Plan Basics
Contract Year 2021
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H1112-006-000
Plan Organization WellCare
Plan Type Local HMO
Plan Name WellCare Access (HMO D-SNP)
Plan Organization Type Local CCP
Drugs Covered Yes
Doctors Choice Plan Doctors for Most Services
Benefit Type Enhanced Alternative
Special Needs Plan Yes
Special Needs Plan Type Dual-Eligible
Overall Star Rating 3.5
Plan Cost Sharing
Premium $0.00
Total Premium (Includes Part B) $135.50
Monthly Part C Premium $0.00
Monthly Part D Basic Premium $29.80
Monthly Part D Supplemental Premium $0.00
Monthly Part D Total Premium $29.80
Monthly Part D Premium Full Assistance $0.00
Monthly Part D Premium 75% Assistance $7.40
Monthly Part D Premium 50% Assistance $14.90
Monthly Part D Premium 25% Assistance $22.30
Part D Drug Deductible $445.00
Annual Drug Deductible $445.00
Tiers Excluded From Deductible 1
Part D Initial Coverage Limit $4130.00
Part D Catastrophic Coverage Threshold $6550.00

Medicare Advantage Plan Health Benefits


Additional Benefits And/or Reduced Cost-sharing For Enrollees With Certain Health Conditions?
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - No
Comprehensive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic services Yes - Yes Yes $0 copay
Endodontics Yes - Yes Yes $0 copay
Extractions Yes - Yes Yes $0 copay
Non-routine services Yes - Yes Yes $0 copay
Periodontics Yes - Yes Yes $0 copay
Prosthodontics, other oral/maxillofacial surgery, other services Yes - Yes Yes $0 copay
Restorative services Yes - Yes Yes $0 copay
Diagnostic Procedures/lab Services/imaging
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic radiology services (e.g., MRI) - - Yes No $0 copay
Diagnostic tests and procedures - - Yes No $0 copay
Lab services - - Yes No $0 copay
Outpatient x-rays - - Yes No $0 copay
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Primary - - - - $0 copay
Specialist - - Yes No $0 copay
Emergency Care/Urgent Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
Emergency - - - - $0 copay
Urgent care - - - - $0 copay
Foot Care (podiatry Services)
Service Cap Network Auth. Req. Ref. Req. Cost Share
Foot exams and treatment - - Yes No $0 copay
Routine foot care - - - - Not covered
Ground Ambulance
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $0 copay
Health Plan Deductible
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $0
Hearing
Service Cap Network Auth. Req. Ref. Req. Cost Share
Fitting/evaluation Yes - Yes Yes $0 copay
Hearing aids Yes - Yes Yes $0 copay
Hearing exam - - Yes Yes $0 copay
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes No $0 copay
Maximum Out-of-pocket Enrollee Responsibility (does Not Include Prescription Drugs)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $3,000 In-network
Medical Equipment/supplies
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diabetes supplies - - Yes - $0 copay
Durable medical equipment (e.g., wheelchairs, oxygen) - - Yes - $0 copay
Prosthetics (e.g., braces, artificial limbs) - - Yes - $0 copay
Medicare Part B Drugs
Service Cap Network Auth. Req. Ref. Req. Cost Share
Chemotherapy - - Yes - $0 copay
Other Part B drugs - - Yes - $0 copay
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Inpatient hospital - psychiatric - - Yes No $0 copay
Outpatient group therapy visit - - Yes No $0 copay
Outpatient group therapy visit with a psychiatrist - - Yes No $0 copay
Outpatient individual therapy visit - - Yes No $0 copay
Outpatient individual therapy visit with a psychiatrist - - Yes No $0 copay
Optional Supplemental Benefits
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - No
Other Health Plan Deductibles?
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - No
Outpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes No $0 copay
Preventive Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - No No $0 copay
Preventive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Cleaning Yes - Yes Yes $0 copay
Dental x-ray(s) Yes - Yes Yes $0 copay
Fluoride treatment Yes - Yes Yes $0 copay
Oral exam Yes - Yes Yes $0 copay
Rehabilitation Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Occupational therapy visit - - Yes No $0 copay
Physical therapy and speech and language therapy visit - - Yes No $0 copay
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes No $0 copay
Transportation
Service Cap Network Auth. Req. Ref. Req. Cost Share
Yes - Yes No $0 copay
Vision
Service Cap Network Auth. Req. Ref. Req. Cost Share
Contact lenses Yes - Yes Yes $0 copay
Eyeglass frames Yes - Yes Yes $0 copay
Eyeglass lenses Yes - Yes Yes $0 copay
Eyeglasses (frames and lenses) Yes - Yes Yes $0 copay
Other No - - - Not covered
Routine eye exam Yes - Yes Yes $0 copay
Upgrades Yes - Yes Yes $0 copay
Wellness Programs (e.g., Fitness, Nursing Hotline)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes No Covered
Plan Drug Info
Formulary Link Drug Formulary Directory
Official Medicare Contact
Medicare Phone 1-800-MEDICARE (1-800-633-4227)
Medicare TTY User 1-877-486-2048
Plan Available in these Counties
Baldwin County, Georgia, Barrow County, Georgia, Bartow County, Georgia, Bibb County, Georgia, Bleckley County, Georgia, Brantley County, Georgia, Bryan County, Georgia, Burke County, Georgia, Butts County, Georgia, Camden County, Georgia, Carroll County, Georgia, Chatham County, Georgia, Chattahoochee County, Georgia, Cherokee County, Georgia, Clarke County, Georgia, Clayton County, Georgia, Cobb County, Georgia, Columbia County, Georgia, Coweta County, Georgia, Crawford County, Georgia, Dekalb County, Georgia, Dodge County, Georgia, Dooly County, Georgia, Douglas County, Georgia, Emanuel County, Georgia, Fayette County, Georgia, Forsyth County, Georgia, Fulton County, Georgia, Glascock County, Georgia, Glynn County, Georgia, Greene County, Georgia, Gwinnett County, Georgia, Haralson County, Georgia, Harris County, Georgia, Heard County, Georgia, Henry County, Georgia, Houston County, Georgia, Jasper County, Georgia, Jefferson County, Georgia, Jenkins County, Georgia, Johnson County, Georgia, Jones County, Georgia, Lamar County, Georgia, Liberty County, Georgia, Lincoln County, Georgia, Long County, Georgia, Macon County, Georgia, Marion County, Georgia, Mcduffie County, Georgia, Mcintosh County, Georgia, Meriwether County, Georgia, Monroe County, Georgia, Morgan County, Georgia, Muscogee County, Georgia, Newton County, Georgia, Oconee County, Georgia, Paulding County, Georgia, Peach County, Georgia, Pickens County, Georgia, Pike County, Georgia, Polk County, Georgia, Pulaski County, Georgia, Putnam County, Georgia, Richmond County, Georgia, Rockdale County, Georgia, Screven County, Georgia, Spalding County, Georgia, Stewart County, Georgia, Talbot County, Georgia, Treutlen County, Georgia, Troup County, Georgia, Twiggs County, Georgia, Upson County, Georgia, Walton County, Georgia, Warren County, Georgia, Washington County, Georgia, Wayne County, Georgia, Wheeler County, Georgia, Wilkes County, Georgia, Wilkinson County, Georgia

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