enter the next coverage phase.
Tier | Preferred Pharmacy | Standard Pharmacy | Preferred Mail | Standard Mail |
|---|---|---|---|---|
1. Preferred Generic | - | $2.00 copay | - | - |
2. Generic | - | $5.00 copay | - | - |
3. Preferred Brand | - | 23% coinsurance | - | - |
4. Non-Preferred Drug | - | 25% coinsurance | - | - |
5. Specialty Tier | - | 25% coinsurance | - | - |
6. Select Care Drugs | - | $0.00 copay | - | - |
Catastrophic Coverage Phase
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2100.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit.
Additional Benefits
VillageCareMAX Medicare Total Advantage Plan (HMO D-SNP) also provides the following benefits.
Inpatient Hospital
Inpatient Hospital benefits are covered.
Inpatient Hospital-Acute
Inpatient Hospital-Acute benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Do you charge the Medicare-defined cost share for tier 1?
Yes
Periodicity
Original Medicare
Additional Days for Inpatient Hospital-Acute
Not covered.
Non-Medicare-covered Stay for Inpatient Hospital-Acute
Not covered.
Upgrades for Inpatient Hospital-Acute
Not covered.
Inpatient Hospital Psychiatric
Inpatient Hospital Psychiatric benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Do you charge the Medicare-defined cost share for tier 1?
Yes
Periodicity
Original Medicare
Additional Days for Inpatient Hospital Psychiatric
Not covered.
Non-Medicare-covered Stay for Inpatient Hospital Psychiatric
Not covered.
Outpatient Services
Outpatient Services benefits are covered.
All Outpatient Hospital Services
All Outpatient Hospital Services benefits are covered.
Cost Sharing:
More Details:
Which Services have a Coinsurance
Medicare-covered Outpatient Hospital Services, Medicare-covered Observation Services
Outpatient Hospital Services
Outpatient Hospital Services benefits are covered. Prior Authorization is required.
Cost Sharing:
Observation Services
Observation Services benefits are covered.
Cost Sharing:
Ambulatory Surgical Center (ASC) Services
Ambulatory Surgical Center (ASC) Services benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Outpatient Substance Abuse Services
Outpatient Substance Abuse Services benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Which Outpatient Substance Abuse services have a Coinsurance
Medicare-covered Individual Sessions, Medicare-covered Group Sessions
Individual Sessions for Outpatient Substance Abuse
Individual Sessions for Outpatient Substance Abuse benefits are covered.
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Group Sessions for Outpatient Substance Abuse
Group Sessions for Outpatient Substance Abuse benefits are covered.
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Outpatient Blood Services
Outpatient Blood Services benefits are covered.
Cost Sharing:
More Details:
Is there a deductible?
No
Do you waive the deductible for the first three pints of blood?
No
Partial Hospitalization
Partial Hospitalization benefits are covered.
Partial Hospitalization
Partial Hospitalization benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Coinsurance percent
20
Partial Hospitalization
Partial Hospitalization benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Coinsurance percent
20
Ambulance and Transportation Services
Ambulance and Transportation Services benefits are covered.
All Ambulance Services
All Ambulance Services benefits are covered. Prior Authorization is required.
More Details:
Is there a coinsurance?
Yes
Which Services have a Coinsurance
Medicare-covered Ground Ambulance Services, Medicare-covered Air Ambulance Services
Is this Coinsurance waived if admitted to hospital?
No
Is there a copayment ?
No
Ground Ambulance Services
Ground Ambulance Services benefits are covered.
Cost Sharing:
Air Ambulance Services
Air Ambulance Services benefits are covered.
Cost Sharing:
Transportation Services
Transportation Services benefits are covered.
Transportation Services - Plan Approved Health-related Location
Not covered.
Transportation Services - Any Health-related Location
Not covered.
Emergency Services
Emergency Services benefits are covered.
Emergency Services
Emergency Services benefits are covered.
Cost Sharing:
More Details:
Is there a coinsurance?
Yes
Is the coinsurance for Medicare-covered benefits waived if admitted to hospital?
Yes
Select either days or hours within which admission must occur for waiver
Days
Enter number of days or hours
1
Is there a copayment?
No
Maximum per visit amount
115.00
Does the cost sharing count towards any plan-level deductible?
Yes
Urgently Needed Services
Urgently Needed Services benefits are covered.
Cost Sharing:
More Details:
Is there a coinsurance?
Yes
Is the coinsurance for Medicare-covered benefits waived if admitted to hospital?
No
Is there a copayment?
No
Maximum per visit amount
40.00
Does the cost sharing count towards any plan-level deductible?
Yes
Worldwide Emergency Services
Worldwide Emergency Services benefits are covered – including services not usually covered by Medicare plans.
More Details:
Is there a maximum plan benefit coverage?
Yes
Is the maximum plan benefit coverage amount unlimited?
No
Maximum amount
50000.00
Worldwide Emergency Coverage
Worldwide Emergency Coverage benefits are covered.
Worldwide Urgent Coverage
Worldwide Urgent Coverage benefits are covered.
Worldwide Emergency Transportation
Worldwide Emergency Transportation benefits are covered.
Primary Care
Primary Care benefits are covered.
Primary Care Physician Services
Primary Care Physician Services benefits are covered.
Cost Sharing:
Chiropractic Services
Chiropractic Services benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Which Chiropractic Services have a Coinsurance
Routine Care
Routine Chiropractic Care
Not covered.
Occupational Therapy Services
Occupational Therapy Services benefits are covered. Prior Authorization is required.
Cost Sharing:
Physician Specialist Services
Physician Specialist Services benefits are covered.
Cost Sharing:
Mental Health Specialty Services
Mental Health Specialty Services benefits are covered.
Cost Sharing:
More Details:
Which Mental Health Specialty Services have a Coinsurance
Medicare-covered Individual Sessions, Medicare-covered Group Sessions
Individual Sessions for Mental Health Specialty Services
Individual Sessions for Mental Health Specialty Services benefits are covered.
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Group Sessions for Mental Health Specialty Services
Group Sessions for Mental Health Specialty Services benefits are covered.
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Podiatry Services
Not covered.
Other Health Care Professional
Other Health Care Professional benefits are covered.
Cost Sharing:
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Psychiatric Services
Psychiatric Services benefits are covered.
Cost Sharing:
More Details:
Which Psychiatric Services have a Coinsurance
Medicare-covered Individual Sessions, Medicare-covered Group Sessions
Individual Sessions for Psychiatric Services
Individual Sessions for Psychiatric Services benefits are covered.
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Group Sessions for Psychiatric Services
Group Sessions for Psychiatric Services benefits are covered.
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Physical Therapy and Speech-Language Pathology Services
Physical Therapy and Speech-Language Pathology Services benefits are covered. Prior Authorization is required.
Cost Sharing:
Additional Telehealth Benefits
Additional Telehealth Benefits benefits are covered – including services not usually covered by Medicare plans. Prior Authorization is required.
Cost Sharing:
More Details:
Medicare-covered benefits that may have Additional Telehealth Benefits available
2: Skilled Nursing Facility (SNF), 3-1: Cardiac Rehabilitation Services, 3-2: Intensive Cardiac Rehabilitation Services, 3-3: Pulmonary Rehabilitation Services, 3-4: SET for PAD Services, 5a: Partial Hospitalization Program, 5b: Intensive Outpatient Program Services, 6: Home Health Services, 7a: Primary Care Physician Services, 7b: Chiropractic Services, 7c: Occupational Therapy Services, 7d: Physician Specialist Services, 7e1: Individual Sessions for Mental Health Specialty Services, 7e2: Group Sessions for Mental Health Specialty Services, 7f: Podiatry Services, 7g: Other Health Care Professional, 7h1: Individual Sessions for Psychiatric Services, 7h2: Group Sessions for Psychiatric Services, 7i: Physical Therapy and Speech-Language Pathology Services, 7k: Opioid Treatment Program Services, 8a2: Lab Services, 9a1: Outpatient Hospital Services, 9c1: Individual Sessions for Outpatient Substance Abuse, 9c2: Group Sessions for Outpatient Substance Abuse, 14d: Kidney Disease Education Services, 14e1: Glaucoma Screening, 14e2: Diabetes Self-Management Training, 17a: Eye Exams, 18a: Hearing Exams
Opioid Treatment Program Services
Opioid Treatment Program Services benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Preventive Services
Preventive Services benefits are covered.
Medicare-covered Zero Dollar Preventive Services
Medicare-covered Zero Dollar Preventive Services benefits are covered.
Annual Physical Exam
Not covered.
Additional Preventive Services
Additional Preventive Services benefits are covered – including services not usually covered by Medicare plans.
More Details:
Is there a service-specific Maximum Plan Benefit Coverage amount for Other Defined Supplemental Benefits?
No
Health Education
Not covered.
In-Home Safety Assessment
Not covered.
Personal Emergency Response System (PERS)
Not covered.
Medical Nutrition Therapy (MNT)
Not covered.
Post discharge In-Home Medication Reconciliation
Not covered.
Re-admission Prevention
Not covered.
Wigs for Hair Loss Related to Chemotherapy
Not covered.
Weight Management Programs
Not covered.
Alternative Therapies
Not covered.
Therapeutic Massage
Not covered.
Adult Day Health Services
Not covered.
Nutritional/Dietary Benefit
Not covered.
Home-Based Palliative Care
Not covered.
In-Home Support Services
Not covered.
Support for Caregivers of Enrollees
Not covered.
Additional Sessions of Smoking and Tobacco Cessation Counseling
Not covered.
Fitness Benefit
Fitness Benefit benefits are covered.
More Details:
Type of Fitness Benefit offered
Physical Fitness, Memory Fitness
Enhanced Disease Management
Not covered.
Telemonitoring Services
Not covered.
Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline)
Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline) benefits are covered.
Home and Bathroom Safety Devices and Modifications
Not covered.
Counseling Services
Not covered.
Kidney Disease Education Services
Kidney Disease Education Services benefits are covered.
Other Preventive Services
Other Preventive Services benefits are covered.
More Details:
Is a referral required for any Services?
No
Glaucoma Screening
Glaucoma Screening benefits are covered.
Diabetes Self-Management Training
Diabetes Self-Management Training benefits are covered.
Digital Rectal Exams
Digital Rectal Exams benefits are covered.
EKG following Welcome Visit
EKG following Welcome Visit benefits are covered.
Hearing Services
Hearing Services benefits are covered.
Hearing Exams
Hearing Exams benefits are covered.
Cost Sharing:
More Details:
Which Hearing Exam Benefits have a Coinsurance
Routine Hearing Exams
Minimum coinsurance
20
Is there a deductible?
No
Routine Hearing Exams
Not covered.
Fitting/Evaluation for Hearing Aid
Not covered.
Prescription Hearing Aids
Prescription Hearing Aids benefits are covered – including services not usually covered by Medicare plans. Prior Authorization is required.
More Details:
Service maximum plan benefit coverage
Yes
Select Coverage
Per ear
Maximum plan benefit coverage type
Plan-specified amount per period
Maximum amount
625.00
Periodicity
Every year
Prescription Hearing Aids (all types)
Prescription Hearing Aids (all types) benefits are covered.
More Details:
Is this benefit unlimited?
Yes
Prescription Hearing Aids - Inner Ear
Not covered.
Prescription Hearing Aids - Outer Ear
Not covered.
Prescription Hearing Aids - Over the Ear
Not covered.
OTC Hearing Aids
OTC Hearing Aids benefits are covered.
More Details:
Is this benefit unlimited?
Yes
Is there a maximum plan benefit coverage?
No
Vision Services
Vision Services benefits are covered.
Eye Exams
Eye Exams benefits are covered – including services not usually covered by Medicare plans.
Cost Sharing:
More Details:
Which Eye Exams have a Coinsurance
Routine Eye Exams
Is there a deductible?
No
Is there a deductible?
No
Is there a maximum plan benefit coverage?
No
Routine Eye Exams
Routine Eye Exams benefits are covered.
More Details:
Is this benefit unlimited?
No, indicate number
Number of visits
1
Periodicity
Every year
Eyewear
Eyewear benefits are covered – including services not usually covered by Medicare plans. Prior Authorization is required.
Cost Sharing:
More Details:
Which Eyewear Benefits have a Coinsurance
Contact lenses
Is there a deductible?
No
Is there a deductible?
No
Is there a maximum plan benefit coverage?
Yes
Maximum plan benefit coverage type
Plan-specified amount per period
Do you offer a Combined Max Plan Benefit Coverage Amount for all Eyewear?
Yes
Combined maximum amount
350.00
Periodicity
Every year
Contact Lenses
Contact Lenses benefits are covered.
More Details:
Is this benefit unlimited?
Yes
Eyeglasses (lenses and frames)
Eyeglasses (lenses and frames) benefits are covered.
More Details:
Is this benefit unlimited?
No, indicate number
Number of pairs
1
Periodicity
Every year
Eyeglass lenses
Eyeglass lenses benefits are covered.
More Details:
Is this benefit unlimited?
No, indicate number
Number of pairs
1
Periodicity
Every year
Eyeglass frames
Eyeglass frames benefits are covered.
More Details:
Is this benefit unlimited?
No, indicate number
Number of eyeglass frames
1
Periodicity
Every year
Upgrades
Not covered.
Dental Services
Dental Services benefits are covered.
Medicare Dental Services
Medicare Dental Services benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Coinsurance percentage
20
Other Dental Services
Other Dental Services benefits are covered.
More Details:
Is there a maximum plan benefit coverage?
No
Oral Exams
Oral Exams benefits are covered.
More Details:
Is this benefit unlimited?
No
Number of visits
3
Periodicity
Other, Describe
Description
Periodic Oral evaluation 2 every 6 monthsLimited oral evaluation 2 every 12 months.Comprehensive oral evaluation 1 per provider in a lifetime.Oral evaluation, problem focused 3 every 12 months, by report.
Dental X-Rays
Dental X-Rays benefits are covered.
More Details:
Is this benefit unlimited?
No
Number of X-Rays
1
Periodicity
Other, Describe
Description
Intraoral, complete series or panoramic x-ray 1 every 36 months. Intraoral, periapical - 3 every 6 months; Intraoral, periapical 6 times every 12 months. Sialography - 2 every week
Other Diagnostic Dental Services
Other Diagnostic Dental Services benefits are covered. Prior Authorization is required.
More Details:
Is this benefit unlimited?
No
Number of visits
1
Periodicity
Other, Describe
Description
Cone beam CT capture and interpretation - 1 every 60 months.
Prophylaxis (Cleaning)
Prophylaxis (Cleaning) benefits are covered.
More Details:
Is this benefit unlimited?
No
Number of visits
1
Periodicity
Every six months
Fluoride Treatment
Fluoride Treatment benefits are covered.
More Details:
Is this benefit unlimited?
No
Number of visits
1
Periodicity
Other, Describe
Description
Covered up to age of 20
Other Preventive Dental Services
Other Preventive Dental Services benefits are covered.
More Details:
Is this benefit unlimited?
No
Number of visits
1
Periodicity
Other, Describe
Description
Tobacco counseling, control prevention oral disease - 1 every 6 months.Unspecified preventive procedure, by report.
Orthodontic Services
Orthodontic Services benefits are covered.
More Details:
Is there a maximum plan benefit coverage?
No
Restorative Services
Restorative Services benefits are covered. Prior Authorization is required.
More Details:
Is this benefit unlimited?
No
Number of visits
1
Periodicity
Other, Describe
Description
Amalgam / Resin based composite filling - 1 per tooth, per surface - every 24 months.Crown services - 1 per tooth - every 60 months.
Adjunctive General Services
Adjunctive General Services benefits are covered. Prior Authorization is required.
More Details:
Is this benefit unlimited?
No
Number of visits
1
Periodicity
Other, Describe
Description
Palliative emergency treatment 2 every 12 months (Not reimbursable in addition to other therapeutic services performedat the same visit or in conjunction with initial or periodic oral examinations). Deep sedation maximum of 60 minutes or 4 units.
Endodontics
Endodontics benefits are covered. Prior Authorization and a doctor referral are required.
More Details:
Is this benefit unlimited?
No
Number of visits
1
Periodicity
Other, Describe
Description
Endodontic Services - 1 per tooth, per lifetime.
Periodontics
Periodontics benefits are covered. Prior Authorization and a doctor referral are required.
More Details:
Is this benefit unlimited?
No
Number of visits
1
Periodicity
Other, Describe
Description
Gingivectomy or gingivopIasty - 1 every 12 months, per quad by report. Crown lengthening - 1 per tooth per ifetime.Periodontal scaling and root planing - 1 every 24 months per site/quad.Periodontal maintenance once every 6 months.
Prosthodontics, removable
Prosthodontics, removable benefits are covered. Prior Authorization is required.
More Details:
Is this benefit unlimited?
No
Number of visits
1
Periodicity
Other, Describe
Description
Complete /Partial denture - 1 every 96 months, per arch.Denture Adjustment - 4 every 12 months, per arch (Not covered within 6 months of placement).
Maxillofacial Prosthetics
Not covered.
Implant Services
Implant Services benefits are covered. Prior Authorization is required.
More Details:
Is this benefit unlimited?
No
Number of visits
1
Periodicity
Other, Describe
Description
Surgical placement of implant - 1 per tooth, in a lifetime.Abutment services - 1 per tooth, every 96 months.Debridement services - 1 per tooth, every 24 months.
Prosthodontics, fixed
Prosthodontics, fixed benefits are covered. Prior Authorization is required.
More Details:
Is this benefit unlimited?
No
Number of visits
1
Periodicity
Other, Describe
Description
1 every 60 months, per tooth
Oral and Maxillofacial Surgery
Oral and Maxillofacial Surgery benefits are covered. Prior Authorization and a doctor referral are required.
More Details:
Is this benefit unlimited?
No
Number of visits
1
Periodicity
Other, Describe
Description
Extraction of erupted or impacted tooth 1 per tooth, in a lifetime. Alveoloplasty once per site/quad in a lifetime. Other Oral and Maxillofacial Surgery by report.
Orthodontics
Not covered.
Home Infusion bundled Services
Home Infusion bundled Services benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Which Medicare Part B Rx Drugs have a Coinsurance
Medicare Part B Chemotherapy/Radiation Drugs, Other Medicare Part B Drugs
Does this plan have a service specific maximum enrollee out-of-pocket cost (MOOP)?
No
Does the plan offer step therapy?
No
Insulin
Insulin benefits are covered.
Medicare Part B Insulin Drugs
Medicare Part B Insulin Drugs benefits are covered.
Cost Sharing:
More Details:
Does the Part B drugs - Insulin cost sharing count towards any plan-level deductible?
Yes
Medicare Part B Chemotherapy/Radiation Drugs
Medicare Part B Chemotherapy/Radiation Drugs benefits are covered.
More Details:
Minimum coinsurance
0
Maximum coinsurance
20
Other Medicare Part B Drugs
Other Medicare Part B Drugs benefits are covered.
More Details:
Minimum coinsurance
0
Maximum coinsurance
20
Dialysis Services
Dialysis Services benefits are covered.
Cost Sharing:
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Medical Equipment
Medical Equipment benefits are covered.
Durable Medical Equipment (DME)
Durable Medical Equipment (DME) benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Are there preferred vendors/manufacturers for Durable Medical Equipment (DME)?
No
Prosthetics/Medical Supplies - Non-Medicare benefit
Prosthetics/Medical Supplies - Non-Medicare benefit benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Which Prosthetics/Medical Supplies have a Coinsurance
Medicare-covered Prosthetic Devices, Medicare-covered Medical Supplies
Prosthetic Devices
Prosthetic Devices benefits are covered.
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Medical Supplies
Medical Supplies benefits are covered.
Cost Sharing:
Diabetic Equipment
Diabetic Equipment benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Which Diabetic Supplies and Services have a Coinsurance
Medicare-covered Diabetic Supplies, Medicare-covered Diabetic Therapeutic Shoes or Inserts
Do you limit Diabetic supplies and services to those from specified manufacturers
Yes
Diabetic Supplies
Diabetic Supplies benefits are covered.
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Diabetic Therapeutic Shoes/Inserts
Diabetic Therapeutic Shoes/Inserts benefits are covered.
More Details:
Minimum coinsurance
20
Maximum coinsurance
20
Diagnostic and Radiological Services
Diagnostic and Radiological Services benefits are covered.
All Diagnostic services
All Diagnostic services benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Which Outpatient Diagnostic Procedures/Tests/Lab Services have a Coinsurance
Medicare-covered Diagnostic Procedures/Tests, Medicare-covered Lab Services
Is there a copayment?
No
Diagnostic Procedures/Tests
Diagnostic Procedures/Tests benefits are covered.
Cost Sharing:
More Details:
Minimum coinsurance
20
Lab Services
Lab Services benefits are covered.
Cost Sharing:
More Details:
Minimum coinsurance
20
All Radiological Services
All Radiological Services benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Which Outpatient Diagnostic/Therapeutic Radiological Services have a Coinsurance
Medicare-covered Diagnostic Radiological Services, Medicare-covered Therapeutic Radiological Services, Medicare-covered X-Ray Services
Is there a copayment?
No
Diagnostic Radiological Services
Diagnostic Radiological Services benefits are covered.
Cost Sharing:
More Details:
Minimum coinsurance
20
Therapeutic Radiological Services
Therapeutic Radiological Services benefits are covered.
Cost Sharing:
More Details:
Minimum coinsurance
20
Outpatient X-Ray Services
Outpatient X-Ray Services benefits are covered.
Cost Sharing:
More Details:
Minimum coinsurance
20
Home Health Services
Home Health Services benefits are covered. Prior Authorization is required.
Cardiac Rehabilitation Services
Cardiac Rehabilitation Services benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Which Cardiac and Pulmonary Rehabilitation Services have a Coinsurance
Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, Additional Cardiac Rehabilitation Services
Cardiac Rehabilitation Services
Not covered.
Intensive Cardiac Rehabilitation Services
Not covered.
Pulmonary Rehabilitation Services
Not covered.
SET for PAD Services
Not covered.
Skilled Nursing Facility (SNF)
Skilled Nursing Facility (SNF) benefits are covered. Prior Authorization is required.
Cost Sharing:
More Details:
Does the plan provide Skilled Nursing Facility Services as a supplemental benefit under Part C?
Yes
Do you allow less than 3 day inpatient hospital stay prior to SNF admission?
Yes
Days
Zero
Do you charge the Medicare-defined cost share for tier 1?
Yes
Periodicity
Original Medicare
Additional Days beyond Medicare-covered for Skilled Nursing Facility (SNF)
Not covered.
Other Services
Other Services benefits are covered.
Acupuncture
Acupuncture benefits are covered – including services not usually covered by Medicare plans. Prior Authorization is required.
More Details:
Is this benefit unlimited for Number of Treatments?
No
Limit for Number of Treatments
40
Periodicity
Every year
Is there a maximum plan benefit coverage amount?
Yes
Maximum plan benefit coverage amount
80.00
Periodicity
Other, Describe
Description
Max plan benefit coverage amount of $80 per visit. Max of 5 visits per calendar month, up to a max of 40 visits per year.
Over-the-Counter (OTC) Items
Over-the-Counter (OTC) Items benefits are covered.
More Details:
Does the plan provide Over-The-Counter (OTC) Items as a supplemental benefit under Part C?
Yes
Is there a maximum plan benefit coverage amount?
No
Plan offers Nicotine Replacement Therapy (NRT) as a Part C OTC benefit?
Yes
The Nicotine Replacement Therapy (NRT) being offered does not duplicate any Part D OTC or formulary drugs.
The Nicotine Replacement Therapy (NRT) being offered does not duplicate any Part D OTC or formulary drugs.
Plan offers Naloxone coverage as a Part C OTC benefit?
No
Does this cover all of the drugs on the CMS OTC list which may be found in Chapter 4 of the Medicare Managed Care Manual
Yes
Indicate mode of delivery for the OTC Items
Claims Processing, Reimbursement
Meal Benefit
Not covered.
Dual Eligible SNPs with Highly Integrated Services
Not covered.
Plan Providers
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross Blue Shield, Anthem Blue Cross, Aspire Health Plan, Capital Blue Cross, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, GlobalHealth, Health Care Service Corporation, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Premera Blue Cross, Medica Central Health Plan, SCAN Health Plan, Baylor Scott & White Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.
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* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
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