Medicare & Long-Term Care Plans Signature (PPO)

Healthfirst Signature (PPO) is a Medicare Advantage Prescription Drug plan that gives you the flexibility to go out of network and visit any doctor or hospital in the U.S. that accepts Medicare for medical care. This Medicare Advantage PPO plan offers the benefits of Original Medicare, plus much more. You will get access to benefits such as prescription drug and dental coverage. This plan is designed for people who may not qualify for programs like Extra Help (also known as Low Income Subsidy), Medicare Savings Programs (MSP), or Medicaid.

Plan Year
2027 2026
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Plan highlights Costs and plan details Prescription drug benefits Additional benefits Plan documents Helpful resources Frequently asked questions

Plan highlights

$0 copay for preferred generic drugs

Preventive and comprehensive dental coverage ($1,500 annual maximum for in- and out-of-network services combined)

Convenient prescription drug delivery options

Worldwide emergency and urgent care coverage with a maximum benefit allowance

A broad network of more than 100,000 participating providers, plus the option to go out of network

Costs and plan details

In-Network
Out-of-Network
Premium
$155 Part D premium*
Medical Deductible
$450 annually for Medicare-covered in-network and out-of-network medical services
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), Nassau, Suffolk, Rockland and Westchester counties
Other Eligibility Requirements
Qualify for Medicare Part A
Enroll in and continue to pay for Medicare Part B
Maximum Out-of-Pocket
In-Network $9,850 annually for Medicare‑covered services received from in‑network providers
Out-of-Network
$14,800 annually for Medicare‑covered services received from both in‑network and out‑of‑network providers
Annual Supplemental Physical Exam
In-Network $0 copay
Out-of-Network $50 copay
Dental
In-Network $0 copay for preventive and comprehensive services†
Out-of-Network $0–$100 copay for preventive and comprehensive services†
Plan pays up to $1,500 per year for both preventive and comprehensive dental services combined

A $750 deductible applies for comprehensive dental services

†This refers to your supplemental dental benefit. Some dental services are covered under your medical plan which may require additional cost-share.
Nutrition Counseling
In-Network $0 copay
Out-of-Network $50 copay
Nutrition counseling is offered for up to six preventive counseling and/or risk factor reduction visits annually
Acupuncture
In-Network $0 copay
Out-of-Network $50 copay for chronic lower back pain visits, after deductible
$50 copay for supplemental visits
Acupuncture is offered for up to 20 visits per year for chronic lower back pain and 12 supplemental visits per year for any condition, including chronic lower back pain
Telemedicine
In-Network $0 copay for telemedicine services with in-network PCPs and mental health providers, or through Teladoc Health®
$0 copay for telemedicine services with network specialists
Out-of-Network $50 copay for telemedicine services with out-of-network PCPs
$75 copay for telehealth services with out-of-network specialists
Nurse Help Line Access
In-Network $0 copay
Out-of-Network $0 copay
Primary Care Provider (PCP) Visit
In-Network $0 copay
Out-of-Network $50 copay, after deductible
Specialist Visit
In-Network $40 copay, after deductible
Out-of-Network $75 copay, after deductible
Outpatient Lab Tests (including COVID-19)
In-Network 20% coinsurance for genetic labs, after deductible
$0 for all other labs, after deductible
Out-of-Network $60 copay, after deductible
Retail Health Clinic
In-Network $15 copay, after deductible
Out-of-Network $60 copay, after deductible
Urgent Care
In-Network $40 copay
Out-of-Network $40 copay
Emergency Room
In-Network $115 copay
Out-of-Network $115 copay
Ambulance
In-Network $340 copay, after deductible
Out-of-Network $340 copay, after deductible
Ambulatory Surgery Visit
In-Network $0 copay for diagnostic colonoscopies, after deductible
$300 copay for all other ambulatory surgery center services, after deductible
Out-of-Network 30% coinsurance, after deductible
Outpatient Facility
In-Network $0 copay for diagnostic colonoscopies, after deductible
20% coinsurance for all other outpatient hospital services, after deductible
Out-of-Network 30% coinsurance, after deductible
Inpatient Hospital Stay
In-Network $540 copay per day for days 1–4, after deductible;
$0 copay per day for days 5–999 and beyond
Out-of-Network 30% coinsurance per stay, after deductible
Skilled Nursing Facility
In-Network $0 each day for days 1‒20, after deductible
$221 each day for days 21–100
Out-of-Network 50% coinsurance per stay, after deductible

Prescription drug benefits

We want to help you get the most out of your Part D prescription drug benefits. To confirm that your drugs are covered and to see which medications fall under each tier, use the Healthfirst prescription drug search tool or the view the Signature (PPO) formulary. Healthfirst may add drugs to or remove them from the Medicare formulary during the year. We will notify you when we make changes.

Please also note that Tier 5 Specialty Drugs are only available for a 30-day supply.

Deductible (Applies to Tiers 3–5)
$700
Preferred Generic Drugs (Tier 1)
$0 copay
Generic Drugs (Tier 2)
$4 copay for a 30-day supply, no deductible
Preferred Brand and Non-Preferred Generic Drugs (Tier 3)
19% of cost after deductible
Non-Preferred Drugs (Tier 4)
45% of cost after deductible
Specialty Drugs (Tier 5)
25% of cost after deductible
Select Care Drugs (Tier 6)
$0 copay
Insulins
Maximum of $35 copay for 30-day supply, no deductible

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 virtual dermatologists and mental health services is also available.

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.

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.

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

•
•

Prescription drug information

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

Frequently asked questions

A PPO (Preferred Provider Organization) plan is a type of health plan that gives you more choice when picking doctors, hospitals, and specialists.

With a PPO plan:

  • You can visit doctors and hospitals in the plan's network to help lower your costs.
  • You can also see doctors outside the network without a referral. This usually costs more.
  • You do not need to choose a primary care doctor.
  • You do not need a referral to see a specialist.

Many people choose PPO plans because they want more freedom to choose their healthcare providers. If you qualify for Medicare, you may be able to get a Healthfirst PPO plan through Medicare Advantage.

HMO and PPO plans have some important differences.

  • An HMO lets you use doctors and providers in its network. A PPO lets you use both in-network and out-of-network providers.
  • HMOs usually have lower deductibles and lower out-of-pocket costs.
  • HMOs often require a referral to see a specialist. PPOs do not.

The Healthfirst Signature (PPO) plan is a Medicare Advantage Prescription Drug (MAPD) plan.

It includes:

  • Original Medicare Part A (hospital coverage)
  • Original Medicare Part B (medical coverage)
  • Medicare Part D (prescription drug coverage)
  • Extra benefits that Original Medicare does not cover

Instead of having separate plans, you get your hospital, medical, and prescription drug coverage in one plan.

This can be a good choice if you want extra benefits and the flexibility of a PPO plan.

A PPO plan gives you flexibility with both doctors and pharmacies.

Many PPO plans let you:

  • Choose from a wide selection of retail pharmacies
  • Get long-term medicines through mail-order pharmacies
  • Fill prescriptions while traveling in the United States

This can be helpful if you travel often or live in more than one place during the year.

Taking care of your teeth is an important part of staying healthy. Original Medicare usually does not cover routine dental care. Many PPO plans include dental benefits.

Depending on your plan, dental coverage may include:

  • Routine exams and cleanings
  • Dental X-rays
  • Other covered dental services

With PPO dental coverage, you may be able to:

  • Visit in-network dentists to help lower your costs.
  • See out-of-network dentists, usually at a higher cost.
  • Choose your dentist without a referral.

This plan might be a fit if you already have a dentist or want more flexibility.

Find out if you qualify

Disclaimers

*The Part D premium for this plan may be reduced or waived if you are receiving the Low Income Subsidy ("Extra Help").

Dental 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 (unless your Part B premium is paid by Medicaid or another third party).

Coverage is provided by Healthfirst Insurance Company, Inc., which offers a PPO plan that contracts with the Federal Government. Enrollment in Healthfirst Medicare Plan depends on contract renewal.

Out-of-network/non-contracted providers are under no obligation to treat Healthfirst Medicare Plan members, except in emergency situations. Out-of-network healthcare services may have higher costs. Please call Member Services or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.

Plans contain exclusions and limitations.

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).

No out-of-pocket costs for entry-level hearing aids. Eyewear allowance can only be used at participating retailers.

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

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

Last update September 23, 2026 @ 1:00 pm

Y0147_MKT27_49 26-5421_M

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

Plan highlights

$1 copay for preferred generic drugs (30-day supply)

Comprehensive dental coverage

Convenient prescription drug delivery options

Routine vision and hearing exams, $75/year allowance for eyeglasses or contacts, and hearing aids for as low as $0

Worldwide emergency and urgent care coverage with a maximum benefit allowance

A broad network of more than 100,000 participating providers, plus the option to go out of network

Costs and plan details

In-Network
Out-of-Network
Premium
In-Network $55
Out-of-Network $55
Medical Deductible
$500 annually for Medicare-covered in-network and out-of-network medical services
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), Nassau, Suffolk, Rockland and Westchester counties.
Other Eligibility Requirements
Qualify for Medicare Part A.
Enroll in and continue to pay for Medicare Part B.
Maximum Out-of-Pocket
In-Network $9,250 annually for Medicare‑covered services received from in‑network providers
Out-of-Network
$13,900 annually for Medicare‑covered services received from both in‑network and out‑of‑network providers
Annual Supplemental Physical Exam
In-Network $0 copay
Out-of-Network $50 copay
Dental
In-Network Preventive $0 copay
Comprehensive $0 copay
Out-of-Network $0‒$20 copay
$0‒$100 copay
Plan pays up to $1,500 per year for both preventive and comprehensive dental services combined

A $750 deductible applies for comprehensive dental services
Vision
$0 copay for routine vision exam, including refraction
$75 eyewear allowance every year for contact lenses or one pair of glasses (lenses and frames)
Hearing
$0 for one routine hearing exam per year
$0‒$1,475 copay per hearing aid
Plan covers one hearing aid per ear, per year
Nutrition Counseling
In-Network $0 copay
Out-of-Network $50 copay
Nutrition counseling is offered for up to six preventive counseling and/or risk factor reduction visits annually
Acupuncture
In-Network $0 copay
Out-of-Network $50 copay for chronic lower back pain visits, after deductible
$50 copay for supplemental visits
Acupuncture is offered for up to 20 visits per year for chronic lower back pain and 12 supplemental visits per year for any condition, including chronic lower back pain
Telemedicine
In-Network $0 copay for telemedicine services with in-network PCPs and mental health providers, or through Teladoc Health®
$0 copay for telemedicine services with network specialists, after deductible
Out-of-Network $50 copay for telemedicine services with out-of-network PCPs;
$75 copay for telehealth services with out-of-network specialists
Nurse Help Line Access
In-Network $0 copay
Out-of-Network $0 copay
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
Primary Care Provider (PCP) Visit
In-Network $0 copay
Out-of-Network $50 copay, after deductible
Specialist Visit
In-Network $40 copay, after deductible
Out-of-Network $75 copay, after deductible
Outpatient Lab Tests (including COVID-19)
In-Network 20% coinsurance for genetic labs, after deductible
$0 for all other labs, after deductible
Out-of-Network $60 copay, after deductible
Retail Health Clinic
In-Network $15 copay
Out-of-Network $60 copay, after deductible
Urgent Care
In-Network $40 copay
Out-of-Network $40 copay
Emergency Room
In-Network $115 copay
Out-of-Network $115 copay
Ambulance
In-Network $340 copay, after deductible
Out-of-Network $340 copay, after deductible
Ambulatory Surgery Visit
In-Network $0 copay for diagnostic colonoscopies and esophageal endoscopies, after deductible
$240 copay for all other ambulatory surgery center services, after deductible
Out-of-Network 30% coinsurance, after deductible
Outpatient Facility
In-Network $0 copay for diagnostic colonoscopies and esophageal endoscopies, after deductible
20% coinsurance for all other outpatient hospital services, after deductible
Out-of-Network 30% coinsurance, after deductible
Inpatient Hospital Stay
In-Network $490 copay per day for days 1‒4, after deductible;
$0 copay per day for days 5-999 and beyond
Out-of-Network 30% coinsurance per stay, after deductible
Skilled Nursing Facility
In-Network $0 each day for days 1‒20, after deductible
$218 each day for days 21-100
Out-of-Network 50% coinsurance per stay, after deductible

Prescription drug benefits

We want to help you get the most out of your Part D prescription drug benefits. Please refer to the formulary links below to see which medications fall under each tier. Healthfirst may add drugs to or remove them from the Medicare formulary during the year. You’ll receive notice when changes are made.

Please also note that Tier 5 Specialty Drugs are only available for a 30-day supply.

Deductible (Applies to Tiers 3–5)
$615
Preferred Generic Drugs (Tier 1)
$1 copay for a 30-day supply or $2.50 for a 90-day supply, no deductible
Generic Drugs (Tier 2)
$2 copay for a 30-day supply or $5 for a 90-day supply, no deductible
Preferred Brand and Non-Preferred Generic Drugs (Tier 3)
18% of cost after deductible
Non-Preferred Drugs (Tier 4)
25% of cost after deductible
Specialty Drugs (Tier 5)
25% of cost after deductible
Select Care Drugs (Tier 6)
$0 copay
Insulins
Maximum of $35 copay for 30-day supply, no deductible

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

•
•
•

Prescription drug information

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

Frequently asked questions

A Preferred Provider Organization (PPO) plan offers access to both in-network and out-of-network providers. With our Healthfirst Signature (PPO) Medicare Advantage Prescription Drug plan, you can access our large network of doctors and hospitals for low cost-sharing, or choose to visit any doctor and hospital in the U.S. that accepts Medicare for medical care.

The Healthfirst Signature (PPO) Medicare Advantage Prescription Drug plan covers preventive and comprehensive dental care such as twice-yearly checkups, cleanings, fluoride treatment, and more complex care such as extractions, dentures, crowns, and more.

Taking advantage of your plan benefits can help you save money on healthcare costs. To help lower your overall health insurance costs, you should always:

  • Use your no-cost benefits, such as annual physical and dental checkups, to help keep you healthy and identify potential health risks early.
  • Make sure you see an in-network doctor or facility first for treatment to avoid out-of-pocket costs.
  • Visit an urgent care center for non-emergency issues such as colds or flu, sprains, and wounds.
  • Ask your in-network doctor or pharmacist for 90-day prescription fills and Tier 6 Select Care Drugs whenever possible.
  • Use your convenient telemedicine benefit whenever you cannot see a healthcare provider in person.

Pharmacy benefits are different for each Healthfirst health insurance plan. Please check your plan’s formulary for more information on which pharmacy medicines and other items are covered.

Healthfirst has partnered with CVS Caremark to bring you a personal prescription drug account that will give you 24/7 access to important drug benefit information and tools that will make getting your prescription drugs easier. Click here to create your account or log in.

Disclaimers

Dental 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 Insurance Company, Inc., which offers a PPO plan that contracts with the Federal Government. Enrollment in Healthfirst Medicare Plan depends on contract renewal.

Out-of-network/non-contracted providers are under no obligation to treat Healthfirst Medicare Plan members, except in emergency situations. Out-of-network healthcare services may have higher costs. Please call Member Services or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.

Plans contain exclusions and limitations.

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).

No out-of-pocket costs for entry-level hearing aids. Eyewear allowance can only be used at participating retailers.

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

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

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

Last update September 23, 2026 @ 1:00 pm

Y0147_MKT26_54 5319-25_M

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