Medicare & Long-Term Care Plans 65 Plus Plan (HMO)

This Medicare Advantage plan offers additional benefits on top of Original Medicare, such as dental, vision, hearing, and acupuncture. It is designed for people who don’t qualify for programs that help pay Medicare costs, like Extra Help or Medicaid.

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Plan highlights Costs and plan details Prescription drug benefits Additional benefits Plan documents Helpful resources Frequently asked questions

Plan highlights

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$25/month OTC Plus card that you can use for over-the-counter (OTC) items, personal emergency response systems (PERS), exercise equipment, activity trackers, and more.

Comprehensive dental coverage for $0 ($1,250 annual benefit max)

8 no-cost, non-emergent one-way trips per year to in-network doctors for covered services

SilverSneakers® fitness program for $0

24/7 access to doctors by phone or video chat for $0

Routine vision and hearing exams, $150/year allowance for eyeglasses or contact lenses, and hearing aids for as low as $0

Costs and plan details

Premium
$0
Medical Deductible
$0
Eligible Age
65 or older (or under 65 with certain disabilities)
Eligible Service Areas
Reside within New York City’s five boroughs (The Bronx, Brooklyn, Manhattan, Queens, and Staten Island), and Nassau county.
Other Eligibility Requirements
Qualify for Medicare Part A.
Enroll and continue to pay for Medicare Part B.
Maximum Out-of-Pocket
$9,250
OTC Plus Card
$25 per month allowance for over-the-counter (OTC) non-prescription drugs, health-related items, exercise equipment, activity trackers, and personal emergency response systems (PERS)
Annual Supplemental Physical Exam
$0 copay
Dental
$0 copay for covered preventive and comprehensive dental services; up to $1,250 maximum coverage per year1
Vision
$0 copay for routine vision exams, including refraction
$150 eyewear allowance every year for contact lenses or one pair of glasses (lenses and frames)
Hearing
$0 copay for one routine hearing exam per year
$0‒$1,475 copay per hearing aid
Plan covers one hearing aid per ear, per year
Acupuncture
$0 copay for up to 20 visits per year for chronic lower back pain and 12 additional visits per year for any condition, including chronic lower back pain
Telemedicine
$0 copay for telemedicine services with network providers, or through Teladoc Health®
Nurse Help Line Access
$0 copay
Rides to Your Healthcare Providers
$0 copay for transportation to/from your doctor for covered services—up to 8 one-way trips per year
Meal Delivery
$0 copay for up to 84 meals delivered to your home for up to 28 days following a discharge from hospital to home or from a skilled nursing facility to home with a stay greater than two days, if recommended by a provider.
Your Annual Checkup
$0 copay
Primary Care Provider (PCP) Visit
$0 copay
Specialist Visit
$35 copay
Outpatient Lab Tests (including COVID-19)
$0 copay
Retail Health Clinic
$15 copay
Urgent Care
$40 copay
Emergency Room
$115 copay
Ambulance
$315 copay
Ambulatory Surgery Visit
$0 copay for diagnostic colonoscopies and esophageal endoscopies
$200 copay for all other ambulatory surgery center services
Outpatient Facility
0% for diagnostic colonoscopies and esophageal endoscopies
20% coinsurance for all other outpatient hospital services
Inpatient Hospital Stay
$489 copay per day for up to 5 days;
$0 copay (days 6–999)
Skilled Nursing Facility
$0 copay per day for up to 20 days;
$218 copay per day for days 21‒100

Prescription drug benefits

We want to help you get the most out of your Part D prescription drug benefits. Please refer to the formulary below to see which medications fall under each tier. Healthfirst may add drugs to or remove them from its Medicare formulary during the year. We will notify you when we make the change. Please note that Tier 5 Specialty Drugs are only available for a 30-day supply.

Depending on your level of Extra Help, these costs may not apply:

Deductible (Applies to Tiers 3–5)
$615
Preferred Generic Drugs (Tier 1)
$0 copay, no deductible
Generic Drugs (Tier 2)
$3 copay for 30-day or 90-day supply, no deductible
Preferred Brand and Non-Preferred Generic Drugs (Tier 3)
21% of cost after deductible
Non-Preferred Drugs (Tier 4)
25% of cost after deductible
Specialty Drugs (Tier 5)
25% of cost after deductible
Insulins
Maximum of $35 copay for 30-day supply, no deductible
Quantity limits (QL)

For safety and cost reasons, plans may limit the amount of a prescription drug they cover over a certain period of time. For example, most people who are prescribed heartburn medication take one tablet a day for four weeks. Therefore, a plan may cover only an initial 30-day supply of the heartburn medication. The quantity allowed is listed after the QL symbol in your formulary and may be read as “units per days’ supply.” If your prescription for any of these medications exceeds the maximum quantity listed, you and your doctor will need to request a formulary exception.

Additional benefits

24/7 access to telemedicine with Teladoc Health®

Talk to a doctor any time—for a $0 copay. Visit with board-certified doctors through video chat or phone for prescriptions, treatment of non-emergency health issues, and more. Access to dermatologists is also available.

Telemedicine (Teladoc Health) isn’t a replacement for your primary care provider (PCP). Your PCP should always be your first choice for care (both in-person and virtual visits).

24/7 access to care with the Nurse Help Line

Talk to a nurse any time—for a $0 copay. Get wellness advice and help finding a doctor.

Telemedicine (Teladoc Health) and the Nurse Help Line are not replacements for your primary care provider (PCP). Your PCP should always be your first choice for care (both in-person and virtual visits).

Urgent care center network

Get the care you need when you need it at an urgent care center in our network – no appointment needed. Urgent care centers offer convenient late-night and weekend hours. Visit an in-network urgent care center to get help with non-emergency health issues like earache, upset stomach, and sprains; for wounds that need stitches; and more.

SilverSneakers®

Get access to live classes and workshops taught by instructors trained in senior fitness, hundreds of workout videos in the SilverSneakers On-Demand™ online library, online fitness and nutrition tips, and their mobile app with digital workout programs.

Healthfirst Medication Therapy Management program

The Healthfirst Medication Therapy Management (MTM) program is an in-depth, one-on-one review of all your medications (prescription drugs, over-the-counter nonprescription drugs, and herbal and nutritional supplements). The goal is to help you get the most from your medications. Services include:

  • Phone consultation with a licensed pharmacist to complete a Comprehensive Medication Review (CMR). The call will take about 30 to 60 minutes, and the pharmacist will answer any questions you may have. (A CMR is offered once each year, if you qualify.)
  • Medication Action Plan (MAP)
  • Medication recommendations may be sent to your provider from the MTM pharmacist, also known as Targeted Medication Review (TMR)
  • A list that shows all your medications

Plan documents

General plan information

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Prescription drug information

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  • List of Drugs Requiring Prior Authorization
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  • List of Drugs Requiring Step Therapy
See all plan documents Find member forms

Frequently asked questions

A Health Maintenance Organization (HMO) is a type of health insurance plan that gives you access to care from a network of doctors and hospitals in a specific service area. HMOs usually don't cover out-of-network care, except in emergencies, and may require you to live or work in its service area to be eligible for coverage. These plans often provide integrated care and focus on prevention and wellness. (Source: HealthCare.gov)

Healthfirst 65 Plus Plan provides coverage for preventive and dental services, including dentures, crowns, root canals, and extractions.

Dental services must be medically necessary; limitations and exclusions apply.

There are many ways Healthfirst members can save on their healthcare costs, including:

  • Generic prescription drugs
  • No-cost delivery options for prescriptions (mail and home delivery)
  • Medicare Savings Program
  • Elderly Pharmaceutical Insurance Coverage (EPIC) program and Extra Help
  • Healthfirst Pharmacy Team (exclusively for Healthfirst Medicare Advantage plan members)
  • Help from community resources
  • And more

Learn more about ways to save on Medicare costs. If you qualify for Medicare and Medicaid, you can save even more on your healthcare costs!

You can get your prescriptions filled at any pharmacy in the Healthfirst network. Find a pharmacy that's convenient for you.

Want your medications delivered to you? Ask your pharmacy if they offer delivery service. If they do not, Caremark Mail Order will deliver to your mailbox.

Learn more about prescription drug benefits.

Generic drugs are approved by the Food and Drug Administration (FDA) to be just as safe and effective as brand-name drugs. They both have the same active ingredients, but generic drugs usually cost a lot less. This means you can save money on your prescriptions and still get the same benefits as you would from brand-name medication. Talk to your doctor about whether generic medications are right for you.

Disclaimers

1Dental services must be medically necessary; limitations and exclusions apply.

This information is not a complete description of benefits. Contact the plan for more information. Benefits, premiums, and/or copayments/coinsurance may change on January 1 of each year. The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

You must continue to pay your Medicare Part B premium.

Coverage is provided by Healthfirst Health Plan, Inc., which offers HMO plans that contract with the Federal Government. Enrollment in Healthfirst Medicare Plan depends on contract renewal.

Plans contain exclusions and limitations.

No out-of-pocket costs for entry-level hearing aids. Eyewear allowance can only be used at participating retailers. OTC items are subject to the plan’s list of eligible items and the plan’s participating network of retail, online, and utility providers.

DentaQuest® is contracted with Healthfirst to provide dental benefits to its members.

EyeMed® is contracted with Healthfirst to provide vision benefits to its members.

Telemedicine (Teladoc Health) and the Nurse Help Line are not replacements for your primary care provider (PCP). Your PCP should always be your first choice for care (both in-person and virtual visits).

SilverSneakers is a registered trademark of Tivity Health, Inc. © 2026 Tivity Health, Inc. All rights reserved.

Modivcare and Medical Answering Services provide the covered transportation services under your plan.

Last update June 15, 2026 @ 12:23 pm

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