HNE Medicare Plus (HMO)

This is a high level overview of premium and benefit information for this plan. HNE Medicare Plus (HMO) covers both Medicare Part B prescription drugs* and Medicare Part D prescription drugs.

Monthly Plan Premium

$114

Medical Out-of-Pocket Maximum

$3,400
Deductible Not Applicable

Office Visits ($0 annual preventive exam)

$20

Specialist Office Visits

$30

Inpatient Hospital (3 copayment maximum)

$600 per admission

Outpatient Surgery

$300*

Skilled Nursing Facility (SNF)

Days 1-20: $40 copay per day*
Days 21-100: $0 copay per day

World Wide Emergency Room (ER)

$75
Urgent Care (Walk-in or Urgent Care clinic) $50

Ambulance

$150*

Outpatient Rehabilitation (Prior authorization after visit 25)**

$30*

High Cost Imaging

$150*
Lab work/X-rays

$0 Labs

$10 X-Rays

Durable Medical Equipment/Prosthetics

20% Coinsurance*

Additional Benefits
Routine Hearing Exam+ $30
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
Up to $3,310 in Drug Costs

$10 Generics; $45 Brand;
$90 Brand Non-preferred;
33% Specialty

Coverage Gap - Over $3,310 in Drug Costs; Up to $4,850 in Out-of-Pocket Costs

$10 copay 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;
$270 Brand Non-preferred

 

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.

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

 

 

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