Health New England Medicare Premier 2 (HMO)

This is a high level overview of premium and benefit information for this plan. Health New England Medicare Premier 2 (HMO) covers both Medicare Part B prescription drugs* and Medicare Part D prescription drugs.

Monthly Plan Premium 

 $85

Medical Out-of-Pocket Maximum

 $3,400

Office Visits ($0 annual preventive exam)

 $20

Specialist Office Visits

 $40

Inpatient Hospital 

 $200 per day for days 1-5 per admission

Outpatient Surgery

 $300*

Skilled Nursing Facility (SNF)

Days 1-20: $20 copay per day*
Days 21-50: $140 copay per day
Days 51-100: $0 copay per day

World Wide Emergency Room (ER)

 $75

Ambulance

 $225*

Outpatient Rehabilitation (Prior Authorization after visit 25)**

 $40*

High Cost Imaging 

 $200*


Lab work/X-rays  

 $10 Labs
 $20 X-Rays

Durable Medical Equipment/Prosthetics

 20%*

 
Additional Benefits

 

Preventative Hearing Exam+

 $40

Hearing Aid Benefit - TruHearingTM+++  $699 copay per aid Flyte 700
 $999 copay per aid Flyte 900


Preventative Vision Exam+  (including refractions)

 
 $0


Vision Eyewear Allowance+ 

 
 $100 every two years

Dental Services Allowance

 $150 per year

 
Fitness Center/Weight Watchers®/Safety Items/
Over-the Counter Item Allowance+

 
 $150 per year

Wig Allowance+  (if on chemotherapy) 

 $350 per year 

Prescription Drug (Part D) Coverage

 

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

 $250

Initial Coverage:
Up to $3,700 Drug Costs 

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

Coverage Gap:
Over $3,700 in Drug Costs;
Up to $4,950 in Out-of-Pocket Costs

 $4 Preferred Generic; $10 Generic; 
 Brand name drugs, you pay 40% of the price
 or the Health New England negotiated price,
 whichever is lower

Catastrophic Coverage: 
Over $4,950 in Out-of-Pocket Costs

$3.30 for Generics and $8.25 for all other drugs; or 5% coinsurance

 

Mail-order (Three month supply) ++

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

   

*Some 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.

** PA after visit 25 or if services are rendered in a SNF as an outpatient benefit when member is a resident of the SNF. PA Members of the Health New England Premier 3 (HMO-POS) plan who choose to get these services out-of-network are responsible for getting prior authorization from Health New England. Please tell your out-of-network provider that prior authorization is required. The provider may be willing to contact Health New England Member Services for you to get prior authorization. Call Member
Services to confirm prior authorization. For a complete list of services that require prior authorization, refer to the Summary of Benefits.

+Health New England additional benefits may 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.

++Mail-order: During the coverage gap stage, under the Premier 2 (HMO) Plan, Preferred generics are covered at $8 for a three month supply. Generic are covered at $20 for a three month supply; for all other drugs, you pay 40% of the price or the Health New England negotiated price, whichever is lower. For the Premier 1 (HMO) Plan and Premier 3 (HMO-POS) Plan, standard coverage gap cost-sharing applies. During the catastrophic coverage stage, standard catastrophic coverage applies for all plans.

+++ You 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. 

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 co-payments/co-insurance may change on January 1 of each year.

You must continue to pay your Medicare Part B premium.

H8578_2017_049 approved
The information on this page was last updated on 11/09/2016