This is a high level overview of premium and benefit information for this plan. HNE Medicare Basic (HMO) covers both Medicare Part B prescription drugs* and Medicare Part D prescription drugs.
Monthly Plan Premium |
$83 |
Medical Out-of-Pocket Maximum |
$3,400 |
| Deductible | Not Applicable |
Office Visits ($0 annual preventive exam) |
$30 |
Specialist Office Visits |
$40 |
Inpatient Hospital (3 copayment maximum) |
$900 per admission |
Outpatient Surgery |
$450* |
Skilled Nursing Facility (SNF) |
Days 1-20: $25 copay per day* Days 51-100: $0 copay |
World Wide Emergency Room (ER) |
$75 |
| Urgent Care (Walk-in or Urgent Care clinic) | $50 |
Ambulance |
$150* |
Outpatient Rehabilitation (Prior authorization after visit 25)** |
$40* |
High Cost Imaging |
$200* |
| Lab work/X-rays | $0 for Labs; $15 for X-rays |
Durable Medical Equipment/Prosthetics |
20% Coinsurance* |
Additional Benefits |
|
| Routine Hearing Exam+ | $40 |
| Routine Eye Exam, including Refraction+ | $0 |
Vision Eyewear Allowance+ |
$100 eyewear allowance every two years |
Dental Services Allowance+ |
$150 allowance per year |
Fitness Center/Weight Watchers®/Over-the-Counter Items+ |
$150 allowance per year |
| Wig Allowance+ | $350 per year (if on chemotherapy) |
Prescription Drug (Part D) Coverage |
|
| Deductible | Not Applicable |
Initial Coverage |
$10 Generics; $45 Brand; |
Coverage Gap - Over $3,310 in Drug Costs; Up to $4,850 in Out-of-Pocket Costs |
58% of the costs for Generic. Brand name drugs, you pay 45% of the price or the HNE negotiated price, whichever is lower. |
Catastrophic Coverage Over $4,850 in Out-of-Pocket Costs |
$2.95 for Generics and $7.40 for all other drugs; or 5% coinsurance |
Mail-order (Three month supply) ++ |
$20 Generics; $90 Brand; |
Make sure that you are familiar with HNE Medicare Advantage plan options before you decide to enroll online. Explore Your Plan Options to review this important information.
If you have additional questions about which HNE Medicare Advantage plan option may be right for you, please call us, attend an Informational Session, or visit us at our office in Springfield. Our contact information is listed below.
*Some services require prior authorization. Our network providers know what we cover under your benefit plan. They also know what requires prior authorization and will request approval from HNE on your behalf.
**Prior Authorization required for rehabilitation services after visit 25 or if services are rendered in a SNF as an outpatient benefit when member is a resident of the SNF.
+HNE 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.
++Mail-order: During the coverage gap stage, generics are covered at $20 for a three month supply; for all other drugs, you pay 45% of the price or the HNE negotiated price, whichever is lower. For the Value plan and the Basic plan, standard coverage gap cost-sharing applies. During the catastrophic coverage stage, standard catastrophic coverage applies for all plans.
The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact the plan. Limitations, copayments, and restrictions may apply. benefits, formulary, pharmacy, network, premium and/or copayments/co-insurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium.
See Eligibility Requirements on the Enrollment Form and Instructions page for more details.
Remember, you can join, switch, or drop a Medicare Advantage Plan only at certain times of year. See Key Enrollment Dates for details.
H8578_2016_049 Approved
The
information on this page was last updated on 2/18/2016