Health New England Medicare Premium No Rx (HMO)

This is a high level overview of premium and benefit information for this plan. Health New England Medicare Premium No Rx (HMO) does NOT cover Medicare Part D prescription drugs. This plan does cover Medicare Part B prescription drugs. 1

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: $20 copay per day2
Days 21-50: $100 copay per day2
Days 51-100 $0 copay per day2

World Wide Emergency Room (ER)




Outpatient Rehabilitation (PA after visit 25)2


High Cost Imaging 


Lab work/X-rays  

 $0 Labs
 $10 X-Rays

Durable Medical Equipment/Prosthetics

 15% coinsurance2

Additional Benefits


Preventative Hearing Exam3


 Hearing Aid Benefit - TruHearingTM4  $699 copay per aid Flyte 700
 $999 copay per aid Flyte 900

Preventative Vision Exam3


Vision Eyewear Allowance3     

 $100 every two years

Dental Services Allowance3

 $150 allowance per year

Fitness Center/Weight Watchers®/Safety Items/
Over-the Counter Item Allowance3

 $150 allowance per year

Wig Allowance3  (if on chemotherapy) 

 $350 per year


1Some 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.
2PA after visit 25 or if services are rendered in a SNF as an outpatient benefit when member is a resident of the SNF.

3Health 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.

4You 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.

Health New England Medicare Advantage is an HMO plan with a Medicare contract. Enrollment in Health New England Medicare Advantage depends on contract renewal.
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_2017_049 approved
The information on this page was last updated on 11/09/2016