2015 Plan Comparison 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/coinsurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium. Massachusetts For 2015, HNE Medicare Advantage received an Overall Star Rating of 4.5 out of a possible 5 Stars from Medicare.** HNE Medicare Advantage is an HMO plan with a Medicare contract. Enrollment in HNE Medicare Advantage depends on contract renewal. Please contact HNE Medicare Advantage for details at 413.787.0010 or 877.431.2122. TTY/TDD users call 800.439.2370. A representative is available between 8:00 a.m. and 8:00 p.m., Monday – Friday (October 1 February 14: 8 a.m. - 8 p.m., 7 days a week). If you’d like to come to our office and meet with an HNE Medicare Specialist* or Member Services Representative, we are located on the 15th floor of Monarch Place in Springfield. HNE’s office hours are 9:00 a.m. to 4:00 p.m., Monday – Friday. For questions related to Prescription Drug coverage, call 800.546.5677, 24 hours a day, 7 days a week. TTY/TDD users should call 866.706.4757. *Licensed health insurance sales representatives **HNE Medicare Advantage is a 4.5 star overall rated plan for 2015. Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next. Go to medicare.gov to check Medicare Star Ratings. To learn more visit hne.com/medicare or call us at 877.431.2122 or TTY 800.439.2370 8:00 a.m. to 8:00 p.m., Monday through Friday (October 1 through February 14: 8:00 a.m. to 8:00 p.m., 7 days a week) One Monarch Place • Suite 1500 Springfield, MA 01144-1500 413.787.0010 • 877.443.3314 TTY/TDD 800.439.2370 hne.com/medicare H8578_2015_023MAS Accepted Kerry, Sarah, Lee, and Carla, Your HNE Medicare Specialist Team* HNE Medicare Freedom (HMO-POS) Point of Service Plan In Network Out-of-Network $210 HNE Medicare Premium (HMO)** HNE Medicare Plus (HMO) HNE Medicare Basic (HMO)** HNE Medicare Value (HMO) $156 $106 $75 $20 $3,400 $3,400 $3,400 $6,700 $3,400 No Out-of-Pocket Maximum Office Visits ($0 annual preventive exam) $15 $20 $30 $35 $15 $55 Specialist Office Visits $20 $30 $40 $45 $20 $55 Inpatient Hospital $300 per admission*** $600 per admission*** $900 per admission*** $295 per day for Days 1-5 $300 per admission*** $300 per day for Days 1-5 PA Outpatient Surgery $150* $300* $450* 20% coinsurance* $150* 20% coinsurance PA Days 1-20: $25 copay per day* Days 21-50: $40 copay per day Days 51-100: $0 copay Days 1-20: $0 copay per day* Days 21-50: $75 copay per day Days 51-100: $0 copay Monthly Plan Premium Medical Out-of-Pocket Maximum Days 1-20: $20 copay per day* Days 1-20: $40 copay per day* Days 21-100: $0 copay Days 21-100: $0 copay Skilled Nursing Facility (SNF) World Wide Emergency Room (ER) Ambulance Outpatient Rehabilitation (PA after visit 25)**** High Cost Imaging Lab Work/X-rays Durable Medical Equipment/ Prosthetics Additional Benefits Preventive Hearing Exam+ Preventive Vision Exam+ Vision Eye Wear Allowance+ Dental Services Allowance+ Fitness Center/Weight Watchers / Safety Items/Over-the-Counter Allowance+ $65 $65 $65 $65 $100* $100* $100* $150* $20* $30* $40* $40* $100* $150* $200* $200* $0 $0 $0 for Labs; $10 for X-Rays 10% coinsurance 10% coinsurance* 15% coinsurance* 20% coinsurance* 20% coinsurance* $20 $30 $40 $45 $0 $0 $0 $0 $100 every two years $100 every two years $100 every two years $100 every two years $100 every two years $150 per year $150 per year $150 per year $150 per year $150 per year $150 per year $150 per year $150 per year $150 per year $150 per year $350 per year (if on chemotherapy) $350 per year (if on chemotherapy) $350 per year (if on chemotherapy) $350 per year (if on chemotherapy) $350 per year (if on chemotherapy) Prescription Drug (Part D) Coverage Deductible N/A N/A N/A $150 N/A $10 Generics; $45 Brand; $90 Brand Non-preferred; 33% Specialty $10 Generics; $45 Brand; $90 Brand Non-preferred; 33% Specialty $10 Generics; $45 Brand; $90 Brand Non-preferred; 33% Specialty $10 Generics; $45 Brand; $90 Brand Non-preferred; 29% Specialty $10 Generics; $45 Brand; $90 Brand Non-preferred; 33% Specialty $10 copay generics. Brand name drugs, you pay 45% of the price or the HNE negotiated price, whichever is lower. $10 copay generics. Brand name drugs, you pay 45% of the price or the HNE negotiated price, whichever is lower. $10 copay generics. Brand name drugs, you pay 45% of the price or the HNE negotiated price, whichever is lower. 65% of the costs for generics. Brand name drugs, you pay 45% of the price or the HNE negotiated price, whichever is lower. $10 copay generics. Brand name drugs, you pay 45% of the price or the HNE negotiated price, whichever is lower. Catastrophic Coverage Over $4,700 in Out-of-Pocket Costs $2.65 for Generics and $6.60 for all other drugs; or 5% coinsurance $2.65 for Generics and $6.60 for all other drugs; or 5% coinsurance $2.65 for Generics and $6.60 for all other drugs; or 5% coinsurance $2.65 for Generics and $6.60 for all other drugs; or 5% coinsurance $2.65 for Generics and $6.60 for all other drugs; or 5% coinsurance Mail-order (Three month supply) ++ $20 Generics; $90 Brand; $270 Brand Non-preferred $20 Generics; $90 Brand; $270 Brand Non-preferred $20 Generics; $90 Brand; $270 Brand Non-preferred $20 Generics; $90 Brand; $270 Brand Non-preferred $20 Generics; $90 Brand; $270 Brand Non-preferred Initial Coverage Up to $2,960 in Drug Costs Coverage Gap Over $2,960 in Drug Costs; Up to $4,700 in Out-of-Pocket Costs **Plan available without Prescription Drug (Part D) Coverage. HNE Medicare Premium No Rx (HMO) monthly premium is $89 and HNE Medicare Basic No Rx (HMO) monthly premium is $19. Days 1-20: $20 copay per day* Days 1-20: $75 copay per day ***3 copayment maximum per year. PA Days 21-100: $0 copay Days 21-100: $0 copay PA Members of the HNE Medicare Freedom (HMO-POS) plan who $65 $65 choose to get these services out$100* $100 PA of-network are responsible for getting prior authorization from $20* $55 PA HNE. Please tell your out-of-network provider that prior authorization $100* 20% coinsurance PA is required. The provider may be $0 10% coinsurance willing to contact HNE Member Services for you to get prior 10% coinsurance* 20% coinsurance PA authorization. Call Member Services to confirm prior authorization. For a complete list of services $20 $55 that require prior authorization, refer to the Summary of Benefits. $0 $0 ® Wig Allowance+ *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. **** PA 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, standard coverage gap cost-sharing applies. During the catastrophic coverage stage, standard catastrophic coverage applies for all plans.