Do You Have The
ADVANTAGE?
PLAN PREMIUM
Medicare Advantage Plan
With Prescription Drug Coverage
(You must continue to pay your Part B premium)
(Part D coverage is provided at no additional premium to you)
(If you are a dual eligible, your Medicare Part B premium will be paid by the state on your behalf)
COPAY
- for inpatient hospital services
- for primary office care visits
- for most specialist office visits
- for all covered dental services
- for routine eye exam
- Up to $1,000 for hearing aids every three years
- Up to $20,000 Emergency Worldwide Coverage
Liberty Health Advantage
members continue to receive All their current Medicare benefits
PLUS MUCH MORE!
Limitations,co-payments and restrictions may apply.
Benefits, formulary, pharmacy network, premium and/or co-payments/co-insurance may change on January
Liberty Health Advantage HMO is a Coordinated Care Plan with a Medicare Advantage contract and a contract with the New York State Medicaid program.
If you would like to file an appeal or grievance for your medical benefit coverage, click on the following link to access our Liberty Health Advantage Grievance and Appeals - Medical
If you would like to file an appeal or grievance for your prescription drug coverage or to request a coverage determination for a drug, click on the following link to access our Liberty Health Advantage Grievance and Appeals - Part D
If you prefer to file a grievance through Medicare, click on the following link: Medicare Electronic Complaint Form
To check the status of your Appeal or Grievances, call Member Services at 866-542-4269