WellCare Value H6439:002-0 (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 Value (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered in Arizona by WellCare. The plan ID is H6439:002-0.

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

Primary Care Doctor Visit

In Network: $0 Copayment

Specialist Doctor Visit

In Network:

  • $25 Copayment

Inpatient Hospital Care

In Network: $200 co-pay per day for days 1-6 and a $0 co-pay per day for days 7-90

Urgent Care

In Network: $40.00

Emergency Room (ER) Visits

In Network: $40.00

Ambulance Transportation

In Network: $115.00 Copayment

Additional Covered Health Care Services and Medical Supplies

WellCare Value (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

In Network: $0.00 Copay

Skilled Nursing Facility (SNF) Care

In Network: $0 co-pay per day for days 1-20 and a $172.00 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
  • Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20%
  • Prior Authorization Required for Diabetic Supplies and Services
    Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage)

Durable Medical Equipment (DME)

Diabetic Supplies:

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

Durable Medical Equipment (DME)

In Network: 20% Coinsurance

Chiropractic Services

In Network:

  • 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

In Network: $40 for individual or group

Outpatient Substance Abuse Care

In Network: $40 for individual or group

Podiatry Services

In Network:

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

Transportation Services

$0 for 48 one-way trips every year

Over-the-Counter (OTC) Items

$100 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.

The dental benefits on this plan include coverage of preventive and comprehensive services up to $1,000, 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 $200 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 $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%
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