NY Medicare Advantage PPO Plan

In-Network

Out-of-Network

Premium

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.

Medical Deductible

Maximum Out-of-Pocket

In-Network $5,000 annually for Medicare‑covered services received from in‑network providers

Out-of-Network

$8,000 annually for Medicare‑covered services received from both in‑network and out‑of‑network providers

Flex Card

$725/year Flex card for dental, vision, and hearing out-of-pocket costs, fitness equipment, activity trackers, and Personal Emergency Response Systems (PERS).

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 combined.

Vision

$0 copay for routine vision exam, including refraction
$250 eyewear allowance every year for contact lenses or one pair of glasses (lenses and frames)

Hearing

$0 for routine hearing exams
$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 for Chronic Lower Back Pain

In-Network $0 copay

Out-of-Network $50 copay

Acupuncture is offered for up to 20 visits per year for chronic lower back pain and 12 supplemental visits per year for any condition

Telemedicine (Teladoc)

$0 copay

Nurse Help Line Access

$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

Specialist Visit

In-Network $35 copay

Out-of-Network $60 copay

Outpatient Lab Tests (including COVID-19)

In-Network $0 copay

Out-of-Network $60 copay

Retail Health Clinic

In-Network $15 copay

Out-of-Network $60 copay

Urgent Care

$45 copay

Emergency Room

$125 copay

Ambulance

$275 copay

Ambulatory Surgery Visit

In-Network 0% for diagnostic colonoscopies and esophageal endoscopies
$240 copay for each ambulatory surgery center visit

Out-of-Network 30% coinsurance

Outpatient Facility

In-Network 0% coinsurance for diagnostic colonoscopies and esophageal endoscopies
20% coinsurance for all other outpatient hospital services

Out-of-Network 30% coinsurance

Inpatient Hospital Stay

In-Network $325 copay per day for days 1‒5;
$0 copay per day for days 6-999 and beyond

Out-of-Network 40% coinsurance per stay

Skilled Nursing Facility

In-Network $10 each day for days 1‒20
$214 each day for days 21-100

Out-of-Network 50% coinsurance per stay

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. Please note that 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 4‒5)

$590

Preferred Generic Drugs (Tier 1)

$0 copay, no deductible

Generic Drugs (Tier 2)

$15 copay for 30-day or 90-day supply, no deductible

Preferred Brand and Generic Drugs (Tier 3)

$47 copay for 30-day or 90-day supply, no deductible

Non-Preferred Drugs (Tier 4)

50% coinsurance for 30-day supply after deductible

Specialty Drugs (Tier 5)

25% of cost after deductible

Select Insulins

Maximum of $35 copay for 30-day supply, no deductible

Additional Plan Highlights

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) 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) 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, 300+ 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

Learn More

Plan Documents

2025 Signature (PPO) Plan

General Plan Information

2025 Star Ratings

Every year, Medicare evaluates plans based on a 5-star rating system.

Low Income Subsidy Pricing

Summary of Benefits

Prescription Drug Information

Comprehensive Formulary (List of Covered Drugs)

English/Español/中文

List of Drugs Requiring Prior Authorization

English

List of Drugs Requiring Step Therapy

English

Find member forms

See all plan documents

Helpful Resources

CMS Online Enrollment Center

Disenrollment Rights and Responsibilities

Healthfirst Medication Therapy Management Program

Medicare Coverage Decisions, Appeals and Complaints

Disclaimer

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

Plans contain exclusions and limitations.

Healthfirst complies with applicable Federal, state and local rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-866-305-0408 (TTY 1-888-867-4132).

注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電1-866-305-0408 (TTY 1-888-542-3821).

Telemedicine (Teladoc) 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.

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

Last update January 31, 2025 @ 10:04 am

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Frequently Asked Questions

See All

What is a PPO health plan?

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.

What can I purchase with the Healthfirst Signature (PPO) Flex card?

The Healthfirst Signature (PPO) Medicare Advantage Prescription Drug plan includes a yearly Flex card allowance that can be used to pay for out-of-pocket dental, vision, and hearing costs as well as exercise equipment, fitness trackers and wearables, and personal emergency response systems (PERS). Plan members can use it toward an extra pair of glasses, premium hearing aids, or out-of-network dental care. Original Medicare does not offer the Flex card.

What dental benefits are available with Healthfirst Signature (PPO)?

The Healthfirst Signature (PPO) Medicare Advantage Prescription Drug plan covers preventive dental care such as twice-yearly checkups, cleanings, fluoride treatment, and more complex care such as extractions, dentures, crowns, and more—all for $0 copay with participating network providers; $0–$100 copay per service for out-of-network dental care, and with up to $1,500 in dental services per year.

How can I save money on my healthcare costs?

Taking advantage of your plan benefits can help you save money on healthcare costs. To help you 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 1 $0 copay Preferred Generic Drugs whenever possible.
Use your convenient telemedicine benefit whenever you cannot see a healthcare provider in person.

How do I access my pharmacy benefits?

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.

Plan Highlights:

Prescription Drug Benefits

Additional Plan Highlights

24/7 Access to Telemedicine with Teladoc^® Health^*