Wellcare Dual Access (HMO D-SNP) H1416-034 2024 Plan Details and Costs (2024)

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Wellcare Dual Access (HMO D-SNP)

Wellcare Dual Access (HMO D-SNP) H1416-034 Plan Details

2.5 out of 5 stars

Wellcare Dual Access (HMO D-SNP) is a HMO Medicare Advantage (Medicare Part C) plan offered by Wellcare Health Plans, Inc.
Plan ID: H1416-034

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Wellcare Dual Access (HMO D-SNP) H1416-034 Plan Details

2.5 out of 5 stars

Have Medicare questions?

Talk to a licensed agent today to find a plan that fits your needs.

Get Medicare Help

^$0.00

Monthly Premium

Mississippi Counties Served

Stone Greene Bolivar Tate Tunica Lawrence Marshall Leflore Harrison Jasper Attala Pike Lamar Coahoma Quitman Sunflower Holmes Hinds Carroll Jones Neshoba Copiah Sharkey Issaquena Kemper Forrest Wayne Jackson Rankin Tallahatchie Yazoo Clarke Montgomery Grenada Madison Washington Smith Lauderdale Claiborne Panola Jefferson Davis Perry Marion Walthall Humphreys Newton Covington Leake Scott Yalobusha Lincoln Desoto Simpson George Warren Hanco*ck Lafayette

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: Doctor Office Visit: Copayment for Primary Care Office Visit $0.00
Specialty Doctor Visit	In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $0.00 Prior Authorization Required for Doctor Specialty Visit Prior authorization required
Inpatient Hospital Care	In-Network: Acute Hospital Services: Copayment for Acute Hospital Services per Stay $0.00 Prior Authorization Required for Acute Hospital Services Prior authorization required
Urgent Care	Copayment for Urgent Care $0.00 Copayment for Medicare Covered Urgent Care waived if you are admitted to hospital within 24 hours Worldwide Coverage: Copayment for Worldwide Urgent Coverage $100.00 Maximum Plan Benefit of $50,000
Emergency Room Visit	Copayment for Emergency Care $0.00 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $100.00 Maximum Plan Benefit of $50,000
Ambulance Transportation	In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $0.00 Air Ambulance: Copayment for Air Ambulance Services $0.00 Please see Evidence of Coverage for Prior Authorization rules Prior authorization required

Health Care Services and Medical Supplies

Wellcare Dual Access (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: Copayment for Medicare-covered Chiropractic Services $0.00 Copayment for Routine Care $0.00 Maximum 12 Routine Care every year Prior Authorization Required for Chiropractic Services Prior authorization required
Diabetes Supplies, Training, Nutrition Therapy and Monitoring	In-Network: Copayment for Medicare-covered Diabetic Supplies $0.00 Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0.00 Prior Authorization Required for Diabetic Supplies and Services Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage) Prior authorization required
Durable Medical Eqipment (DME)	In-Network: Copayment for Medicare-covered Durable Medical Equipment $0.00 Prior Authorization Required for Durable Medical Equipment Prior authorization required
Diagnostic Tests, Lab and Radiology Services, and X-Rays	In-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare-covered Diagnostic Procedures/Tests $0.00 Copayment for Medicare-covered Lab Services $0.00 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $0.00 Copayment for Medicare-covered Therapeutic Radiological Services $0.00 Copayment for Medicare-covered X-Ray Services $0.00 Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services Prior authorization required
Home Health Care	In-Network: Copayment for Medicare-covered Home Health Services $0.00 Prior Authorization Required for Home Health Services Prior authorization required
Mental Health Inpatient Care	In-Network: Psychiatric Hospital Services: Copayment for Psychiatric Hospital Services per Stay $0.00 Prior Authorization Required for Psychiatric Hospital Services Prior authorization required
Mental Health Outpatient Care	In-Network: Copayment for Medicare-covered Individual Sessions $0.00 Copayment for Medicare-covered Group Sessions $0.00 Prior Authorization Required for Outpatient Mental Health Services Prior authorization required
Outpatient Services / Surgery	In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0.00 Prior Authorization Required for Outpatient Hospital Services Outpatient Observation Services: Copayment for Medicare Covered Observation Services $0.00 Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $0.00 Prior Authorization Required for Ambulatory Surgical Center Services Prior authorization required
Outpatient Substance Abuse Care	In-Network: Copayment for Medicare-covered Individual Sessions $0.00 Copayment for Medicare-covered Group Sessions $0.00 Prior Authorization Required for Outpatient Substance Abuse Services Prior authorization required
Over-the-counter (OTC) Items	In-Network: Over-The-Counter (OTC) Items: Copayment for Over-The-Counter (OTC) Items $0.00 Maximum Plan Benefit of $180.00 every month Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit
Podiatry Services	In-Network: Copayment for Medicare-Covered Podiatry Services $0.00 Copayment for Routine Foot Care $0.00 Maximum 6 visits every year Prior Authorization Required for Podiatry Services Prior authorization required
Skilled Nursing Facility Care	In-Network: Skilled Nursing Facility Services: $0.00 per day for days 1 to 20 $0.00 per day for days 21 to 100 Prior Authorization Required for Skilled Nursing Facility Services Prior authorization required

Dental Benefits

The following dental services are covered from in-network providers.

Coverage	Cost
Dental Care	In-Network: Preventive Dental: Copayment for Oral Exams $0.00 Maximum 2 visits every year Copayment for Prophylaxis (Cleaning) $0.00 Maximum 2 visits every year Copayment for Fluoride Treatment $0.00 Maximum 1 visit every year Copayment for Dental X-Rays $0.00 Maximum 1 visit (Please see Evidence of Coverage for details) Referral Required for Preventive Dental Comprehensive Dental: Copayment for Medicare-covered Benefits $0.00 Copayment for Non-routine Services $0.00 Maximum 1 visit (Please see Evidence of Coverage for details) Copayment for Diagnostic Services $0.00 Maximum 1 visit every year Copayment for Restorative Services $0.00 Maximum 1 visit (Please see Evidence of Coverage for details) Copayment for Endodontics $0.00 Maximum 1 visit (Please see Evidence of Coverage for details) Copayment for Periodontics $0.00 Maximum 1 visit (Please see Evidence of Coverage for details) Copayment for Extractions $0.00 Maximum 1 visit (Please see Evidence of Coverage for details) Copayment for Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services $0.00 Maximum 1 visit (Please see Evidence of Coverage for details) Maximum Plan Benefit of $3000.00 every year for Non-Medicare Covered Comprehensive Prior Authorization Required for Comprehensive Dental Prior authorization required

Coverage

Cost

Dental Care

In-Network:

Preventive Dental:
Copayment for Oral Exams $0.00

Maximum 2 visits every year

Copayment for Prophylaxis (Cleaning) $0.00

Maximum 2 visits every year

Copayment for Fluoride Treatment $0.00

Maximum 1 visit every year

Copayment for Dental X-Rays $0.00

Maximum 1 visit (Please see Evidence of Coverage for details)

Referral Required for Preventive Dental

Comprehensive Dental:
Copayment for Medicare-covered Benefits $0.00
Copayment for Non-routine Services $0.00

Maximum 1 visit (Please see Evidence of Coverage for details)

Copayment for Diagnostic Services $0.00

Maximum 1 visit every year

Copayment for Restorative Services $0.00

Maximum 1 visit (Please see Evidence of Coverage for details)

Copayment for Endodontics $0.00

Maximum 1 visit (Please see Evidence of Coverage for details)

Copayment for Periodontics $0.00

Maximum 1 visit (Please see Evidence of Coverage for details)

Copayment for Extractions $0.00

Maximum 1 visit (Please see Evidence of Coverage for details)

Copayment for Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services $0.00

Maximum 1 visit (Please see Evidence of Coverage for details)

Maximum Plan Benefit of $3000.00 every year for Non-Medicare Covered Comprehensive
Prior Authorization Required for Comprehensive Dental
Prior authorization required

Vision Benefits

The following vision services are covered from in-network providers.

Coverage	Cost
Vision Benefits	In-Network: Eye Exams: Copayment for Medicare Covered Benefits $0.00 Copayment for Routine Eye Exams $0.00 Maximum 1 Routine Eye Exam every year Prior Authorization Required for Eye Exams Eyewear: Copayment for Medicare-Covered Benefits $0.00 Maximum Plan Allowance of $200.00 every year for all Non-Medicare covered eyewear Prior Authorization Required for Eyewear Prior authorization required

Coverage

Cost

Vision Benefits

In-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $0.00
Copayment for Routine Eye Exams $0.00

Maximum 1 Routine Eye Exam every year

Prior Authorization Required for Eye Exams

Eyewear:
Copayment for Medicare-Covered Benefits $0.00
Maximum Plan Allowance of $200.00 every year for all Non-Medicare covered eyewear
Prior Authorization Required for Eyewear
Prior authorization required

Hearing Benefits

The following hearing services are covered from in-network providers.

Coverage	Cost
Hearing Benefits	In-Network: Hearing Exams: Copayment for Medicare Covered Benefits $0.00 Copayment for Routine Hearing Exams $0.00 Maximum 1 visit every year Copayment for Fitting/Evaluation for Hearing Aid $0.00 Maximum 1 visit every year Prior Authorization Required for Hearing Exams Hearing Aids: Copayment for Hearing Aids $0.00 Maximum 2 Hearing Aids every year Maximum Plan Benefit of $1000.00 every year per ear Prior Authorization Required for Hearing Aids Prior authorization required

Coverage

Cost

Hearing Benefits

In-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $0.00
Copayment for Routine Hearing Exams $0.00

Maximum 1 visit every year

Copayment for Fitting/Evaluation for Hearing Aid $0.00

Maximum 1 visit every year

Prior Authorization Required for Hearing Exams

Hearing Aids:
Copayment for Hearing Aids $0.00

Maximum 2 Hearing Aids every year

Maximum Plan Benefit of $1000.00 every year per ear
Prior Authorization Required for Hearing Aids
Prior authorization required

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: Abdominal aortic aneurysm screening Alcohol misuse screenings & counseling Bone mass measurements (bone density) Cardiovascular disease screenings Cardiovascular disease (behavioral therapy) Cervical & vagin*l cancer screening Colorectal cancer screenings Depression screenings Diabetes screenings Diabetes self-management training Glaucoma tests Hepatitis B (HBV) infection screening Hepatitis C screening test HIV screening Lung cancer screening Mammograms (screening) Nutrition therapy services Obesity screenings & counseling One-time Welcome to Medicare preventive visit Prostate cancer screenings(PSA) Sexually transmitted infections screening & counseling Shots: COVID-19 shots Flu shots Hepatitis B shots Pneumococcal shots Tobacco use cessation Yearly "Wellness" visit

Coverage

Cost

Preventive Services and Health/Wellness Education Programs

In-Network:
$0.00 copay for Medicare Covered Preventive Services:

Abdominal aortic aneurysm screening
Alcohol misuse screenings & counseling
Bone mass measurements (bone density)
Cardiovascular disease screenings
Cardiovascular disease (behavioral therapy)
Cervical & vagin*l cancer screening
Colorectal cancer screenings
Depression screenings
Diabetes screenings
Diabetes self-management training
Glaucoma tests
Hepatitis B (HBV) infection screening
Hepatitis C screening test
HIV screening
Lung cancer screening
Mammograms (screening)
Nutrition therapy services
Obesity screenings & counseling
One-time Welcome to Medicare preventive visit
Prostate cancer screenings(PSA)
Sexually transmitted infections screening & counseling
Shots:

COVID-19 shots

Flu shots

Hepatitis B shots

Pneumococcal shots

Tobacco use cessation
Yearly "Wellness" visit

Prescription Drug Costs and Coverage

The Wellcare Dual Access (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	Standard retail $0.00 Standard mail order $0.00 Preferred cost-share mail order $0.00 Preferred cost-share retail $0.00
Generic	Standard retail $0.00 Standard mail order $0.00 Preferred cost-share mail order $0.00 Preferred cost-share retail $0.00
Preferred Brand	Standard retail $0.00 Standard mail order $0.00 Preferred cost-share mail order $0.00 Preferred cost-share retail $0.00
Non-Preferred Drug	Standard retail $0.00 Standard mail order $0.00 Preferred cost-share mail order $0.00 Preferred cost-share retail $0.00
Specialty Tier	Standard retail $0.00 Standard retail $0.00 Standard retail $0.00 Standard mail order $0.00 Standard mail order $0.00 Standard mail order $0.00 Preferred cost-share mail order $0.00 Preferred cost-share mail order $0.00 Preferred cost-share mail order $0.00 Preferred cost-share retail $0.00 Preferred cost-share retail $0.00 Preferred cost-share retail $0.00
Annual Drug Deductible	$0
Preferred Generic	Standard retail $0.00 Standard mail order $0.00 Preferred cost-share mail order $0.00 Preferred cost-share retail $0.00
Generic	Standard retail $0.00 Standard mail order $0.00 Preferred cost-share mail order $0.00 Preferred cost-share retail $0.00
Preferred Brand	Standard retail $0.00 Standard mail order $0.00 Preferred cost-share mail order $0.00 Preferred cost-share retail $0.00
Non-Preferred Drug	Standard retail $0.00 Standard mail order $0.00 Preferred cost-share mail order $0.00 Preferred cost-share retail $0.00
Specialty Tier	Standard retail $0.00 Standard retail $0.00 Standard retail $0.00 Standard mail order $0.00 Standard mail order $0.00 Standard mail order $0.00 Preferred cost-share mail order $0.00 Preferred cost-share mail order $0.00 Preferred cost-share mail order $0.00 Preferred cost-share retail $0.00 Preferred cost-share retail $0.00 Preferred cost-share retail $0.00
Annual Drug Deductible	$0
Preferred Generic	Standard retail $0.00 Standard mail order $0.00 Preferred cost-share mail order $0.00 Preferred cost-share retail $0.00
Generic	Standard retail $0.00 Standard mail order $0.00 Preferred cost-share mail order $0.00 Preferred cost-share retail $0.00
Preferred Brand	Standard retail $0.00 Standard mail order $0.00 Preferred cost-share mail order $0.00 Preferred cost-share retail $0.00
Non-Preferred Drug	Standard retail $0.00 Standard mail order $0.00 Preferred cost-share mail order $0.00 Preferred cost-share retail $0.00
Specialty Tier	Standard retail $0.00 Standard retail $0.00 Standard retail $0.00 Standard mail order $0.00 Standard mail order $0.00 Standard mail order $0.00 Preferred cost-share mail order $0.00 Preferred cost-share mail order $0.00 Preferred cost-share mail order $0.00 Preferred cost-share retail $0.00 Preferred cost-share retail $0.00 Preferred cost-share retail $0.00

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