Wellpoint Kidney Care (HMO-POS C-SNP)
Medicare Advantage Health Plan Details
Chronic Condition (C-SNP)
Health insurance company offering plan: Wellpoint
- Rx
- Dental
- Vision
- Hearing
General Plan Details
Additional Benefits
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Mon-Fri: 8am-10pm, Sat-Sun: 8am-9pm ETNo Obligation to EnrollDoctor & Hospital Coverage
Out-of-network: $0 copay
Out-of-network: $0 copay
Out-of-network: 20% coinsurance
Emergency Room
$115 copay
Ambulance Coverage
In-network: 20% coinsurance
Out-of-network: 20% coinsurance
Lab, X-Ray, Radiology Coverage
Diagnostic tests & procedures:
In-network: 20% coinsurance
Out-of-network: 20% coinsurance
Lab services:
In-network: 20% coinsurance
Out-of-network: 20% coinsurance
Diagnostic radiology services (e.g., CT, MRI, etc):
In-network: 20% coinsurance
Out-of-network: 20% coinsurance
Outpatient x-rays:
In-network: 20% coinsurance
Out-of-network: 20% coinsurance
Hospital Services
Inpatient hospital coverage:
In-network:
Tier 1
$0 per day for days 1-60
$419 per day for days 61-90
$838 per day for days 91-150
Out-of-network:
$0 per day for days 1-60
$419 per day for days 61-90
$838 per day for days 91-150
Outpatient hospital coverage:
In-network: 20% coinsurance
Out-of-network: 20% coinsurance
Rehabilitation Coverage
Occupational therapy services:
In-network: 20% coinsurance
Out-of-network: 20% coinsurance
Urgent Care Coverage
$115 copay
Skilled Nursing Facility (SNF)
Out-of-network:
$ per stay
Mental Health Coverage
Outpatient group therapy with a psychiatrist:
In-network: 20% coinsurance
Out-of-network: 20% coinsurance
Outpatient individual therapy with a psychiatrist:
In-network: 20% coinsurance
Out-of-network: 20% coinsurance
Outpatient group therapy visits:
In-network: 20% coinsurance
Out-of-network: 20% coinsurance
Outpatient individual therapy visit:
In-network: 20% coinsurance
Out-of-network: 20% coinsurance
Dental, Vision, Hearing Benefits
Dental Services
Oral exams:
In-network: $0 copay
Out-of-network: 20%-50% coinsurance
Prophylaxis (cleaning):
In-network: $0 copay
Out-of-network: 20%-50% coinsurance
Dental x-rays:
In-network: $0 copay
Out-of-network: 20%-50% coinsurance
Vision Benefits
Routine eye exams:
In-network: $0 copay
Out-of-network: $0 copay
Contact Lenses:
In-network: $0 copay
Out-of-network: $0 copay
Eyeglasses:
In-network: $0 copay
Out-of-network: $0 copay
Hearing Benefits
Hearing exam:
In-network: $0 copay
Out-of-network: $0 copay
Fitting/evaluation:
In-network: $0 copay
Out-of-network: $0 copay
Hearing aids - prescription:
In-network: $0 copay
Out-of-network: $0 copay
Hearing aids - over the counter:
In-network: $0 copay
Out-of-network: $0 copay
Rx Drug Coverage - Preferred Retail Cost
Tier 1: Preferred Generic
$0.00 copay (30-day supply)
$0.00 copay (90-day supply)
Tier 2: Generic
$0.00 copay (30-day supply)
$0.00 copay (90-day supply)
Tier 3: Preferred Brand
10% coinsurance (30-day supply)
10% coinsurance (90-day supply)
Tier 4: Non-Preferred Drug
30% coinsurance (30-day supply)
30% coinsurance (90-day supply)
Tier 5: Specialty Tier
29% coinsurance (30-day supply)
Rx Drug Coverage - Standard Retail Cost
Tier 1: Preferred Generic
$0.00 copay (30-day supply)
$0.00 copay (90-day supply)
Tier 2: Generic
$10.00 copay (30-day supply)
$30.00 copay (90-day supply)
Tier 3: Preferred Brand
15% coinsurance (30-day supply)
15% coinsurance (90-day supply)
Tier 4: Non-Preferred Drug
30% coinsurance (30-day supply)
30% coinsurance (90-day supply)
Tier 5: Specialty Tier
29% coinsurance (30-day supply)
Rx Drug Coverage - Standard Mail Order Cost
Tier 1: Preferred Generic
$0.00 copay (30-day supply)
$0.00 copay (90-day supply)
Tier 2: Generic
$0.00 copay (30-day supply)
$0.00 copay (90-day supply)
Tier 3: Preferred Brand
10% coinsurance (30-day supply)
10% coinsurance (90-day supply)
Tier 4: Non-Preferred Drug
30% coinsurance (30-day supply)
30% coinsurance (90-day supply)
Tier 5: Specialty Tier
29% coinsurance (30-day supply)
Additional Added Benefits
Plan Links
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