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Martin’s Point Generations Advantage Prime (HMO-POS)

H5591 - 015 - 1

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Martin’s Point Generations Advantage Prime (HMO-POS) is a Medicare Advantage Plan by Martin’s Point Generations Advantage.

This page features plan details for 2025 Martin’s Point Generations Advantage Prime (HMO-POS) H5591 – 015 – 1.

IMPORTANT: This page features the 2025 version of this plan. See the 2025 version using the link below:

2025 Martin’s Point Generations Advantage Prime (HMO-POS) H5591 - 015 - 1

Locations

Martin’s Point Generations Advantage Prime (HMO-POS) is offered in the following locations.

Belknap County, New Hampshire

Carroll County, New Hampshire

Coos County, New Hampshire

Click to see more locations

Plan Overview

Martin’s Point Generations Advantage Prime (HMO-POS) offers the following coverage and cost-sharing.

Insurer:	Martin’s Point Generations Advantage
Health Plan Deductible:	$0
MOOP:	$6,350 In and Out-of-network $6,350 In-network
Drugs Covered:	Yes

Ready to sign up for Martin’s Point Generations Advantage Prime (HMO-POS) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Premium Breakdown

Martin’s Point Generations Advantage Prime (HMO-POS) has a monthly premium of $93.00. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.

Part B	Part C	Part D	Part B Give Back	Total
$185.00	$84.50	$8.50	$	$

Please Note:

Your Part B premium may differ based on factors including late enrollment, income, and disability status.
You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.

Drug Info

Martin’s Point Generations Advantage Prime (HMO-POS) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Deductible:	$0.00
Drug Out-Of-Pocket maximum:	$2,000.00
Drug Benefit Type:	Enhanced Alternative

Part D Premium Reduction

The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs.

The table below shows how the LIS impacts the Part D premium of this plan.

Part D	LIS Full
$8.50	$0.00

Initial Coverage Phase

After you pay your $0.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $2,000.00. Once you reach that amount, you will enter the next coverage phase.

30 Day

60 Day

90 Day

30 Day

Tier	Pref. Pharm	Std. Pharm	Std. Mail
1) Preferred Generic		$4.00 Copay	$4.00 Copay
2) Generic	$10.00 Copay	$18.00 Copay	$18.00 Copay
3) Preferred Brand	$42.00 Copay	$47.00 Copay	$47.00 Copay
4) Non-Preferred Drug	$95.00 Copay	$100.00 Copay	$100.00 Copay
5) Specialty Tier	33.00% Coinsurance	33.00% Coinsurance
6) Select Care Drugs		$4.00 Copay

60 Day

Tier	Pref. Pharm	Std. Pharm	Std. Mail
1) Preferred Generic		$8.00 Copay	$8.00 Copay
2) Generic	$20.00 Copay	$36.00 Copay	$36.00 Copay
3) Preferred Brand	$84.00 Copay	$94.00 Copay	$94.00 Copay
4) Non-Preferred Drug	$190.00 Copay	$200.00 Copay	$200.00 Copay
5) Specialty Tier
6) Select Care Drugs		$8.00 Copay

90 Day

Tier	Pref. Pharm	Std. Pharm	Std. Mail
1) Preferred Generic		$12.00 Copay	$10.00 Copay
2) Generic	$30.00 Copay	$54.00 Copay	$45.00 Copay
3) Preferred Brand	$126.00 Copay	$141.00 Copay	$117.50 Copay
4) Non-Preferred Drug	$285.00 Copay	$300.00 Copay	$250.00 Copay
5) Specialty Tier
6) Select Care Drugs		$12.00 Copay

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2,000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. Please note, that this plan has a Enhanced Alternative benefit type.

Additional Benefits

Martin’s Point Generations Advantage Prime (HMO-POS) also provides the following benefits.

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

- In-Network: Yes, contact plan for further details

Comprehensive Dental

Endodontics
- In-Network: 50 Coins – 50.00 Copay (Limits Apply, Authorization Required, Referral Required)
Maxillofacial Prosthetics
- In-Network: 50 Coins – 50.00 Copay (Limits Apply, Authorization Required, Referral Required)
Oral and Maxillofacial Surgery
- In-Network: 50 Coins – 50.00 Copay (Limits Apply, Authorization Required, Referral Required)
Periodontics
- In-Network: 50 Coins – 50.00 Copay (Limits Apply, Authorization Required, Referral Required)
Prosthodontics, fixed
- In-Network: 50 Coins – 50.00 Copay (Limits Apply, Authorization Required, Referral Required)
Prosthodontics, removable
- In-Network: 50 Coins – 50.00 Copay (Limits Apply, Authorization Required, Referral Required)
Restorative Services
- In-Network: 50 Coins – 50.00 Copay (Limits Apply, Authorization Required, Referral Required)

Diagnostic and Preventive Dental

Dental X-Rays
- In-Network: No Coins – – Copay
Oral Exams
- In-Network: No Coins – – Copay
Other Diagnostic Dental Services
- In-Network: 50 Coins – 50.00 Copay (Limits Apply, Authorization Required, Referral Required)
Other Preventive Dental Services
- In-Network: 50 Coins – 50.00 Copay (Limits Apply, Authorization Required, Referral Required)
Prophylaxis (cleaning)
- In-Network: No Coins – – Copay

Diagnostic procedures/lab services/imaging

Lab services
- Out-of-Network: $0-5 copay or 0-20% coinsurance (Authorization Required, Referral Required)
Diagnostic tests and procedures
- In-Network: 0-15% coinsurance (Authorization Required, Referral Required)
- Out-of-Network: 0-15% coinsurance (Authorization Required, Referral Required)
Outpatient x-rays
- Out-of-Network: 15% coinsurance (Authorization Required, Referral Required)
Diagnostic radiology services (e.g., MRI)
- In-Network: 20% coinsurance (Authorization Required, Referral Required)
- Out-of-Network: 30% coinsurance (Authorization Required, Referral Required)
Lab services
- In-Network: $0-5 copay or 0-20% coinsurance (Authorization Required, Referral Required)
Outpatient x-rays
- In-Network: 15% coinsurance (Authorization Required, Referral Required)

Doctor visits

Specialist
- In-Network: $45 copay per visit (Referral Required)
- Out-of-Network: $55 copay per visit (Referral Required)
Primary
- In-Network: $0 copay
- Out-of-Network: $35 copay per visit

Emergency care/Urgent care

Emergency
- $125 copay per visit (always covered)
Urgent care
- $55 copay per visit (always covered)

Foot care (podiatry services)

Routine foot care
- Not covered
Foot exams and treatment
- In-Network: $0-45 copay (Referral Required)
- Out-of-Network: $35-55 copay (Referral Required)

Ground ambulance

- Out-of-Network: $325 copay
- In-Network: $325 copay

Health plan deductible

- $0

Hearing

Fitting/evaluation
- In-Network: $0 copay (Limits Apply)
- In-Network: $0 copay (Limits Apply, Referral Required)
Hearing aids
- In-Network: $0 copay (Limits Apply)
Hearing aids OTC
- Not covered
Medicare-Covered Hearing Exam
- In-Network: $45 copay
- Out-of-Network: $55 copay
- In-Network: $45 copay (Referral Required)
- Out-of-Network: $55 copay (Referral Required)

Inpatient hospital coverage

- In-Network: $395 per day for days 1 through 7
  $0 per day for days 8 through 90 (Authorization Required)
- Out-of-Network: 40% per day for days 1 and beyond (Authorization Required)
- In-Network: $375 per day for days 1 through 7
  $0 per day for days 8 through 90 (Authorization Required)

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

- $6,350 In and Out-of-network
  $6,350 In-network
- $6,750 In and Out-of-network
  $6,750 In-network

Medical equipment/supplies

Durable medical equipment (e.g., wheelchairs, oxygen)
- In-Network: 20% coinsurance per item (Authorization Required)
Prosthetics (e.g., braces, artificial limbs)
- In-Network: 20% coinsurance per item (Authorization Required)
Diabetes supplies
- In-Network: $0 copay
Durable medical equipment (e.g., wheelchairs, oxygen)
- Out-of-Network: 30% coinsurance per item (Authorization Required)
Prosthetics (e.g., braces, artificial limbs)
- Out-of-Network: 30% coinsurance per item (Authorization Required)
Diabetes supplies
- Out-of-Network: 20% coinsurance per item

Medicare Part B drugs

Chemotherapy
- Out-of-Network: 20% coinsurance (Authorization Required)
Other Part B drugs
- Out-of-Network: 20% coinsurance (Authorization Required)
Chemotherapy
- In-Network: 0-20% coinsurance (Authorization Required)
Other Part B drugs
- In-Network: 0-20% coinsurance (Authorization Required)

Mental health services

Inpatient hospital – psychiatric
- Out-of-Network: Not Applicable (Authorization Required)
Outpatient group therapy visit
- Out-of-Network: $30 copay (Authorization Required)
Outpatient individual therapy visit with a psychiatrist
- Out-of-Network: $30 copay (Authorization Required)
Outpatient group therapy visit with a psychiatrist
- Out-of-Network: $30 copay (Authorization Required)
Outpatient individual therapy visit
- In-Network: $25 copay (Authorization Required)
Outpatient individual therapy visit with a psychiatrist
- In-Network: $25 copay (Authorization Required)
Inpatient hospital – psychiatric
- In-Network: $220 per day for days 1 through 7
  $0 per day for days 8 through 90 (Authorization Required)
Outpatient group therapy visit
- In-Network: $10 copay (Authorization Required)
Outpatient group therapy visit with a psychiatrist
- In-Network: $10 copay (Authorization Required)
Outpatient individual therapy visit
- Out-of-Network: $30 copay (Authorization Required)

Optional supplemental benefits

- No

Other health plan deductibles?

- In-Network: No

Outpatient hospital coverage

- Out-of-Network: $450 copay per visit (Authorization Required)
- In-Network: $0-325 copay per visit (Authorization Required)
- Out-of-Network: $475 copay per visit (Authorization Required)

Preventive care

- In-Network: $0 copay

Rehabilitation services

Occupational therapy visit
- Out-of-Network: $55 copay (Referral Required)
Physical therapy and speech and language therapy visit
- In-Network: $30 copay (Referral Required)
Occupational therapy visit
- In-Network: $30 copay (Referral Required)
Physical therapy and speech and language therapy visit
- Out-of-Network: $55 copay (Referral Required)

Skilled Nursing Facility

- In-Network: $10 per day for days 1 through 20
  $214 per day for days 21 through 100 (Authorization Required)
- Out-of-Network: Not Applicable (Authorization Required)

Transportation

- Not covered

Vision

Eyeglass lenses
- In-Network: $0 copay (Limits Apply)
Eyeglasses (frames and lenses)
- In-Network: $0 copay (Limits Apply)
Other
- Not covered
Upgrades
- In-Network: $0 copay (Limits Apply)
Eyeglass frames
- In-Network: $0 copay (Limits Apply)
Routine eye exam
- In-Network: $0 copay (Limits Apply)
Contact lenses
- In-Network: $0 copay (Limits Apply)

Wellness programs (e.g., fitness, nursing hotline)

- Covered