2022 Select (LPPO) Plan Details

Looking for 2021 Plan Information for the current year?
Visit our 2021 Select (LPPO) Plan Page


This is of the few plans in the country to receive 5 stars from Medicare, earning Medicare’s highest quality rating!

Generations Advantage Select (LPPO) provides complete medical, hospital, and Part D Prescription Drug coverage and you can see out-of-network doctors for all covered medical services, though you pay less for in-network doctors. Find out more about your benefits.

  • No deductible
  • $0 annual routine physical and annual routine vision exam (in-network)
  • $20 copays for primary care office visits in-network (30% out-of-network)
  • $0 copays for many preventive services when you see an in-network provider
  • $40 copays for specialist visits (30% out-of-network)
  • $0 copays for many generics at Hannaford Pharmacies1
  • $7,300 out-of-pocket maximum in-network ($10,000 combined in- and out-of-network) for services in all Maine Counties; and Cheshire, Coos, Hillsborough, Merrimack, Rockingham, Strafford, and Sullivan Counties in New Hampshire.
  • $6,700 out-of-pocket maximum in-network ($10,000 combined in- and out-of-network) for services in Belknap, Carroll, and Grafton 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.
Benefit for Select (LPPO) plan members in Belknap, Carroll, and Grafton, New Hampshire Counties only.


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

  • No waiting periods for coverage
  • $1,000 annual benefit maximum 
  • $50 OFFICE VISIT COPAY FOR ALL VISITS, then
    • Diagnostic and preventive services include oral exam and routine cleaning once per calendar year, problem-focused exams as needed, and X-rays and are covered with no coinsurance/deductible. *Periodontal maintenance (cleaning) is not a covered benefit.

Out-of-Network: See dentists who accept Medicare at a higher cost share.

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


Tier 1 2 3 4 5
Pharmacies with preferred cost sharing (including Hannaford pharmacies), 30-day supply* $0 $10 $40 $95 33% of cost
Pharmacies with Standard cost sharing, 30-day supply* $4 $18 $47 $100 33% of cost
Mail-order, 90-day supply $10 $45 $117.50 $250 33% of cost

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))

 


  • Free 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

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 

2021 Wellness Wallet Member Reimbursement (PDF)

This form is for any services covered under your 2021 Wellness Wallet reimbursement benefit. To be eligible for payment, the date of service or purchase must be in 2021 and you must submit your claim by March 31, 2022.  

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. 

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. 5Copays vary based on the type of hearing aid selected.
  • 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: 1-763-268-4264) 

*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 $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 three years  At home
DNA-based Test: Cologuard® Every three years At home
Flexible Sigmoidoscopy6 OR 
Screening Barium Enema
 
Every four years At facility
Colonoscopy6 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 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 registered dietitian.

If you prefer to reach out online, you can:

  • Visit MartinsPoint.Zipongo.com 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. 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.

1At pharmacies with preferred cost-sharing, you pay $0 for Cost-Sharing Tier 1
(preferred generic drugs and certain preferred brand name drugs). Other pharmacies are available in our network.

2Influenza (flu) vaccines are covered under your Medicare Part B benefit through Generations Advantage Select and costs do not count toward your Part D drug spend or out-of-pocket costs. 

3The Vaccine Pharmacy Network is offered through our relationship with our pharmacy benefit manager, CVS Caremark. Pharmacy network may change on January 1 of each year. Other pharmacies are available in our network.

4To qualify for reimbursement, services must be provided by practitioners who are practicing in the state in which they are licensed or certified, and are furnishing services within the scope of practice as defined by their licensing or certifying state (i.e., physician, nurse, registered dietitian, or nutritionist).

5The 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. 

6Ask your primary care provider what schedule is right for you. We cover these screenings more frequently for people at high risk for colorectal cancer. See your Evidence of Coverage for more information.
 

You may download Adobe Reader free to view the PDF documents.

The materials on this page may be made available in other formats such as Braille, large print or other alternate formats. Please contact us for more information. Call Member Services at 1-866-544-7504 (TTY:711). We are available 8 am - 8 pm, seven days a week from October 1 to March 31, and Monday through Friday the rest of the year. Calls to this number are free.

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