>

Health New England Medicare Value (HMO)

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


Monthly Plan Premium 

   

 $39

Medical Out-of-Pocket Maximum

   

 $6,700

Office Visits ($0 annual preventive exam)

   

 $35

Specialist Office Visits

   

 $45

Inpatient Hospital

   

 $225 per day for days 1-7, per admission
 $4,725 inpatient maximum per calendar year

Outpatient Surgery

   

 $4501

Skilled Nursing Facility (SNF)

��  

Days 1-20: $0 copay per day1
Days 21-50: $160 copay per day 1
Days 51-100: $0 copay per day 1

World Wide Emergency Room (ER)

   

 $80

Ambulance

   

 $1751

Outpatient Rehabilitation (PA after visit 25)2

   

 $401

High Cost Imaging 

   

 $2501


Lab work/X-rays  

   

 $25 Labs
 $25 X-Rays

Durable Medical Equipment/Prosthetics

   

 20% coinsurance1

 
Additional Benefits


   

 

Preventive Hearing Exam3

   

 $45

Hearing Aid Benefit - TruHearing®4      $699 copay per aid Flyte Advanced
 $999 copay per aid Flyte Premium

Preventive Vision Exam3

   

 $0

Vision Eyewear Allowance3

   

 $100 every two years

Dental Services Allowance3

   

 $150 per year

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

   

 
 $150 per year

Wig Allowance3 (if on chemotherapy) 

   

 $350 per year  

Prescription Drug (Part D) Coverage      
  Deductible - Applies to Preferred Brand,
 Non-Preferred Brand,Specialty Medication  		    $320
 Initial Coverage:
 Up to $3,820 in Drug Costs 		    $4 Preferred Generic; $10 Generic;
$45 Preferred Brand; $95 Non-Preferred Brand;
26% Specialty Tier
 Coverage Gap:
 Over $3,820 in Drug Costs;
 Up to $5,100 in Out-of-Pocket Costs 		    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 $5,100 in Out-of-Pocket Costs 		    $3.35 for Generics and $8.35 for all other drugs; or 5% coinsurance 
 Mail-order (Three month supply)5      $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.

5Mail-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


HNE