2022 Focus DC (HMO SNP) Plan Details

• $0 monthly premium. Remember, you must continue to pay your Medicare Part B premium
• No medical deductibles
• $0 annual routine physical and annual routine vision exam (in-network)
• $0 copays for primary care office visits
• $0 copays for a range of preventive services
• $0 copays for endocrinologists, podiatrists, mental health and substance use specialists
• $40 copays for all other specialist visits
• $0 copays for many generics at Hannaford Pharmacies²
• $5,700 out-of-pocket maximum. 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.

The Martin’s Point Generations Advantage Dental Benefit is administered by Northeast Delta Dental (NEDD).

In-Network Only: See a Delta Dental network dentist in Maine, New Hampshire, or Vermont

• No waiting periods for coverage
• $1,000 annual benefit maximum (the maximum amount the plan will pay each year toward your covered dental services after you have paid any applicable copays, deductibles, and coinsurance)

• $50 OFFICE VISIT COPAY FOR ALL VISITS (Please note: Any applicable deductible and/or coinsurance applied first.) 
  • Diagnostic and preventive services include cleanings, exams, and X-rays once per calendar year and are covered with no coinsurance/deductible. 
  • Basic restorative services include amalgam (silver) fillings, oral surgery, root canals, and periodontal maintenance and are covered with 50% coinsurance and a once-per-plan-year $50 deductible. Additional costs may apply for resin fillings. Please contact Northeast Delta Dental for more information.
  • Major restorative services include dentures, bridges, crowns, onlays, and implants and are covered with 50% coinsurance and a once-per-plan-year $50 deductible.

For Focus DC, there are no deductibles to meet. With your very first prescription, you only pay a small copayment or coinsurance.

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.

Initial Coverage Phase*
You begin this phase when you fill your first prescription of the year and pay the cost-shares noted above for covered drugs until your total yearly drug costs (what you pay PLUS what the plan pays) reach $4,430.

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 $4,430, 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 $7,050.
Focus DC only: You continue to pay the standard copayments for Tier 1 and Tier 2 drugs through the Coverage Gap stage.

Catastrophic Coverage Stage*

After your yearly out-of-pocket drug costs reach $7,050, you pay:

• For generics (including brand-name drugs treated as generic): The greater of $3.95 or a 5% coinsurance.
• For all other drugs, the greater of $9.85 or a 5% coinsurance.

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

• Shots include Quadrivalent, Trivalent, Trivalent (high dose), and Intradermal.
• Free at participating pharmacies⁴ 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.
• 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, they should call our Part D Pharmacy Help Desk at 1-800-364-6331

Download the reimbursement form HERE (PDF)

Your flexible Wellness Wallet benefit reimburses up to your plan’s annual amount for a wide range of eligible gear, fees, and services that help keep you active and well.

On our Wellness Wallet Information page you can find:

• A list of reimbursable items
• How to use your Wellness Wallet benefit
• Wellness Wallet FAQs  

2022 Wellness Wallet Member Reimbursement (PDF)

This form is for any services covered under your 2022 Wellness Wallet reimbursement benefit. To be eligible for payment, the date of service or purchase must be in 2022 and you must submit your claim by March 31, 2023.

What you pay when you get these services in network:

• $0: Annual routine eye exam (eye refraction) to determine the need for eyeglasses/contacts, once per calendar year.
• $40: Medicare-covered, non-routine outpatient physician services for the diagnosis and treatment of diseases and injuries of the eye, including treatment for age-related macular degeneration.
• $0: One glaucoma screening each year for people who are at high risk of glaucoma (includes people with a family history of glaucoma, people with diabetes, African Americans who are age 50 and older and Hispanic Americans who are 65 or older).
• $0: One diabetic eye exam (retinopathy screening) per year for people with diabetes.
• 20% of Medicare-allowable rate for standard eyeglasses (standard frames/standard lenses) or contacts after cataract surgery that includes insertion of intraocular lens.

Prescription Eyewear ONLY, including Frames, Lenses, and Contacts: May be reimbursed using the Wellness Wallet benefit.

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, $1,095, $1,495 or $2,095 per ear. Copays vary based on the type of hearing aid selected⁶
• 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: 1-855-533-7486 (TTY: 711)

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

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 350 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).

Martin’s Point Health Care has teamed up with Foodsmart™ to provide you with free, unlimited chats with a nutrition coach—plus much more—to support healthy eating from the comfort of home by telephone or online. You don’t need to use your health plan’s Wellness Wallet reimbursement program to take advantage of this benefit as your Generations Advantage plan covers 100% of the program cost. The Foodsmart program is tailored to your individual needs and preferences—from nutrition tips for managing a medical condition, to simply wanting to eat healthier, or just trying to save on groceries. Your Foodsmart nutrition coach and other resources can make healthy eating easier and more affordable.

To get started, call 1-888-837-5325 to schedule an appointment with a nutrition coach.

If you prefer to reach out online, you can:

• Visit https://www.foodsmart.com/martinspoint to sign up. If you are having online difficulties signing up, call 1-888-837-5325 for technical support. 
• Send an email requesting an appointment to [email protected].
• Download the Foodsmart app in the App Store or Google Play. Click on “Sign Up.” Your Group is “Martin’s Point Generations Advantage.”

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.

As a Martin’s Point Generations Advantage member, you are eligible to receive FREE, personalized care management. 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

One of our care managers will be in contact with you. We want to help you live the healthiest life possible. You may reach 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 voluntary. 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.

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.