Health New England Medicare Premium (HMO)1

This is a high level overview of premium and benefit information for this plan. Health New England Medicare Premium (HMO) covers both Medicare Part B prescription drugs* and Medicare Part D prescription drugs.

Monthly Plan Premium 



Medical Out-of-Pocket Maximum



Office Visits ($0 annual preventive exam)



Specialist Office Visits



Inpatient Hospital 


 $100 per day for days 1-5, per admission

 $1,500 inpatient maximum per calendar year

Outpatient Surgery



Skilled Nursing Facility (SNF)


Days 1-20: $0 copay per day2
Days 21-50: $130 copay per day 2
Days 51-100 $0 copay per day 2

World Wide Emergency Room (ER)






Outpatient Rehabilitation (PA after visit 25)3



High Cost Imaging 



Lab work/X-rays  


 $0 Labs
 $10 X-Rays

Durable Medical Equipment/Prosthetics


 15% coinsurance2

Additional Benefits



Preventative Hearing Exam4



  Hearing Aid Benefit - TruHearing®5       $699 copay per aid Flyte Advanced
 $999 copay per aid Flyte Premium

Preventative Vision Exam 4



Vision Eyewear Allowance4     


 $100 every two years

Dental Services Allowance4


 $150 per year

Fitness, Weight Watchers®, Acupuncture
and Over-the-Counter Items Allowance 4


 $150 per year

Wig Allowance4  (if on chemotherapy) 


 $350 per year

Prescription Drug (Part D) Coverage



Deductible - Applies to Preferred Brand,
Non-Preferred Brand, Specialty Medication



Initial Coverage:
Up to $3,750 in Drug Costs 


$4 Preferred Generics; $10 Generic;
$45 Preferred Brand; $95 Non-Preferred Brand;
28% Specialty Tier

Coverage Gap:
Over $3,750 in Drug Costs;
Up to $5,000 in Out-of-Pocket Costs


$4 Preferred Generic. 44% of the costs for Generic.
Brand name drugs, you pay 35% of the price or the Health New England
negotiated price, whichever is lower

Catastrophic Coverage: 
Over $5,000 in Out-of-Pocket Costs


$3.35 for Generics and $8.35 for all other drugs; or 5% coinsurance

Mail-order (Three month supply)6 


$8 Preferred Generics; $20 Generic;
$90 Preferred Brand; $285 Non-Preferred Brand


1Plan available without Prescription Drug (Part D) Coverage. Health New England Medicare Premium No Rx (HMO) monthly premium is $108.

2Some services require prior authorization (PA). Our network providers know what we cover under your benefit plan. They also know what requires prior authorization and will request approval from Health New England on your behalf. For a complete list of services that require prior authorization, refer to the summary of benefits.

3PA after visit 25 or if services are rendered in a SNF as an outpatient benefit when member is a resident of the SNF.

4Health New England additional benefits include allowances that must be used within the one or two calendar year period, as well as other additional benefits. Refer to the Summary of Benefits or call Member Services if you have questions about what items and services are covered.

5You must see a TruHearing® provider to use this benefit. Other providers are available in our network. Please note, hearing aids purchased through other providers are not covered.

6Mail-order: During the coverage gap stage, for the Health New England Premium (HMO) plan, preferred generics are covered at $8 for a three month supply. Non-preferred generics are covered at 44%, and Preferred and Non-Preferred Brands are covered at 35% of the price or the Health New England negotiated price, whichever is lower. For the Plus plan and the Value plan, standard coverage gap cost-sharing applies. During the catastrophic coverage stage, standard catastrophic coverage applies for all plans.

This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or copayments/ co-insurance may change on January 1 of each year. 

You must continue to pay your Medicare Part B premium.

H8578_2018_049 approved 
last updated 9/30/17