WellCare Compass H6439:003-0 (HMO) Plan Details

Arizona Counties Served

Pinal County

Yavapai County

Pima County

Maricopa County

Plan Details and Plan Costs

WellCare Compass (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered in Arizona by WellCare Compass (HMO). The plan ID is H6439:003-0.

  • Monthly Premium: $15.50 Copayment
  • Plan Deductible: $0.00 Copayment
  • Out of Pocket Spending Max: $3400

Primary Care Doctor Visit

$0 Copayment

Specialist Doctor Visit

$5 Copayment

Inpatient Hospital Care

$175 co-pay per day for days 1-6 and a $0 co-pay per day for days 7-90

Urgent Care

$40.00 Copayment

Emergency Room (ER) Visits

$120.00 Copayment

Ambulance Transportation

$250.00 Copayment

Additional Covered Health Care Services and Medical Supplies

WellCare Compass (HMO) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).

Home Health Care

$0.00 Copayment

Skilled Nursing Facility (SNF) Care

$0 co-pay per day for days 1-20 and a $178.00 co-pay per day for days 21-100

Medical Diagnostic Tests, Labs and Radiology Services

X-Ray Services and Lab Services: $0. For other services, please refer to your Evidence of Coverage for more information.

Diabetes Supplies, Training, Nutrition Therapy and Monitoring

Diabetic Supplies and Services:

  • $0 / Diabetes Self-Management Training: $0
  • Diabetic Therapeutic Shoes or Inserts: 20%

Durable Medical Equipment (DME)

20% Coinsurance

Chiropractic Services

In Network:

  • Medicare Covered Chiropractic Services: $5 per visit
  • Routine Chiropractic Services: $20 for 12 visits every year

Mental Health Inpatient Care

$175 co-pay per day for days 1-6 and a $0 co-pay per day for days 7-90

Mental Health Outpatient Care

$40 for individual or group

Outpatient Substance Abuse Care

$40 for individual or group

Transportation Services

$0 Copayment for 60 one-way trips every year

Podiatry Services

  • Medicare Covered Podiatry Services: $5 per visit
  • Routine Podiatry Services: $25 per visit for 6 visits every year

Over-the-Counter (OTC) Items

$60 every quarter OTC Retail/Catalog. Unused amounts do not carry over to the next quarter.

Dental Benefits

The following dental services are covered from in-network providers.

Preventive Dental Care / Comprehensive Dental Care

The dental benefits on this plan include coverage of preventive and comprehensive services up to $2,000, including but not limited to: cleanings, x-ray(s), oral exams, fluoride treatments, fillings, dentures or a bridge or a crown and a root canal.

Vision Benefits

The following vision services are covered from in-network providers:

The vision benefits on this plan cover routine eye exams and up to $300 for unlimited contacts, glasses, lenses, and/or frames per year.

Hearing Benefits

The following vision services are covered from in-network providers:

The hearing benefits on this plan cover, but are not limited to: routine hearing exams, hearing aid fittings and evaluations, and up to $3,000 for 2 hearing aids per year with a maximum of $1,500 per ear

Prescription Drug Costs and Coverage

The WellCare Compass (HMO) plan offers the following prescription drug coverage in Arizona, with an annual drug deductible of $445.00

Preferred Generic Drugs

  • Preferred Mail Order Cost Sharing (90 Day Supply) $0.00
  • Standard Retail Cost Sharing (30 Day Supply) $1.00
  • Standard Mail Order Cost Sharing (90 Day Supply) $3.00

Generic Drugs

  • Preferred Mail Order Cost Sharing (90 Day Supply) $0.00
  • Standard Retail Cost Sharing (30 Day Supply) $20.00
  • Standard Mail Order Cost Sharing (90 Day Supply) $60.00

Preferred Brand Name Drugs

  • Preferred Mail Order Cost Sharing (90 Day Supply) $94.00
  • Standard Retail Cost Sharing (30 Day Supply) $47.00
  • Standard Mail Order Cost Sharing (90 Day Supply) $141.00

Non-Preferred Drugs

  • Preferred Mail Order Cost Sharing (90 Day Supply) 50%
  • Standard Retail Cost Sharing (30 Day Supply) 50%
  • Standard Mail Order Cost Sharing (90 Day Supply) 50%

Specialty Tier Drugs

  • Standard Retail Cost Sharing (30 Day Supply) 25%