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2016 Medicare Advantage Plan Benefit Details for the Martin's Point Generations Advantage Prime (HMO-POS)
This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.

2016 Medicare Advantage Plan Details
Medicare Plan Name:Martin's Point Generations Advantage Prime (HMO-POS)
Location:Hancock, Maine     Click to see other locations
Plan ID:H5591 - 001 - 0     Click to see other plans
Member Services:1-866-544-7504 TTY users 711
— This plan information is for research purposes only. —
Click here to see plans for the current plan year
Medicare Contact Information:Please go to Medicare.gov or call 1-800-MEDICARE (1-800-633-4227) to get information on all of your options.
TTY users 1-877-486-2048
or contact your local SHIP for assistance
Email a copy of the Martin's Point Generations Advantage Prime (HMO-POS) benefit details
— Medicare Plan Features —
Monthly Premium:$89.00 (see Plan Premium Details below)
Annual Deductible:$0
Annual Initial Coverage Limit (ICL):$3,310
Health Plan Type:Local HMO
Maximum Out-of-Pocket Limit for Parts A & B (MOOP):$5,500
Additional Gap Coverage?No additional gap coverage, only the Donut Hole Discount
Total Number of Formulary Drugs:3,173 drugsBrowse the Martin's Point Generations Advantage Prime (HMO-POS) Formulary
This plan has 5 drug tiers. See cost-sharing for all pharmacies and tiers. 
Formulary Drug Details:Tier 1Tier 2Tier 3Tier 4Tier 5
• Preferred Pharmacy
  Cost-Sharing during
  initial coverage phase:		$0.00$8.00$40.00$95.0033%
• Number of Drugs per
  Tier:		4541465309388557
Plan's Pharmacy Search:http://www.martinspoint.org/medicare
Plan Offers Mail Order?Yes
Number of Members enrolled in this plan in Hancock, Maine:1,602 members
Number of Members enrolled in this plan in Maine:11,835 members
Number of Members enrolled in this plan in (H5591 - 001):11,858 members
Plan’s Summary Star Rating: 5 out of 5 Stars.  
This plan qualifies for the 5-star rating Special Enrollment period. Read more.
• Customer Service Rating: 5 out of 5 Stars.
• Member Experience Rating: 5 out of 5 Stars.
• Drug Cost Accuracy Rating: 5 out of 5 Stars.
— Plan Premium Details —
The Monthly Premium is Split as Follows: ❔
Total
Premium		Part C
Premium		Part D Base
Premium		Part D Supplemental
Premium
$89.00$56.80$32.20$0.00
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔100%
Subsidy		75%
Subsidy		50%
Subsidy		25%
Subsidy
Monthly Part D Premium with LIS:$0.00$8.00$16.10$24.10
Total Monthly Premium with LIS (Parts C & D):$56.80$64.80$72.90$80.90
— Plan Health Benefits —
** Cost **
Monthly premium, deductible, and limits on how much you pay for covered services
$89 per month. In addition you must keep paying your Medicare Part B premium.
This plan does not have a deductible.
Yes. Like all Medicare health plans our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care.
Your yearly limit(s) in this plan:
  • $5 500 for services you receive from in-network providers.
  • $5 500 for services you receive from any provider. Your limit for services received from in-network providers will count toward this limit.
If you reach the limit on out-of-pocket costs you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year.

Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs.
** Doctor and Hospital Choice **
Acupuncture
Not covered
** Extra Benefits **
Inpatient mental health care
For inpatient mental health care see the "Mental Health Care" section.
Outpatient prescription drugs
For Part B drugs such as chemotherapy drugs1:
  • In-network:  20% of the cost
  • Out-of-network:  20% of the cost
Other Part B drugs1:
  • In-network:  20% of the cost
  • Out-of-network:  20% of the cost
You pay the following until your total yearly drug costs reach $3 310. Total yearly drug costs are the total drug costs paid by both you and our Part D plan.
You may get your drugs at network retail pharmacies and mail order pharmacies.
Standard Retail Cost-Sharing
TierOne-month supplyTwo-month supplyThree-month supply
Tier 1 (Preferred Generic)$4 copay$8 copay$12 copay
Tier 2 (Generic)$15 copay$30 copay$45 copay
Tier 3 (Preferred Brand)$47 copay$94 copay$141 copay
Tier 4 (Non-Preferred Brand)$100 copay$200 copay$300 copay
Tier 5 (Specialty Tier)33% of the cost33% of the cost33% of the cost
Preferred Retail Cost-Sharing
TierOne-month supplyTwo-month supplyThree-month supply
Tier 1 (Preferred Generic)$0$0$0
Tier 2 (Generic)$8 copay$16 copay$24 copay
Tier 3 (Preferred Brand)$40 copay$80 copay$120 copay
Tier 4 (Non-Preferred Brand)$95 copay$190 copay$285 copay
Tier 5 (Specialty Tier)33% of the cost33% of the cost33% of the cost
Standard Mail Order Cost-Sharing
TierOne-month supplyTwo-month supplyThree-month supply
Tier 1 (Preferred Generic)$4 copay$8 copay$10 copay
Tier 2 (Generic)$15 copay$30 copay$37.50 copay
Tier 3 (Preferred Brand)$47 copay$94 copay$117.50 copay
Tier 4 (Non-Preferred Brand)$100 copay$200 copay$250 copay
Tier 5 (Specialty Tier)33% of the cost33% of the cost33% of the cost
If you reside in a long-term care facility you pay the same as at a retail pharmacy.
You may get drugs from an out-of-network pharmacy but may pay more than you pay at an in-network pharmacy.
Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means that there's a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $3 310.

After you enter the coverage gap you pay 45% of the plan's cost for covered brand name drugs and 58% of the plan's cost for covered generic drugs until your costs total $4 850 which is the end of the coverage gap. Not everyone will enter the coverage gap.

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4 850 you pay the greater of:
  • 5% of the cost or
  • $2.95 copay for generic (including brand drugs treated as generic) and a $7.40 copayment for all other drugs.
** Important Information **
Monthly premium, deductible, and limits on how much you pay for covered services
$89 per month. In addition you must keep paying your Medicare Part B premium.
This plan does not have a deductible.
Yes. Like all Medicare health plans our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care.
Your yearly limit(s) in this plan:
  • $5 500 for services you receive from in-network providers.
  • $5 500 for services you receive from any provider. Your limit for services received from in-network providers will count toward this limit.
If you reach the limit on out-of-pocket costs you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year.

Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs.
** Outpatient Care and Services **
Acupuncture
Not covered
Ambulance
  • In-network:  $200 copay
  • Out-of-network:  $200 copay
Chiropractic care
Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position):
  • In-network:  $20 copay
  • Out-of-network:  $40 copay
Dental services
Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth):
  • In-network:  $35 copay
  • Out-of-network:  $40 copay
A single office visit that includes:
  • In-network:  $35 copay
  • Cleaning (for up to 1 every year)
  • Dental x-ray(s) (for up to 1 every two years)
  • Oral exam (for up to 1 every year)
Diabetes supplies and services
Diabetes monitoring supplies:
  • In-network:  You pay nothing
  • Out-of-network:  20% of the cost
Diabetes self-management training:
  • In-network:  You pay nothing
  • Out-of-network:  You pay nothing
Therapeutic shoes or inserts:
  • In-network:  You pay nothing
  • Out-of-network:  20% of the cost
Diagnostic tests, lab and radiology services, and x-rays (Costs for these services may be different if received in an outpatient surgery setting)
Diagnostic radiology services (such as MRIs CT scans):
  • In-network:  20% of the cost
  • Out-of-network:  30% of the cost
Diagnostic tests and procedures:
  • In-network:  0-15% of the cost depending on the service
  • Out-of-network:  0-15% of the cost depending on the service
Lab services:
  • In-network:  0-20% of the cost depending on the service
  • Out-of-network:  0-20% of the cost depending on the service
Outpatient x-rays:
  • In-network:  $15 copay
  • Out-of-network:  $15 copay
Therapeutic radiology services (such as radiation treatment for cancer):
  • In-network:  20% of the cost
  • Out-of-network:  30% of the cost
Doctor's office visits
Primary care physician visit:
  • In-network:  You pay nothing
  • Out-of-network:  $35 copay
Specialist visit:
  • In-network:  $35 copay
  • Out-of-network:  $40 copay
Durable medical equipment (wheelchairs, oxygen, etc.)
  • In-network:  20% of the cost
  • Out-of-network:  30% of the cost
Emergency care
$75 copay
If you are admitted to the hospital within 24 hours you do not have to pay your share of the cost for emergency care. See the "Inpatient Hospital Care" section for other costs.
Foot care (podiatry services)
Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions:
  • In-network:  $35 copay
  • Out-of-network:  $40 copay
Hearing services
Exam to diagnose and treat hearing and balance issues:
  • In-network:  $35 copay
  • Out-of-network:  $40 copay
Home health care
  • In-network:  You pay nothing
Mental health care
Inpatient visit:
Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital.
The copays for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you're admitted as an inpatient and ends when you haven't received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There's no limit to the number of benefit periods.
Our plan covers 90 days for an inpatient hospital stay.
Our plan also covers 60 "lifetime reserve days." These are "extra" days that we cover. If your hospital stay is longer than 90 days you can use these extra days. But once you have used up these extra 60 days your inpatient hospital coverage will be limited to 90 days.
  • In-network:  
    • $220 copay per day for days 1 through 7
    • You pay nothing per day for days 8 through 90
      • Outpatient group therapy visit:
      • In-network:  $25 copay
      • Out-of-network:  $30 copay
      Outpatient individual therapy visit:
      • In-network:  $25 copay
      • Out-of-network:  $30 copay
      Outpatient rehabilitation
      Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks):
      • In-network:  You pay nothing
      Occupational therapy visit:
      • In-network:  $35 copay
      • Out-of-network:  $40 copay
      Physical therapy and speech and language therapy visit:
      • In-network:  $35 copay
      • Out-of-network:  $40 copay
      Outpatient substance abuse
      Group therapy visit:
      • In-network:  $25 copay
      • Out-of-network:  $30 copay
      Individual therapy visit:
      • In-network:  $25 copay
      • Out-of-network:  $30 copay
      Outpatient surgery
      Ambulatory surgical center:
      • In-network:  $175 copay
      • Out-of-network:  $200 copay
      Outpatient hospital:
      • In-network:  $0-325 copay depending on the service
      • Out-of-network:  $0-350 copay depending on the service
      Over-the-counter items
      Not Covered
      Prosthetic devices (braces, artificial limbs, etc.)
      Prosthetic devices:
      • In-network:  20% of the cost
      • Out-of-network:  30% of the cost
      Related medical supplies:
      • In-network:  20% of the cost
      • Out-of-network:  30% of the cost
      Renal dialysis
      • In-network:  20% of the cost
      • Out-of-network:  20% of the cost
      Transportation
      Not covered
      Urgently needed services
      $40 copay
      If you are admitted to the hospital within 24 hours you do not have to pay your share of the cost for urgently needed services. See the "Inpatient Hospital Care" section for other costs.
      Vision services
      Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening):
      • In-network:  $0-35 copay depending on the service
      • Out-of-network:  $40 copay
      Routine eye exam:
      • In-network:  You pay nothing. You are covered for up to 1 every year.
      Eyeglasses or contact lenses after cataract surgery:
      • In-network:  20% of the cost
      • Out-of-network:  20% of the cost
      ** Hospice **
      Hospice
      You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the cost for drugs and respite care.
      ** Preventive Care **
      Preventive care
      • In-network:  You pay nothing
      Our plan covers many preventive services including:
      • Abdominal aortic aneurysm screening
      • Alcohol misuse counseling
      • Bone mass measurement
      • Breast cancer screening (mammogram)
      • Cardiovascular disease (behavioral therapy)
      • Cardiovascular screenings
      • Cervical and vaginal cancer screening
      • Colorectal cancer screenings (Colonoscopy Fecal occult blood test Flexible sigmoidoscopy)
      • Depression screening
      • Diabetes screenings
      • HIV screening
      • Medical nutrition therapy services
      • Obesity screening and counseling
      • Prostate cancer screenings (PSA)
      • Sexually transmitted infections screening and counseling
      • Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease)
      • Vaccines including Flu shots Hepatitis B shots Pneumococcal shots
      • "Welcome to Medicare" preventive visit (one-time)
      • Yearly "Wellness" visit
      Any additional preventive services approved by Medicare during the contract year will be covered.
      ** Inpatient Care **
      Inpatient hospital care
      The copays for hospital and skilled nursing facility (SNF) benefits are based on benefit periods. A benefit period begins the day you're admitted as an inpatient and ends when you haven't received any inpatient care (or skilled care in a SNF) for 60 days in a row. If you go into a hospital or a SNF after one benefit period has ended a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There's no limit to the number of benefit periods.
      Our plan covers an unlimited number of days for an inpatient hospital stay.
      • In-network:  
        • $275 copay per day for days 1 through 7
        • You pay nothing per day for days 8 through 90
        • You pay nothing per day for days 91 and beyond
          • Inpatient mental health care
          For inpatient mental health care see the "Mental Health Care" section.
          Skilled Nursing Facility (SNF)
          Our plan covers up to 100 days in a SNF.
          • In-network:  
            • You pay nothing per day for days 1 through 20
            • $160 copay per day for days 21 through 100
              • Outpatient prescription drugs
              For Part B drugs such as chemotherapy drugs1:
              • In-network:  20% of the cost
              • Out-of-network:  20% of the cost
              Other Part B drugs1:
              • In-network:  20% of the cost
              • Out-of-network:  20% of the cost
              You pay the following until your total yearly drug costs reach $3 310. Total yearly drug costs are the total drug costs paid by both you and our Part D plan.
              You may get your drugs at network retail pharmacies and mail order pharmacies.
              Standard Retail Cost-Sharing
              TierOne-month supplyTwo-month supplyThree-month supply
              Tier 1 (Preferred Generic)$4 copay$8 copay$12 copay
              Tier 2 (Generic)$15 copay$30 copay$45 copay
              Tier 3 (Preferred Brand)$47 copay$94 copay$141 copay
              Tier 4 (Non-Preferred Brand)$100 copay$200 copay$300 copay
              Tier 5 (Specialty Tier)33% of the cost33% of the cost33% of the cost
              Preferred Retail Cost-Sharing
              TierOne-month supplyTwo-month supplyThree-month supply
              Tier 1 (Preferred Generic)$0$0$0
              Tier 2 (Generic)$8 copay$16 copay$24 copay
              Tier 3 (Preferred Brand)$40 copay$80 copay$120 copay
              Tier 4 (Non-Preferred Brand)$95 copay$190 copay$285 copay
              Tier 5 (Specialty Tier)33% of the cost33% of the cost33% of the cost
              Standard Mail Order Cost-Sharing
              TierOne-month supplyTwo-month supplyThree-month supply
              Tier 1 (Preferred Generic)$4 copay$8 copay$10 copay
              Tier 2 (Generic)$15 copay$30 copay$37.50 copay
              Tier 3 (Preferred Brand)$47 copay$94 copay$117.50 copay
              Tier 4 (Non-Preferred Brand)$100 copay$200 copay$250 copay
              Tier 5 (Specialty Tier)33% of the cost33% of the cost33% of the cost
              If you reside in a long-term care facility you pay the same as at a retail pharmacy.
              You may get drugs from an out-of-network pharmacy but may pay more than you pay at an in-network pharmacy.
              Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means that there's a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $3 310.

              After you enter the coverage gap you pay 45% of the plan's cost for covered brand name drugs and 58% of the plan's cost for covered generic drugs until your costs total $4 850 which is the end of the coverage gap. Not everyone will enter the coverage gap.

              After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4 850 you pay the greater of:
              • 5% of the cost or
              • $2.95 copay for generic (including brand drugs treated as generic) and a $7.40 copayment for all other drugs.
              ** Outpatient Care **
              Diabetes supplies and services
              Diabetes monitoring supplies:
              • In-network:  You pay nothing
              • Out-of-network:  20% of the cost
              Diabetes self-management training:
              • In-network:  You pay nothing
              • Out-of-network:  You pay nothing
              Therapeutic shoes or inserts:
              • In-network:  You pay nothing
              • Out-of-network:  20% of the cost
              Foot care (podiatry services)
              Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions:
              • In-network:  $35 copay
              • Out-of-network:  $40 copay
              Hearing services
              Exam to diagnose and treat hearing and balance issues:
              • In-network:  $35 copay
              • Out-of-network:  $40 copay
              ** Outpatient Medical Services and Supplies **
              Outpatient substance abuse
              Group therapy visit:
              • In-network:  $25 copay
              • Out-of-network:  $30 copay
              Individual therapy visit:
              • In-network:  $25 copay
              • Out-of-network:  $30 copay
              Prosthetic devices (braces, artificial limbs, etc.)
              Prosthetic devices:
              • In-network:  20% of the cost
              • Out-of-network:  30% of the cost
              Related medical supplies:
              • In-network:  20% of the cost
              • Out-of-network:  30% of the cost
              ** Additional Benefits **
              Inpatient mental health care
              For inpatient mental health care see the "Mental Health Care" section.




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              .