Health New England Medicare Premium (HMO)


Monthly Plan 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
 $1,500 inpatient maximum per calendar year

Outpatient Surgery2

   

 $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 

Teladoc8      $10
Urgent Care      $50

Worldwide Emergency Room (ER)

   

 $90

Ambulance2

   

 $150

Outpatient Rehabilitation (PA after visit 25)3

   

 $20

High Cost Imaging2     

   

 $125

Lab work/X-rays  

   

 $0 Labs
 $10 X-Rays

Durable Medical Equipment/Prosthetics2

   

 15% coinsurance

 
Additional Benefits

   

 

Preventative Hearing Exam4

   

 $20

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

Preventative 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 Allowance4  (if on chemotherapy) 

   

 $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

   

$4 Preferred Generic. 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

       

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. Please note, hearing aids purchased through other providers are not covered. Other providers are available in our network.

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 File & Use 
last updated 10/1/2018
HNE