Health New England Medicare Plus (HMO)


Monthly Plan Premium 

   

 $109

Medical Out-of-Pocket Maximum

   

 $4,900

Office Visits ($0 annual preventive exam)

   

 $15

Specialist Office Visits

   

 $35

Inpatient Hospital

   

 $225 per day for days 1-5, per admission

 $3,375 inpatient maximum per calendar year

Outpatient Surgery2

    

 $300

Skilled Nursing Facility (SNF)2

    

Days 1-20: $0 copay per day
Days 21-50: $160 copay per day
Days 51-100: $0 copay per day               

Teladoc8      $15
Urgent Care       $50

Worldwide Emergency Room (ER)

   

 $90

Ambulance2

    

 $150

Outpatient Rehabilitation (PA after visit 25)3

   

 $35

High Cost Imaging2              

   

 $225


Lab Work/X-Rays  

   

 $0 Labs
 $15 X-Rays

Durable Medical Equipment/Prosthetics2

    

 20% coinsurance

 
Additional Benefits

   

 

Preventive Hearing Exam4

   

 $35

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

Preventive Vision Exam - EyeMed@4†        

   

  $0

Vision Eyewear Allowance - EyeMed@4†                   

   

 $100 every two years

Dental Services Allowance4 

   

 $250 per year

Fitness/Weight Watchers®/Safety Items/

Over-the-Counter Allowance/

Acupuncture/Fitness Tracker4 
    

 
 $150 per year

Wig Allowance (if on chemotherapy)4 

    

$350 per year 

Prescription Drug (Part D) Coverage

   

 

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

   

 $250

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

   

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

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

 

Mail-order (Three month supply)6 

   

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

       

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.

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 or TTY 711 for more information.


H8578_2019_049 Accepted
last updated 10/1/18
HNE