2022 Prime (HMO-POS) Plan Details

• No deductibles
• $0 annual routine physical and annual routine vision exam (in-network)
• $0 copays for primary care office visits
• $0 copays for many preventive services
• $40 copays for specialist visits
• $0 copays for many generic drugs at Hannaford Pharmacies¹
• $6,500 out-of-pocket maximum for in and out-of-network services in Androscoggin, Aroostook, Cumberland, Franklin, Hancock, Kennebec, Knox, Lincoln, Oxford, Penobscot, Piscataquis, Sagadahoc, Somerset, Waldo, Washington, and York Counties in Maine and Belknap, Carroll, Coos, and Grafton Counties in New Hampshire. Note: Plan premium and prescription drug copayments don't count toward this maximum.
• $7,050 out-of-pocket maximum for in and out-of-network services in Cheshire, Hillsborough, Merrimack, Rockingham, Strafford and Sullivan Counties in New Hampshire. 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 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 the Prime plan, there are no deductibles to meet. With your very first prescription, you only pay a small copayment or coinsurance. The copayment/coinsurance is determined by what type of drug you are receiving as well as which pharmacy you use.

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.

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))

• 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 Intradermal
• 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.

COVERAGE OVERVIEW

Hearing benefits from Martin's Point are covered via Amplifon Hearing Health Care. 

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.

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

Coverage includes:

• Hearing Aids (Copays vary): Two hearing aids (one per ear) per year.
  *Copays (per ear) cost $495, $695, $1,095, $1,495, or $2,095, depending on the type of hearing aid selected

• Hearing Aid Batteries: Two years of free hearing aid batteries.

• Follow-Up Care: One year of free follow-up care for hearing aid fittings and evaluations

• Warranties: 3-year warranty on hearing devices 

*The copays listed are for hearing aids offered through the Martin’s Point-Amplifon Five-Tier program. Your provider will recommend a hearing aid on these tier levels based on your lifestyle and hearing loss.

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

Screening Test	How Often6	Mode of Screening
Fecal Occult Blood Test (gFOBT, iFOBT) Fecal Immunochemical Test (FIT)	Every calendar year	At home
DNA-based Test: Cologuard®	Every three years	At home
Flexible Sigmoidoscopy OR  Screening Barium Enema	Every four years	At facility
Colonoscopy Screening	Every 10 years	At facility

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 2022 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.

• 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.

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 Carenet Healthcare Services 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.