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2019 Medicare Value (HMO)

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Additional Benefits Prescription Drug Coverage (Part D) Plan Documents

Plan Overview

Monthly Premium $25
Medical Out-of-Pocket Maximum $6,700
Office Visits ($0 annual preventive exam) $30
Specialist Office Visits $45
Inpatient Hospital $225 per day for days 1-7, per admission
Inpatient Hospital Maximum (per calendar year) $4,725
Outpatient Surgery 2 $450
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
Teladoc Virtual Doctor Visits 8 $30
Urgent Care $50
World Wide Emergency Room (ER) $90
Ambulance 2 $175
Outpatient Rehabilitation (PA after 25 visits) 3 $40
High Cost Imaging 2 $250
Lab Work / X-rays $25 Labs / $25 X-rays
Durable Medical Equipment and Prosthetics 2 20% coinsurance

Additional Benefits

Preventive Hearing Exam 4 $45
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

Prescription Drug Coverage (Part D)

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

Tier 1
Preferred Generic
$0
$4 retail / $8 mail-order6
Tier 2
Generic
$0
$10 retail / $20 mail-order6
Tier 3
Preferred
$320
$45 retail / $90 mail-order6
Tier 4
Non-Preferred
$320
$95 retail / $285 mail-order6
Tier 5
Specialty
$320
26%
Mail-order price is for three month supply

Additional Coverage Information

Coverage Type Details
Coverage Gap: Over $3,820 in Drug Costs; Up to $5,000 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

Plan Documents

$25


per month

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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 Accepted
Last updated on 10/1/18