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2019 Medicare Premium (HMO)

Name: Health New England
Address: One Monarch Place, Suite 1500, Springfield, MA, 01144
Telephone: (413) 787-0010

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Additional Benefits Prescription Drug Coverage (Part D) Plan Documents

Plan Overview

Monthly Premium	$166
Medical Out-of-Pocket Maximum	$4,400
Office Visits ($0 annual preventive exam)	$10
Specialist Office Visits	$20
Inpatient Hospital	$100 per day for days 1-5, per admission
Inpatient Hospital Maximum (per calendar year)	$1,500
Outpatient Surgery ²	$150
Skilled Nursing Facility (SNF) ²	Days 1–20: $0 copay per day Days 21–50: $130 copay per day Days 51–100: $0 copay per day
Teladoc Virtual Doctor Visits ⁸	$10
Urgent Care	$50
World Wide Emergency Room (ER)	$90
Ambulance ²	$150
Outpatient Rehabilitation (PA after 25 visits) ³	$20
High Cost Imaging ²	$125
Lab Work / X-rays	$0 Labs / $10 X-rays
Durable Medical Equipment and Prosthetics ²	15% coinsurance

Additional Benefits

Preventive Hearing Exam ⁴	$20
Hearing Aid Benefit - TruHearing ^®5	$699 copay per aid for Advanced Aids $999 copay per aid Premium Aids
Preventive Vision Exam - EyeMed ^{® 4✝}	$0
Vision Eyewear Allowance - EyeMed ^{® 4✝}	$100 every two years
Dental Services Allowance ⁴	$250 per year
Fitness Center / Weight Watcher ^® / Safety Items / Over-the-Counter Allowance / Acupuncture / Activity Tracker ⁴	$150 per year
Wig Allowance (if on chemotherapy) ⁴	$350 per year

Prescription Drug Coverage (Part D)

Initial Coverage: Up to $3,820 in Drug Costs

Tier Type Deductible: Copay
Tier 1 Preferred Generic Deductible: $0 Copay: $4 retail / $8 mail-order⁶
Tier 2 Generic Deductible: $0 Copay: $10 retail / $20 mail-order⁶
Tier 3 Preferred Deductible: $250 Copay: $45 retail / $90 mail-order⁶
Tier 4 Non-Preferred Deductible: $250 Copay: $95 retail / $285 mail-order⁶
Tier 5 Specialty Deductible: $250 Copay: 28%
Mail-order price is for three month supply⁶

Additional Coverage Information

Coverage Type	Details
Coverage Gap: Over $3,820 in Drug Costs; Up to $5,100 in Out-of-Pocket Costs	37% of the costs for generic. Brand name drugs, you pay 25% of the price or the Health New England negotiated price, whichever is lower
Catastrophic Coverage: Over $5,100 in Out-of-Pocket Costs	$3.40 for Generics and $8.50 for all other drugs; or 5% coinsurance

Plan Documents

$166

per month

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TTY: 711

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¹Plan available without Prescription Drug (Part D) Coverage. Health New England Medicare Premium No Rx (HMO) monthly premium is $79.

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 37%, and Preferred and Non-Preferred Brands are covered at 25% of the price or the Health New England negotiated price, whichever is lower. For the Plus (HMO) plan, the Value (HMO) plan and Select (HMO-POS) plan, standard coverage gap cost-sharing applies. During the catastrophic coverage stage, standard catastrophic coverage applies for all plans. For questions related to Prescription Drug coverage, call (800) 546-5677, 24 hours a day, 7 days a week. TTY users should call (866) 706-4757.

⁸You must use Teladoc® service to receive this benefit.

†You must use an EyeMed® provider.

This information is not a complete description of benefits. Call (413) 787-0010 TTY: 711.

Health New England complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. ATTENTION: If you speak any language other than English, language assistance services, free of charge, are available to you. Call (413) 787-0010 or TTY 711. Health New England cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (413) 787-0010 o TTY 711. Health New England cumpre as leis de direitos civis federais aplicáveis e não exerce discriminação com base na raça, cor, nacionalidade, idade, deficiência ou sexo. ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para (413) 787-0010 ou TTY 711.

H8578_2018_049 Accepted
Last updated on 10/1/18