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MetroPlus Platinum Plan (HMO) 2012 Benefit Highlights
To be eligible for MetroPlus Platinum Plan (HMO), you must be eligible for Medicare Parts A and B; reside in Manhattan, Brooklyn, Queens or the Bronx; and not have End-Stage Renal Disease (ESRD).
In 2012, MetroPlus Platinum Plan (HMO) provides all the benefits of Original Medicare PLUS:
• $51.30 monthly plan premium, however, the amount you pay depends on your level of Extra Help. Click for Extra Help chart.
• $0 copay for Primary Care visits.
• Medicare Prescription Drug Coverage (Medicare Part D)
• Hearing Services - $20 copay for routine hearing test every year. Up to $500 for hearing aids every three years.
• $0 Diabetic Supplies.
• Vision Services - $0 copay for one (1) pair of glasses or one (1) pair of Contacts every year, plus $125 for eye glass frames every year.
• Dental Services - $0 copay for oral exams, cleanings, fluoride treatment and x-rays.
• Transportation - $0 copay up to 3 round trips to any plan-approved location every 3 months using New York City MTA.
• Specialized Care Management Programs, including AsthmaPlus and DiabetesCARE (plus Telehealth Program).
Platinum Summary of Benefits English Spanish
Platinum Evidence of Coverage English
Spanish
H0423_MKT0908v5 CMS APPROVED 10142011
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