Wellpoint Medicare Advantage (HMO-POS)
Wellpoint Medicare Advantage (HMO-POS) H5828-012 Plan Details
Wellpoint Medicare Advantage (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Wellpoint
Plan ID: H5828-012
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 Medicare Advantage (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Wellpoint
Plan ID: H5828-012
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.
Tennessee Counties Served
Robertson
Cannon
Wilson
Hickman
Dickson
Smith
Trousdale
Davidson
Williamson
Rutherford
Macon
Sumner
Cheatham
Loudon
Jackson
Hamilton
Houston
Clay
Carter
Grainger
Dekalb
Benton
Bedford
Polk
Weakley
Haywood
Marion
Perry
Blount
Mcnairy
Montgomery
Greene
Moore
Sullivan
Gibson
Roane
Monroe
Warren
Carroll
Rhea
Giles
Hamblen
Sevier
Lake
Bradley
Lewis
Lincoln
Union
Claiborne
Meigs
Hawkins
Henry
Sequatchie
Hardeman
Putnam
Hardin
Bledsoe
Dyer
Mcminn
Lauderdale
Chester
Johnson
Stewart
Pickett
Madison
Morgan
White
Grundy
Campbell
Van Buren
Hancock
Obion
Decatur
Washington
Wayne
Coffee
Anderson
Cocke
Humphreys
Crockett
Marshall
Unicoi
Scott
Overton
Henderson
Maury
Lawrence
Jefferson
Fentress
Cumberland
Franklin
Knox
Tipton
Fayette
Shelby
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $0 |
| Out of Pocket Max |
In-Network: $5500 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: $30.00 copay |
| Specialty Doctor Visit | In-Network: $40.00 copay Out-of-Network: $50.00 copay |
| Inpatient Hospital Care | In-Network: Days 1-5: $290.00 per day, per admission / Days 6-90: $0.00 per day, per admission Additional Hospital Days: Unlimited additional days Out-of-Network: 40% coinsurance per stay |
| Urgent Care | Urgent Care: $30.00 copay |
| Emergency Room Visit | Emergency Care: $90.00 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: $295.00 copay Per Trip Air Ambulance: $295.00 copay |
Health Care Services and Medical Supplies
Wellpoint Medicare Advantage (HMO-POS) 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: $20.00 copay Out-of-Network: Medicare Covered Chiropractic Services: 40% coinsurance |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network: Diabetic Supplies: $0.00 copay Out-of-Network: 40% coinsurance |
| Durable Medical Eqipment (DME) | In-Network: 20% coinsurance Out-of-Network: 40% coinsurance |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | In-Network: Lab Services: $0.00 copay - $10.00 copay X-Rays: $50.00 copay - $110.00 copay Therapeutic Radiological Services: 20% coinsurance Outpatient Diagnostic Procedures/Tests: $0.00 copay - $150.00 copay Diagnostic Radiological Services: $130.00 copay - $220.00 copay Out-of-Network: Lab Services: 40% coinsurance X-Rays: 40% coinsurance Therapeutic Radiological Services: 40% coinsurance Outpatient Diagnostic Procedures/Tests: 40% coinsurance Diagnostic Radiological Services: 40% coinsurance |
| Home Health Care | In-Network: $0.00 copay |
| Mental Health Inpatient Care | In-Network: Days 1-5: $250.00 per day, per admission / Days 6-90: $0.00 per day, per admission Additional Hospital Days: Unlimited additional days Out-of-Network: 40% coinsurance per stay |
| Mental Health Outpatient Care | In-Network: Individual and Group Sessions: $40.00 copay Out-of-Network: 40% coinsurance |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital - Surgery: $280.00 copay Observation Services: $280.00 copay Ambulatory Surgical Center: $225.00 copay Out-of-Network: Outpatient Hospital - Surgery: 40% coinsurance Observation Services: 40% coinsurance Ambulatory Surgical Center: 40% coinsurance |
| Outpatient Substance Abuse Care | In-Network: Individual and Group Sessions: $40.00 copay Out-of-Network: 40% coinsurance |
| Over-the-counter (OTC) Items | This plan covers certain approved, non-prescription, over-the-counter drugs and health-related items, up to $95 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 - $40.00 copay Routine Foot Care: $0.00 copay Unlimited routine foot care visits each year. Out-of-Network: Medicare Covered Podiatry Services: $50.00 copay |
| Skilled Nursing Facility Care | In-Network: SNF Days 1 - 20: $0.00 per day / Days 21 - 100: $203.00 per day |
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 $2,000 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 POS (Out-of-Network): Medicare Covered Dental Services: Copayment for Medicare Covered Comprehensive Dental $50.00 |
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 - $40.00 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 $200.00 for eyeglasses or contact lenses every year. Out-of-Network: Medicare Covered Eye Exam: $50.00 copay Medicare Covered Eye Wear: $50.00 copay |
Hearing Benefits
The following hearing services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Hearing Benefits | In-Network: Medicare Covered Hearing Exam: $40.00 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. Out-of-Network: Medicare Covered Hearing Exam: $50.00 copay |
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: 40% coinsurance |
