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Wellpoint Full Dual Advantage (HMO D-SNP)

Wellpoint Full Dual Advantage (HMO D-SNP) H5828-002 Plan Details
3.5 out of 5 stars

Wellpoint Full Dual Advantage (HMO D-SNP) is a HMO Medicare Advantage (Medicare Part C) plan offered by Wellpoint
Plan ID: H5828-002

HelpAdvisor Editorial Team analysis of data from the 2024 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.

$0.00
Monthly Premium

Wellpoint Full Dual Advantage (HMO D-SNP) is a HMO Medicare Advantage (Medicare Part C) plan offered by Wellpoint
Plan ID: H5828-002

HelpAdvisor Editorial Team analysis of data from the 2024 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.

Wellpoint Full Dual Advantage (HMO D-SNP) H5828-002 Plan Details
3.5 out of 5 stars

Wellpoint Full Dual Advantage (HMO D-SNP) is a HMO Medicare Advantage (Medicare Part C) plan offered by Wellpoint
Plan ID: H5828-002

HelpAdvisor Editorial Team analysis of data from the 2024 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.

$0.00
Monthly Premium

Tennessee Counties Served

Loudon Jackson Robertson Hamilton Cannon Houston Clay Carter Grainger Dekalb Benton Bedford Polk Weakley Haywood Marion Wilson Perry Blount Mcnairy Montgomery Hickman Greene Moore Sullivan Gibson Roane Monroe Warren Carroll Tipton Rhea Giles Hamblen Dickson Smith Sevier Lake Trousdale Bradley Lewis Lincoln Union Claiborne Meigs Hawkins Henry Davidson Fayette Sequatchie Williamson Hardeman Putnam Hardin Bledsoe Dyer Mcminn Lauderdale Johnson Chester Stewart Pickett Madison Morgan White Grundy Campbell Van Buren Hancock Rutherford Shelby Obion Decatur Washington Wayne Coffee Anderson Cocke Humphreys Crockett Marshall Unicoi Scott Overton Henderson Macon Sumner Maury Lawrence Jefferson Cheatham Fentress Cumberland Franklin Knox

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 per stay
Urgent Care
Urgent Care: $0.00 copay
Emergency Room Visit
Emergency Care: $0.00 copay
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 Per Trip
Air Ambulance: $0.00 copay

Health Care Services and Medical Supplies

Wellpoint Full 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
Routine Chiropractic Services: $0.00 copay 48 visits each year
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
In-Network:
Diabetic Supplies: $0.00 copay
Durable Medical Eqipment (DME)
In-Network:
$0.00 copay
Diagnostic Tests, Lab and Radiology Services, and X-Rays
In-Network:
Lab Services: $0.00 copay
X-Rays: $0.00 copay
Therapeutic Radiological Services: $0.00 copay
Outpatient Diagnostic Procedures/Tests: $0.00 copay
Diagnostic Radiological Services: $0.00 copay
Home Health Care
In-Network:
$0.00 copay
Mental Health Inpatient Care
In-Network:
$0.00 copay per stay
Mental Health Outpatient Care
In-Network:
Individual and Group Sessions: $0.00 copay
Outpatient Services / Surgery
In-Network:
Outpatient Hospital - Surgery: $0.00 copay
Observation Services: $0.00 copay
Ambulatory Surgical Center: $0.00 copay
Outpatient Substance Abuse Care
In-Network:
Individual and Group Sessions: $0.00 copay
Podiatry Services
In-Network:
Medicare Covered Podiatry Services: $0.00 copay
Routine Foot Care: $0.00 copay
Unlimited routine foot care visits each year.
Skilled Nursing Facility Care
In-Network:
$0.00 copay per stay

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 $5,500 for covered preventive and comprehensive dental services every year.

Medicare Covered Dental: $0.00 copay
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
Routine Eye Exam: $0.00 copay
This plan covers 1 routine eye exam(s) every year.
Medicare Covered Eye Wear: $0.00 copay
Routine Eye Wear: $0.00 copay
This plan covers up to $600.00 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
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 Full 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
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