WellCare Dividend H6439:004-0 (HMO) Plan Details

In this article...
  • Learn more about HumanaChoice R7220-002 (Regional PPO) R7220:002-0 Plan Details, including how much you can expect to pay for coinsurance, deductibles, premiums and copays for various services covered by the plan.

Arizona Counties Served

Pinal County

Yavapai County

Pima County

Maricopa County

Plan Details and Plan Costs

WellCare Dividend (HMO) is a Network Type, HMO or other designation as worded on Aon Medicare Advantage (Medicare Part C) plan offered in Arizona by WellCare Dividend (HMO). The plan ID is H6439:004-0

  • Monthly Premium: $0
  • Plan Deductible: $0.00
  • Out of Pocket Spending Max: $3400

Primary Care Doctor Visit

$0 Copayment

Specialist Doctor Visit

$25 Copayment

Inpatient Hospital Care

$375 co-pay per day for days 1-5 and a $0 co-pay per day for days 6-90

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 Dividend (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

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

Medical Diagnostic Tests, Labs and Radiology Services

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

Diabetes Supplies, Training, Nutrition Therapy and Monitoring

In-Network:

  • Copayment for Medicare-covered Diabetic Supplies $0.00
  • Diabetes Self-Management Training: $0
  • Diabetic Therapeutic Shoes or Inserts: 20%

Durable Medical Equipment (DME)

In Network: 20% Coinsurance

Chiropractic Services

In Network:

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

Mental Health Inpatient Care

In Network: $200 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

Podiatry Services

  • Medicare Covered Podiatry Services: $40 per visit
  • Routine Podiatry Services: $40 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 $750, including but not limited to: cleanings, x-ray(s), oral exams, fluoride treatments, fillings, and dentures or a bridge.

Vision Benefits

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

Eye Exams

The vision benefits on this plan cover routine eye exams and up to $100 for unlimited contacts, glasses, lenses, and/or frames per year

Hearing Benefits

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

Hearing Exams

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

Prescription Drug Costs and Coverage

The WellCare Value (HMO) plan offers the following prescription drug coverage in Arizona, with an annual drug deductible of $0.00 per year.

Preferred Generic Drugs

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

Generic Drugs

  • Preferred Mail Order Cost Sharing (90 Day Supply) $0.00
  • Standard Retail Cost Sharing (30 Day Supply) $15.00
  • Standard Mail Order Cost Sharing (90 Day Supply) $45.00

Preferred Brand Name Drugs

  • Preferred Mail Order Cost Sharing (90 Day Supply) $90.00
  • Standard Retail Cost Sharing (30 Day Supply) $45.00
  • Standard Mail Order Cost Sharing (90 Day Supply) $135.00

Non-Preferred Drugs

  • Preferred Mail Order Cost Sharing (90 Day Supply) $200.00
  • Standard Retail Cost Sharing (30 Day Supply) $100.00
  • Standard Mail Order Cost Sharing (90 Day Supply) $300.0

Specialty Tier Drugs

  • Standard Retail Cost Sharing (30 Day Supply) 33%
Read More
Smiling couple outdoors with sun in the background
How do Medigap plans and Medicare Advantage plans differ? How can you decide which type of plan is ...
Happy Couple Visiting With Friends
How much does Medicare cost? Are there affordable options available to help seniors with out-of-pocket ...
Man uses laptop computer at home in his kitchen
Medicare.gov is an important resource for Medicare enrollees. Learn about some of the features the ...