Flex (RPPO) Plan Details 2021

• No medical deductible; $275 prescription deductible for Tiers 3– 5 drugs only
• $0 annual routine physical and annual routine vision exam (30% out-of-network)
• $0 copays for primary care in-network and in-service-area (30% out-of-service-area)
• $0 copays for many preventive services when you see an in-network provider
• $50 copays for specialist visits (30% out-of-network)
• $2 copays for many generics at Hannaford Pharmacies¹
• $0 for generic drugs through the mail-order pharmacy benefit
• $5,500 out-of-pocket maximum ($8,000 combined in and out-of-network). Note: Plan premium and prescription drug copayments don't count toward this maximum.
• Emergency care coverage worldwide
• Urgent care coverage worldwide

*Note: This is not a comprehensive list of plan benefits, please refer to the Evidence of Coverage (EOC) for a full list of plan benefits.

In-Network: See a Delta Dental Premier and PPO/Martin’s Point Generations Advantage network dentist in Maine, New Hampshire, or Vermont

Out-of-Network: See any out-of-network dentist, cost shares differ

• No waiting periods for coverage
• $1,000 annual benefit maximum (in- and out-of-network combined)

• $50 OFFICE VISIT COPAY FOR ALL VISITS, then
  • Diagnostic and preventive services include cleanings, exams, and X-rays: In-network—fully covered with no coinsurance/deductible; out-of-network—covered at 50% with no deductible
  • Basic restorative services include fillings, oral surgery, root canals, and periodontal maintenance: In-network—covered with 50% coinsurance and a once-per-plan-year $50 deductible; out-of-network—covered with 75% coinsurance and a once-per-plan-year $50 deductible
  • Major restorative services include dentures, bridges, crowns, onlays, and implants: In-network—covered with 50% coinsurance and a once-per-plan-year $50 deductible; out-of-network—covered at 75% coinsurance and a once-per-plan-year deductible

There is a $275 prescription deductible for Tiers 3–5 drugs only. There is no deductible for Tiers 1 and 2 medications; you only pay a small copayment or coinsurance. 

For Tiers 3, 4 and 5, you pay the full cost of the drug until you reach your $275 deductible.

What you pay for your drugs depends on the drug tier, what “drug payment phase” you are in when you get the drug, and which pharmacy you use.

Deductible Phase
You begin this phase when you fill your first prescription of the year and pay your Tier 1 and 2 cost-share and total cost of your tier 3, 4, and 5 drugs until you reach your $275 deductible.

Initial Coverage Phase
You begin this phase when you fill your first prescription after your deductible phase and pay the the cost-shares noted above for covered drugs until your total yearly drug costs (what you pay PLUS what the plan pays) reach $4,130. 

IMPORTANT NOTE ABOUT PRESCRIPTION PRICING: In some cases, the cost of a drug is lower than the copay amount of its tier. In that situation, the plan would only charge the member the amount of the medication, not the full copay amount.

Coverage Gap Stage* 
After your total yearly drug costs (what you pay PLUS what the plan pays) reach $4,130, you will pay 25% of the price for brand name drugs (plus a portion of the dispensing fee) and pay 25% of the plan's costs for all generic drugs until your yearly out-of-pocket drug costs reach $6,350.

Catastrophic Coverage Stage* 
After your yearly out-of-pocket drug costs reach $6,550 you pay:
For generics (including brand-name drugs treated as generic): The greater of $3.70 or a 5% coinsurance.
For all other drugs, the greater of $9.20 or a 5% coinsurance.

*Different cost-sharing applies for Members who receive "Extra Help" (Low-Income Subsidy (LIS/LICS))

• Free² at participating pharmacies³ including Hannaford, Rite Aid, CVS (including former Target pharmacies), Shaw’s/Osco, Walgreens, and Walmart.
• If you get the shot at your Primary Care Provider’s office, you may have to pay a copayment for the office visit, but there will be no cost for the flu shot.
• Shots include Quadrivalent, Trivalent, Trivalent (high dose), and Intraderma.
• If you get your flu shot at a pharmacy that is not in the Vaccine Pharmacy Network, it may still be covered by your plan. You will pay the full cost at the pharmacy and submit a form to us for reimbursement.
• If you don’t show your Generations Advantage member ID card when you get your flu shot, you will pay the full cost at the pharmacy and submit a form to us for reimbursement.
• If your pharmacist has problems sending your claim to us, he or she should call our Part D Pharmacy Help Desk at 1-800-364-6331.

Download the reimbursement form HERE (PDF).

• Fitness services, gym membership, personal trainer fees at a facility, fitness classes, fitness equipment, outdoor bicycles, bicycle repair, sport leagues, bowling, ski passes/skis, exercise sneakers and hiking boots
• Wearable fitness tracker (including Apple Watch and other smart watches)
• Eyewear, including prescription glasses, lenses, frames, and contact lenses
• Acupuncture and naturopathic services through a licensed naturopathic doctor (homeopathy and hypnotherapy do not qualify)
• Good Measures dietary services through a registered dietitian⁴
• Nutrition and dietary benefit⁴
• Weight management programs

*Members with a diagnosis of chronic kidney disease, diabetes, or pre-diabetes can access Good Measures services at no cost.

Please note this is not a complete list. If you have any questions about an item/service, please call Member Services to confirm it is covered.

Face masks are now covered under the Wellness Wallet and subject to your benefit maximum. Masks must be purchased through a website, retail store, or Durable Medical Equipment (DME) provider.

The approved benefit includes:

• Cloth masks
• Surgical masks are now covered (limit 50 per month to reserve supplies for health care workers and medical first responders).
• Exclusions: N95 respirators, homemade cloth mask supplies.

Download your reimbursement form to mail in: 

2021 Wellness Wallet Member Reimbursement (PDF)

The 2020 form is for any services covered under your 2020 Wellness Wallet reimbursement benefit. To be eligible for payment, the date of service or purchase must be in 2020 and you must submit your claim by March 31, 2021. 

2020 Wellness Wallet Member Reimbursement (PDF)

If you are not sure whether your expense is eligible for reimbursement, please call Martin's Point Generations Advantage Member Services at 1-866-544-7504 or see the Wellness Wallet FAQs for details.

Amplifon will help you find a hearing aid provider near you, explain the process, help you schedule an appointment, and send information to you and the provider, ensuring your discount is applied. Your coverage includes:

• Two hearing aids (one per ear) per year
• Hearing aid copays (per ear): $495, $695 or $1095. Copays vary based on the type of hearing aid selected.⁵
• Two years of free hearing aid batteries
• One year of free follow-up care for hearing aid fittings and evaluations
• 3-year warranty on hearing devices 

Call Amplifon, 8 am–8 pm, Monday through Friday to get started: 1-888-669-2167 (TTY: 1-763-268-4264)

*These benefits are only available when purchasing a hearing aid through the Martin’s Point-Amplifon program.

• Choose an in-home system (landline or cellular that can be used only in the home) or a mobile system with location services which can be used outside of the home
• Get discounted monthly costs ranging from $19.95–29.95, depending on the unit (approximately 25% off regular consumer pricing)
• Fall-detection option available for an additional fee (automatically alerts Lifestation that you have fallen, even if you do not press the emergency button)
• Product warranty on all service plans (a $5 per month value at no charge)
• Spousal coverage available on all in-home units (a $3.99 per month value at no charge)

For more information, call LifeStation at: 1-866-220-0934

Talk to your doctor about which screening is right for you—all have a $0 copay when you go to an In-network provider.

Members receive a quarterly amount to purchase from over 300 CVS brand, over-the-counter products, including:

• Smoking cessation: Nicotine replacement patches
• Oral health: Toothpaste, toothbrushes, floss
• Pain relief: Ibuprofen, acetaminophen
• Allergy: Allergy relief tablets
• Cold remedies: Cough drops, daytime/nighttime cold medicine
• Digestive health: Heartburn relief tablets, daily fiber
• First aid: Bandages
• Incontinence: Bladder control products

You may make a purchase in-person at participating CVS locations, over the phone by calling OTC Health Solutions at 1-888-628-2770 (TTY: 711), or online.

Search and buy products online.
Download the catalog (PDF)
Search OTC Benefit Pharmacy Locations

Note that unused quarterly amounts are forfeited (do not roll over into the next quarter).

As a Martin’s Point Generations Advantage member, you are eligible to receive FREE, personalized care management. Sign up for a dedicated medical or behavioral health care manager who will help you succeed at leading a healthy, active, and full life. Our care managers can help you:

• Manage your health care
• Navigate your health plan
• Understand medications
• Find community support and resources

We want to help you live the healthiest life possible. Get started by calling a Martin’s Point care manager at 1-877-659-2403 or visit our Health Services page for more details.

Martin’s Point care management programs are entirely voluntary. You can choose not to participate or to stop participating in the program at any time. If you have immediate concerns regarding your health, please contact your doctor. Always consult your health care provider before making any lifestyle changes. Only your doctor can diagnose and treat a medical condition.

Talk with a trained nurse anytime, 24 hours a day, 7 days a week, to answer any questions about symptoms, injuries, or illness. 

Call 1-800-530-1021 if you need to know:

• If a cut requires stitches
• If you should head to an urgent care clinic, the ER, or wait until morning to see your doctor
• General information about a condition, medication, or other health concerns

This service is provided by SironaHealth in partnership with Martin's Point. This service is not intended to take the place of your primary care provider. 

At Martin’s Point, we are committed to providing our members a fair and timely process for resolving any complaints or disputes. We encourage Martin’s Point Generations Advantage members to contact us with questions, concerns, or problems related to any benefits or service. Please call us at 1-866-544-7504 (TTY: 711), 8 am to 8 pm, seven days a week from October 1–March 31, and Monday through Friday the rest of the year, to discuss your concerns.

For more information on this process, please visit our Grievances & Appeals page.