2019 Medicare Value (HMO)

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Plan Overview

Monthly Premium

Medical Out-of-Pocket Maximum

$X
Office Visits ($0 annual preventive exam)

$X
Specialist Office Visits

$X
Inpatient Hospital

$350

per day for days 1-5 per admission
Inpatient Hospital Maximum (per calendar year) $5,250
Outpatient Surgery 1 $400
Skilled Nursing Facility (SNF) 1 Days 1–20: $0 copay per day
Days 21–50: $170 copay per day
Days 51–100: $0 copay per day
Teladoc Virtual Doctor Visits 7 $30
Urgent Care $50
World Wide Emergency Room (ER) $90
Ambulance 1 $175
Outpatient Rehabilitation (PA after 25 visits) 2 $40
High Cost Imaging 1 $250
Lab Work / X-rays $25 Labs / $25 X-rays
Durable Medical Equipment and Prosthetics 1 20% coinsurance

Additional Benefits

Preventive Hearing Exam 3 $45
Hearing Aid Benefit - TruHearing ® 4✝ $699 copay per aid for Advanced Aids
$999 copay per aid Premium Aids
Preventive Vision Exam - EyeMed ® 3✝ $0
Dental Services Allowance 3 $250 per year
Fitness Center / Weight Watcher ® / Safety Items /
Over-the-Counter Allowance / Acupuncture /
Activity Tracker 3 		$150 per year
Wig Allowance (if on chemotherapy) 3 $350 per year

Pharmacy

Initial Coverage: Up to $4,020 in Drug Costs

Tier 1
Preferred Generic
$0
$4 retail / $8 mail-order 5
Tier 2
Generic
$0
$10 retail / $20 mail-order 5
Tier 3
Preferred
$320
$45 retail / $90 mail-order 5
Tier 4
Non-Preferred
$320
$95 retail / $285 mail-order 5
Tier 5
Specialty
$320
26%

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 $8.35 for all other drugs; or 5% coinsurance

Plan Documents

$25.00


per month

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