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2019 Medicare Premium No Rx (HMO)

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Plan Overview

Monthly Premium $79
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

Plan Documents


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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. Members of the Health New England Medicare Select (HMO-POS) plan who choose to get these services out-of-network are responsible for getting prior authorization from Health New England. Please tell your out-of-network provider that prior authorization is required. The provider may be willing to contact Health New England Member Services for you to get prior authorization. For a complete list of services that require prior authorization, refer to the Summary of Benefits.

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.

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

†You must use an EyeMed® provider.

9Out-of-network/non-contracted providers are under no obligation to treat Health New England members, except in emergency situations. Please call our Member Services number or see your Evidence of Coverage for more information, including the cost sharing that applies to out-of-network services.

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

H8578_2018_049 Accepted
Last updated on 10/1/18