Plan ID: H3342-023

What You Need to Know:

  • Empire MediBlue Access (PPO) is a Medicare Advantage Health Maintenance Organization Local PPO plan.
  • It must provide all of the same hospital and medical benefits as Medicare Part A and Part B, however, costs may be different.
  • It has additional benefits not included in Medicare Part A and Part B, including prescription drug coverage.
  • The plan's monthly premium is $90, which does not include your monthly Medicare Part B premium.
  • The annual deductible for this health plan is $310 (Tier 1 and 2 excluded from the Deductible.).
  • The plan includes an out-of-pocket maximum of $6,200 per year (in-network).
  • Empire MediBlue Access (PPO) includes a Part D prescription drug plan for prescription medication coverage. The annual deductible is $310 (Tier 1 and 2 excluded from the Deductible.).
  • This plan's Part D Initial Coverage Limit is $47.

$90

Monthly Premium

Medicare Plan Features
Monthly Premium: $90.00
Part C Premium: $43.30
Monthly Premium: Part C Premium: Part D Drug Premium: Part D Supplemental Premium: Total Part D Premium: Drug Deductible: Tiers with No Deductible:
$90.00 $43.30 $46.70 $0 $46.70 $310.0 1.0
Gap Coverage: Yes
Benchmark: not below the regional benchmark
Type of Medicare Health: Enhanced Alternative
Health Plan Type: Local PPO
Similar Plan: H3342-023
Special Needs Type: NULL
Chronic Condition: NULL
Additional Gap Coverage: Yes, some additional gap coverage.
Maximum Out-of-Pocket Limit for Parts A & B (Moop): $6,200
Annual Deductible: $310 (Tier 1 and 2 excluded from the Deductible.)
Annual Initial Coverage Limit ICL: $4,130
Number of Members enrolled in this plan in Essex, New York: Plans Summary Star Rating: Customer Service Rating: Drug Cost Rating:
less than 10 members Insufficient data to rate this plan. Insufficient data to rate this plan. 4 out of 5 Stars.
Plan Offers Mail Order: Yes
Plan Health Benefits
Total # of Formulary Drugs: 3,708 drugs
Number of Members Enrolled in this Plan in Essex, New York: NULL
Number of Drugs Per Tier: NULL
Preferred Pharmacy Cost Sharing During Initial Coverage Phase: NULL
Special Needs Plan SNP Eligibility Requirement: NULL
Monthly Premium Split as Follows:
Part C Premium Part D Base Premium Part D Supplemental Premium Total Premium
$43.30 $46.70 $0.00 $90.00
Monthly Premium with Extra Help Low Income Subsidy:
LIS100 Subsidy Total Monthly Premium with LIS Parts CD LIS25 Subsidy Monthly PartD Premium with LIS LIS25 Subsidy Total Monthly Premium with LIS Parts CD LIS50 Monthly PartD Premium with LIS LIS50 Subsidy Total Monthly Premium with LIS Parts CD LIS75 Monthly PartD Premium with LIS LIS75 Subsidy Total Monthly Premium with LIS Parts CD
$47.70 $36.10 $79.40 $25.60 $68.90 $15.00 $58.30
Formulary Drug Details:
Tier 1 # of Drugs per Tier Tier 1 Preferred Pharmacy Cost Sharing (initial coverage phase) Tier 2 # of Drugs per Tier Tier 2 Preferred Pharmacy Cost Sharing (initial coverage phase) Tier 3 # of Drugs per Tier Tier 3 Preferred Pharmacy Cost Sharing (initial coverage phase) Tier 4 # of Drugs per Tier Tier 4 Preferred Pharmacy Cost Sharing (initial coverage phase) Tier 5 # of Drugs per Tier Tier 6 Preferred Pharmacy Cost Sharing (initial coverage phase)
306 $3.00 609 $10.00 942 $38.00 1061 $88.00 700 27%

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