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Wellpoint Premium Savings (HMO) - H1423-005-000
$0.00
Monthly Premium
Wellpoint Premium Savings (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Wellpoint
Plan ID: H1423-005-000
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$0.00
Monthly Premium
Arizona Medicare beneficiaries may want to consider reviewing their Medicare Advantage (Medicare Part C) plan options. A Medicare Advantage plan combines your Original Medicare (Part A and Part B) benefits into a single plan.
Most Medicare Advantage plans cover prescription drugs, and many plans may offer other extra benefits Original Medicare doesn’t cover.
Learn more about Arizona Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.
Basic Costs and Coverage
| Coverage | Details |
|---|---|
| Monthly plan premium | $0.00 |
| Vision coverage | |
| Dental coverage | |
| Hearing coverage | |
| Prescription drugs | |
| Medical deductible | $0.00 |
| Out-of-pocket maximum | $3,400.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $2,000.00 |
| Primary care doctor visit | In-Network: $0.00 copay - $10.00 copay |
| Specialty doctor visit | In-Network: $0.00 copay - $40.00 copay |
| Inpatient hospital care | In-Network: Days 1-5: $225.00 per day, per admission / Days 6-90: $0.00 per day, per admission |
| Urgent care | Urgent Care: $30.00 copay |
| Emergency room visit | Emergency Care: $120.00 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 per year. |
| Ambulance transportation | Ground Ambulance: $195.00 copay Per Trip Air Ambulance: $195.00 copay |
Health Care Services and Medical Supplies
Wellpoint Premium Savings (HMO) covers a range of additional benefits. Learn more about Wellpoint Premium Savings (HMO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).
| Coverage | Details |
|---|---|
| Chiropractic services | In-Network: Medicare Covered Chiropractic Services: $20.00 copay |
| Diabetes supplies, training, nutrition therapy and monitoring | In-Network: Diabetic Supplies: 20% coinsurance |
| Durable medical equipment (DME) | In-Network: Your cost is $0.00 copay when the value of the DME is $499.99 or less. Your cost is 20% coinsurance when the value of the DME is $500.00 or more. |
| Diagnostic tests, lab and radiology services, and X-rays | In-Network: Lab Services: $0.00 copay X-Rays: $15.00 copay Therapeutic Radiological Services: 20% coinsurance Outpatient Diagnostic Procedures/Tests: $0.00 copay Diagnostic Radiological Services: $0.00 copay - $150.00 copay |
| Home health care | In-Network: $0.00 copay |
| Mental health inpatient care | In-Network: Days 1-5: $225.00 per day, per admission / Days 6-90: $0.00 per day, per admission |
| Mental health outpatient care | In-Network: Individual and Group Sessions: $0.00 copay to $35.00 copay |
| Outpatient services/surgery | In-Network: Outpatient Hospital - Surgery: $225.00 copay Observation Services: $225.00 copay Ambulatory Surgical Center: $100.00 copay |
| Outpatient substance abuse care | In-Network: Individual and Group Sessions: $35.00 copay |
| Over-the-counter 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 expire at the end of the calendar year. |
| Podiatry services | In-Network: Medicare Covered Podiatry Services: $0.00 copay - $40.00 copay |
| Skilled Nursing Facility (SNF) care | In-Network: Days 1 - 20: $0.00 per day / Days 21 - 100: $125.00 per day |
Dental Benefits
The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Dental care | Medicare Covered Dental: $0.00 copay - $40.00 copay |
Vision Benefits
The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage
| Coverage | Details |
|---|---|
| Vision care | 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 $300 for eyeglasses or contact lenses every year. |
Hearing Benefits
The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Hearing care | 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 maximum plan benefit for over-the-counter hearing aids OR 1 routine hearing aid fitting evaluation and a $1,500 maximum plan benefit for prescribed hearing aids every year. |
Preventive Services and Health/Wellness Education Programs
The following services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Preventive services and health/wellness education programs | In-Network: $0.00 copay for Medicare Covered Preventive Services |
When reviewing Arizona Medicare plans, be sure to find out if your doctors are part of the plan network. If a Medicare Advantage plan covers prescription drugs, make sure the plan formulary (list of drugs covered by the plan) includes your drugs.
You may be able to find plans in your part of Arizona that offer similar benefits at similar or lower prices than the plan above. Call 1-800-557-6059 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.
Plan Documents
| Links to plan documents |
Arizona Counties Served
We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.