2015 - Advantage Value One NY-Dual
Dual Eligible - Special Needs Plan

Advantage Value On NY-Dual is a special needs plan designed to coordinate benefits for individuals eligible for both Medicare and Medicaid.  This plan includes Health/Fitness club membership, Dental, Vision and Hearing benefits as well as a quarterly Over-The-Counter Drug and Supply allowance. Part D Drug benefits are also included in the plan. Depending on your level of Medicaid eligibility, your cost sharing for most services is $0.  This plan is available in Richmond, Queens, Suffolk and Nassau counties.



Plan Summary
County: Richmond, Queens, Nassau, Suffolk
Premium: $36.90 * plus Medicare Part B premium
OOP Max $6,700
Hospital:

In 2014 the amounts for each benefit period were $0 or:

Days 1 - 60: $1,216 deductible*

Days 61 - 90: $304 per day*

$608 per lifetime reserve day*

*These amounts may change for 2015.

PCP Visit: 0% to 20%*
Specialist Visit: 0% to 20%*
Emergency Room: 0% or 20% of the cost (up to $65)*
Outpatient Surgery: Ambulatory Surgical Center: 0% or 20%*
Outpatient Hospital: % or 20%*
DME: 0% - 20%*
Preventive Services: 0%
Prescription Drugs:
Retail:

For generic drugs (including brand drugs treated as generic), either:

- A $0 copay; or

- A $1.20 copay; or

- A $2.65 copay

For all other drugs, either:

- A $0 copay; or

- A $3.60 copay; or

- A $6.60 copay
Mail Order Available!
OTC Medications: $40 per Quarter
Vision: Annual Exam: $0
Eyewear: $0
Hearing: $1,000 Hearing Aid Allowance every 2 years*
Annual Test*: 20% of the Cost
Fitting/Evaluation*: 20% of the Cost
Dental:

0% to 20% fo the cost for Medicare-covered Dental Benefits
$0 copay for preventive dental benefits:
-1 oral exam every year,
-1 cleaning every 6 months
- dental x-rays

Additional Benefits: $0 Health Education
Fitness Program
Transportation