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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
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 +
Wig Allowance3 (if on chemotherapy)
$350 per year
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.