Wellpoint Kidney Care (HMO-POS C-SNP)
Wellpoint Kidney Care (HMO-POS C-SNP) H2593-031 Plan Details
Wellpoint Kidney Care (HMO-POS C-SNP) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Wellpoint
Plan ID: H2593-031
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$19.40
Monthly Premium
Wellpoint Kidney Care (HMO-POS C-SNP) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Wellpoint
Plan ID: H2593-031
Have Medicare questions?
Talk to a licensed agent today to find a plan that fits your needs.
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $100 |
| Out of Pocket Max |
In-Network: $8300 Out-of-Network: N/A |
| Initial Coverage Limit | $5030 |
| Catastrophic Coverage Limit | $8,000 |
| Primary Care Doctor Visit | In-Network: $0.00 copay Out-of-Network: $0.00 copay |
| Specialty Doctor Visit | In-Network: $0.00 copay - 20% coinsurance Out-of-Network: $0.00 copay - 20% coinsurance |
| Inpatient Hospital Care | In-Network: Medicare-defined Cost Share Out-of-Network: Medicare-defined Cost Share |
| Urgent Care | Urgent Care: $20.00 copay |
| Emergency Room Visit | Emergency Care: $90.00 copay |
| Ambulance Transportation | Ground Ambulance: 20% coinsurance Per Trip Air Ambulance: 20% coinsurance |
Health Care Services and Medical Supplies
Wellpoint Kidney Care (HMO-POS C-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: 20% coinsurance Out-of-Network: Medicare Covered Chiropractic Services: 20% coinsurance |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network: Diabetic Supplies: $0.00 copay Out-of-Network: 20% coinsurance |
| Durable Medical Eqipment (DME) | In-Network: 20% coinsurance |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | In-Network: Lab Services: 20% coinsurance X-Rays: 20% coinsurance Therapeutic Radiological Services: 20% coinsurance Outpatient Diagnostic Procedures/Tests: 20% coinsurance Diagnostic Radiological Services: 20% coinsurance Out-of-Network: Lab Services: 20% coinsurance X-Rays: 20% coinsurance Therapeutic Radiological Services: 20% coinsurance Outpatient Diagnostic Procedures/Tests: 20% coinsurance Diagnostic Radiological Services: 20% coinsurance |
| Home Health Care | In-Network: $0.00 copay |
| Mental Health Inpatient Care | In-Network: Medicare-defined Cost Share Out-of-Network: Medicare-defined Cost Share |
| Mental Health Outpatient Care | In-Network: Individual and Group Sessions: 20% coinsurance Out-of-Network: 20% coinsurance |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital - Surgery: 20% coinsurance Observation Services: 20% coinsurance Ambulatory Surgical Center: 20% coinsurance Out-of-Network: Outpatient Hospital - Surgery: 20% coinsurance Observation Services: 20% coinsurance Ambulatory Surgical Center: 20% coinsurance |
| Outpatient Substance Abuse Care | In-Network: Individual and Group Sessions: 20% coinsurance Out-of-Network: 20% coinsurance |
| Over-the-counter (OTC) Items | This plan covers certain approved, non-prescription, over-the-counter drugs and health-related items, up to $100 every quarter. Unused OTC amounts do roll over to the next quarter. Unused OTC amounts do not roll over to the next calendar year. |
| 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. Out-of-Network: Medicare Covered Podiatry Services: 20% coinsurance |
| Skilled Nursing Facility Care | In-Network: 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 Cobmined Allowance This plan covers up to $1,000 for covered preventive and comprehensive dental services every year. Medicare Covered Dental: 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: 20% coinsurance Routine Eye Exam: $0.00 copay This plan covers 1 routine eye exam(s) every year. Medicare Covered Eye Wear: 20% coinsurance Routine Eye Wear: $0.00 copay This plan covers up to $300.00 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: 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 $2,000.00 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 Out-of-Network: 20% coinsurance |
Prescription Drug Costs and Coverage
The Wellpoint Kidney Care (HMO-POS C-SNP) plan offers the following prescription drug coverage, with an annual drug deductible of $100 (excludes Tiers 1 and 6) per year.
| Coverage |
Cost
|
|---|---|
|
Coverage & Cost
|
|
| Annual Drug Deductible | $100 (excludes Tiers 1 and 6) |
| Preferred Generic |
|
| Select Care Drugs |
|
| Annual Drug Deductible | $100 (excludes Tiers 1 and 6) |
| Preferred Generic |
|
| Select Care Drugs |
|
| Annual Drug Deductible | $100 (excludes Tiers 1 and 6) |
| Preferred Generic |
|
| Select Care Drugs |
|
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