Wellpoint Dual Advantage (HMO D-SNP)

Wellpoint Dual Advantage (HMO D-SNP) H8849-011 Plan Details
3 out of 5 stars

Wellpoint Dual Advantage (HMO D-SNP) is a HMO Medicare Advantage (Medicare Part C) plan offered by Wellpoint
Plan ID: H8849-011

Have Medicare questions?

Talk to a licensed agent today to find a plan that fits your needs.

$28.40
Monthly Premium

Wellpoint Dual Advantage (HMO D-SNP) is a HMO Medicare Advantage (Medicare Part C) plan offered by Wellpoint
Plan ID: H8849-011

Have Medicare questions?

Talk to a licensed agent today to find a plan that fits your needs.

Wellpoint Dual Advantage (HMO D-SNP) H8849-011 Plan Details
3 out of 5 stars

Wellpoint Dual Advantage (HMO D-SNP) is a HMO Medicare Advantage (Medicare Part C) plan offered by Wellpoint
Plan ID: H8849-011

Have Medicare questions?

Talk to a licensed agent today to find a plan that fits your needs.

$28.40
Monthly Premium

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $0
Out of Pocket Max In-Network: $8850
Out-of-Network: N/A
Initial Coverage Limit $5030
Catastrophic Coverage Limit $8,000
Primary Care Doctor Visit
In-Network:
$0.00 copay
Specialty Doctor Visit
In-Network:
$0.00 copay
Inpatient Hospital Care
In-Network:
$0.00 copay - Medicare-defined cost share
Urgent Care
Urgent Care: $0.00 copay - $55.00 copay
Emergency Room Visit
Emergency Care: $0.00 copay -$90.00 copay
Copay waived if admitted to hospital within 24 hours
Worldwide Coverage: This plan covers urgent care and emergency services when traveling outside of the United States for less than six months. This benefit is limited to $100,000.00 per year.
Ambulance Transportation
Ground Ambulance: $0.00 copay - 20% coinsurance Per Trip
Air Ambulance: $0.00 copay - 20% coinsurance

Health Care Services and Medical Supplies

Wellpoint Dual Advantage (HMO D-SNP) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).

Coverage Cost
Chiropractic Services
In-Network:
Medicare Covered Chiropractic Services: $0.00 copay - 20% coinsurance
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
In-Network:
Diabetic Supplies: $0.00 copay
Durable Medical Eqipment (DME)
In-Network:
$0.00 copay - 20% coinsurance
Diagnostic Tests, Lab and Radiology Services, and X-Rays
In-Network:
Lab Services: $0.00 copay - 20% coinsurance
X-Rays: $0.00 copay - 20% coinsurance
Therapeutic Radiological Services: $0.00 copay - 20% coinsurance
Outpatient Diagnostic Procedures/Tests: $0.00 copay - 20% coinsurance
Diagnostic Radiological Services: $0.00 copay - 20% coinsurance
Home Health Care
In-Network:
$0.00 copay
Mental Health Inpatient Care
In-Network:
$0.00 copay - Medicare-defined cost share
Mental Health Outpatient Care
In-Network:
Individual and Group Sessions: $0.00 copay - 20% coinsurance
Outpatient Services / Surgery
In-Network:
Outpatient Hospital - Surgery: $0.00 copay - 20% coinsurance
Observation Services: $0.00 copay - 20% coinsurance
Ambulatory Surgical Center: $0.00 copay - 20% coinsurance
Outpatient Substance Abuse Care
In-Network:
Individual and Group Sessions: $0.00 copay - 20% coinsurance
Podiatry Services
In-Network:
Medicare Covered Podiatry Services: $0.00 copay - 20% coinsurance
Routine Foot Care: $0.00 copay
Unlimited routine foot care visits each year.
Skilled Nursing Facility Care
In-Network:
$0.00 copay - Medicare-defined cost share

Dental Benefits

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

Coverage Cost
Dental Care
In-Network:
Preventive and Comprehensive Dental Combined Allowance
This plan covers up to $2,250 for covered preventive and comprehensive dental services every year.

Medicare Covered Dental: $0.00 copay - 20% coinsurance
Preventive Dental Services: $0.00 copay
Comprehensive Dental Services: $0.00 copay

Vision Benefits

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

Coverage Cost
Vision Benefits
In-Network:
Medicare Covered Eye Exam: $0.00 copay - 20% coinsurance
Routine Eye Exam: $0.00 copay
This plan covers 1 routine eye exam(s) every year.
Medicare Covered Eye Wear: $0.00 copay - 20% coinsurance
Routine Eye Wear: $0.00 copay
This plan covers up to $200.00 for eyeglasses or contact lenses every year.

Hearing Benefits

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

Coverage Cost
Hearing Benefits
In-Network:
Medicare Covered Hearing Exam: $0.00 copay - 20% coinsurance
Routine Hearing Exam: $0.00 copay for routine hearing exam(s). $0.00 copay for hearing aids up to the maximum plan benefit amount.
This plan covers 1 routine hearing exam every year. $300.00 maximum plan benefit for over-the-counter hearing aids OR 1 routine hearing aid fitting evaluation and a $3,000.00 maximum plan benefit for prescribed hearing aids every year.

Preventive Services and Health/Wellness Education Programs

The following services are covered from in-network providers.

Coverage Cost
Preventive Services and Health/Wellness Education Programs
In-Network:
$0.00 copay for Medicare Covered Preventive Services

Prescription Drug Costs and Coverage

The Wellpoint Dual Advantage (HMO D-SNP) plan offers the following prescription drug coverage, with an annual drug deductible of $0 per year.

Coverage
Cost
Coverage & Cost
Annual Drug Deductible $0
Preferred Generic
  • Preferred cost-share retail $0.00
  • Standard mail order $0.00
  • Standard retail $0.00
Generic
  • Preferred cost-share retail $0.00
  • Standard mail order $0.00
  • Standard retail $0.00
Preferred Brand
  • Preferred cost-share retail $0.00
  • Standard mail order $0.00
  • Standard retail $0.00
Non-Preferred Drug
  • Preferred cost-share retail $0.00
  • Standard mail order $0.00
  • Standard retail $0.00
Specialty Tier
  • Preferred cost-share retail $0.00
  • Standard mail order $0.00
  • Standard retail $0.00
Select Care Drugs
  • Preferred cost-share retail $0.00
  • Standard mail order $0.00
  • Standard retail $0.00
Annual Drug Deductible $0
Preferred Generic
  • Preferred cost-share retail $0.00
  • Standard mail order $0.00
  • Standard retail $0.00
Generic
  • Preferred cost-share retail $0.00
  • Standard mail order $0.00
  • Standard retail $0.00
Preferred Brand
  • Preferred cost-share retail $0.00
  • Standard mail order $0.00
  • Standard retail $0.00
Non-Preferred Drug
  • Preferred cost-share retail $0.00
  • Standard mail order $0.00
  • Standard retail $0.00
Specialty Tier
  • Preferred cost-share retail N/A
  • Standard mail order N/A
  • Standard retail N/A
Select Care Drugs
  • Preferred cost-share retail $0.00
  • Standard mail order $0.00
  • Standard retail $0.00
Annual Drug Deductible $0
Preferred Generic
  • Preferred cost-share retail $0.00
  • Standard mail order $0.00
  • Standard retail $0.00
Generic
  • Preferred cost-share retail $0.00
  • Standard mail order $0.00
  • Standard retail $0.00
Preferred Brand
  • Preferred cost-share retail $0.00
  • Standard mail order $0.00
  • Standard retail $0.00
Non-Preferred Drug
  • Preferred cost-share retail $0.00
  • Standard mail order $0.00
  • Standard retail $0.00
Specialty Tier
  • Preferred cost-share retail N/A
  • Standard mail order N/A
  • Standard retail N/A
Select Care Drugs
  • Preferred cost-share retail $0.00
  • Standard mail order $0.00
  • Standard retail $0.00