2020 Full Dual (D-SNP) MAPD- D... · 2019. 10. 22. · Allwell Dual Medicare (HMO D-SNP) Page 3...
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BENEFITS ASSISTANCE PROGRAM - (602) 280-1059 State Health Insurance Assistance Program (SHIP) A program of the Area Agency on Aging, Region One 1366 East Thomas, Suite 108, Phoenix, AZ 85014 2020 This project was supported in part by grant number 15AAAZMSHI, from the U.S. Administration for Community Living, Department of Health and Human Services, Washington, D.C. 20201. Grantees undertaking projects under government sponsorship are encouraged to express freely their findings and conclusions. Points of view or opinions do not, therefore, necessarily represent official Administration for Community Living policy. Full Dual (D-SNP) Medicare Advantage Special Needs Plans Maricopa County Most current revision 10/10/2019 Full Dual Special Needs Plans (D-SNP) are Medicare Advantage plan options for beneficiaries who have both Medicare and an AHCCCS (Medicaid) health plan under one of the following programs: QMB, Caretaker, Freedom to Work, ALTCS, other. These plans may offer extra benefits like dental, vision, and hearing aids which are not standard benefits under either Original Medicare or an AHCCCS plan. Those enrolled in SLMB or QI-1 are not eligible for these plans. D-SNPs work with AHCCCS health plans to provide both medical services and drug coverage. If a beneficiary has BOTH plans, there should be no copays for covered services provided by in-network providers (with both plans) and very small copays for prescribed medications. D-SNPs have networks (just like the AHCCCS health plans) and you must generally get your care and services from doctors and hospitals in the plan’s network with the exception of emergency or urgent care. It is suggested that clients choose the D-SNP that is aligned with their AHCCCS plan IF the D-SNP covers all of their prescribed medications and preferred providers are "in-network". Alignment means that the same insurance company is offering both your Medicare and Medicaid plans and it ensures that billing between the provider and the plan will be seamless eliminating billing problems. See the next page for how to align plans. If the beneficiary currently is in an "unaligned situation", it is suggested that they align their two plans as soon as allowed. Keep in mind that D-SNPs can be changed quarterly but AHCCCS plans can only be changed once per year on their enrollment anniversary month. Call MASP at (602) 417-5010 to determine the month you can make that change. To align plans, follow the steps on Page 2.
Transcript of 2020 Full Dual (D-SNP) MAPD- D... · 2019. 10. 22. · Allwell Dual Medicare (HMO D-SNP) Page 3...
BENEFITS ASSISTANCE PROGRAM - (602) 280-1059
State Health Insurance Assistance Program (SHIP)
A program of the Area Agency on Aging, Region One
1366 East Thomas, Suite 108, Phoenix, AZ 85014
2020
This project was supported in part by grant number 15AAAZMSHI, from the U.S. Administration for Community Living, Department of Health and Human Services,
Washington, D.C. 20201. Grantees undertaking projects under government sponsorship are encouraged to express freely their findings and conclusions. Points of view
or opinions do not, therefore, necessarily represent official Administration for Community Living policy.
Full Dual (D-SNP)Medicare Advantage Special Needs Plans
Maricopa County
Most current revision 10/10/2019
Full Dual Special Needs Plans (D-SNP) are Medicare Advantage plan options for beneficiaries who have both
Medicare and an AHCCCS (Medicaid) health plan under one of the following programs: QMB, Caretaker,
Freedom to Work, ALTCS, other. These plans may offer extra benefits like dental, vision, and hearing aids which
are not standard benefits under either Original Medicare or an AHCCCS plan. Those enrolled in SLMB or QI-1 are
not eligible for these plans.
D-SNPs work with AHCCCS health plans to provide both medical services and drug coverage. If a beneficiary has
BOTH plans, there should be no copays for covered services provided by in-network providers (with both plans)
and very small copays for prescribed medications.
D-SNPs have networks (just like the AHCCCS health plans) and you must generally get your care and services
from doctors and hospitals in the plan’s network with the exception of emergency or urgent care.
It is suggested that clients choose the D-SNP that is aligned with their AHCCCS plan IF the D-SNP covers all of
their prescribed medications and preferred providers are "in-network". Alignment means that the same
insurance company is offering both your Medicare and Medicaid plans and it ensures that billing between the
provider and the plan will be seamless eliminating billing problems. See the next page for how to align plans.
If the beneficiary currently is in an "unaligned situation", it is suggested that they align their two plans as soon as
allowed. Keep in mind that D-SNPs can be changed quarterly but AHCCCS plans can only be changed once per
year on their enrollment anniversary month. Call MASP at (602) 417-5010 to determine the month you can
make that change. To align plans, follow the steps on Page 2.
Page
Allwell Dual Medicare (HealthNet) 3
Banner University Care Advantage Plan 007 5
Magellan Complete Care of Arizona 7 Magellan Complete Care
Mercy Care Advantage Plan 001 9
Steward Health Choice Generations 11
United Healthcare Dual Complete 13
Wellcare Liberty 15
Descriptions for Plans below NOT included in this packet.
Covered by an AHCCCS health plan and NOT in your enrollment anniversary month:
1. If you are not in your AHCCCS enrollment anniversary month, you will have to wait until your anniversary
month to change your AHCCCS plan. Two months prior to your anniversary month you will be reminded of your
opportunity to make a change.
2. If you're not enrolled in the D-SNP of your choice, you can enroll into it. However, you will be in an
"unaligned" situation untill you can change your AHCCCS plan at 602-417-7100 option 1.
How to Align your D-SNP and AHCCCS Plan - choose the situation below that applies to you and follow the steps
indicated.
D-SNP Medicare Advantage Plans
None ___________
Newly eligible for an AHCCCS plan:
1. If you are within 90 calendar days of being approved for an AHCCCS plan, call AHCCCS at (602) 417-7100
option 1, and enroll into the AHCCCS plan aligned with the D-SNP plan you have selected. If you are already
enrolled in the AHCCCS plan that aligns with the D-SNP of your choice, skip this step.
2. Enroll into the D-SNP of your choice by calling them. The telephone number for the D-SNP is available in the
upper right corner of the page in this booklet.
Covered by an AHCCCS health plan and in your enrollment anniversary month:
1. If you are in your AHCCCS enrollment anniversary month, call AHCCCS at (602) 417-7100 option 1, and switch
to the AHCCCS plan aligned with the D-SNP plan you have selected.
2. Then call and enroll into the aligned D-SNP. If already enrolled in the D-SNP of your choice, skip this step.
D-SNPs (and their aligned AHCCCS/ALTCS Plans)Aligned AHCCCS Plans
United Healthcare Dual Complete One United Healthcare Community Plan
Developmentally Disabled - There is a small group of AHCCCS beneficiaries who are "DDD". We rarely encounter
these and they require special handling. Please contact a SHIP staff member for assistance.
Mercy Care Advantage Plan 005 Mercy Care Plan
Care 1st Arizona
American Indian Health Program
D-SNP options for those on ALTCS Aligned ALTCS Plans
Banner University Care Advantage Plan 015 Banner University Family Care
Arizona Complete Health
Banner University Family Care
Mercy Care Plan or Mercy Maricopa Integrated
Steward Health Choice
United Healthcare Community Plan
Allwell Dual Medicare (HMO D-SNP) Page 3
Plan Number H5590-008 800 333-3930
STAR Rating TBA www.allwellmedicare.com
Monthly Plan Premium $0
Maximum-out-of-Pocket Limit (MOOP) $0
Out-of-Network Services Not covered
Physician/Provider Services Copayments
Primary Care $0
Specialist $0
Mental Health / Substance Abuse $0
PT, OT, Speech Therapy $0
Chiropractic (limited services) $0
Podiatry $0
Hospital (Inpatient) Care - Copayments
Hospital inpatient Per Days 1 - 7 $0
Hospital inpatient Per Days 8 - beyond $0
Skilled Nursing Facility (SNF) Per Days 1 - 20 $0
Skilled Nursing Facility (SNF) Per Days 21 - 100 $0
Oupatient Care - Copayments
Hospital Surgery Center $0
Ambulatory Surgery Center $0
Emergency/Urgent Care Services - Copayments
Emergency Room $0
Urgent Care $0
Ambulance per Trip $0
Diagnostic Testing
Radiology Tests and Imaging $0
Lab Tests $0
Durable Medical Equipment (DME)
Diabetes Supplies and Self-Management Training $0
Diabetes therapeutic shoes and inserts $0
Equipment (e.g. wheelchairs, oxygen) and Prosthetics (e.g. braces) $0
Prescription Drugs
Part D drugs - Deductible $0
Call Plan or consult Medicare.gov Plan Finder to determine your estimated drug cost
Part B Immunizations - Flu, pheumonia, and hepititis B vacinnations $0
Transplant drug and facility based infusions such as chemotherapy $0
Allwell Dual Medicare (HMO D-SNP) Page 4
Additional Benefits, Physician Network, Preferred Pharmacies and Hospital Networks
Additional Benefits
Vision eyewear: up to $250 allowance every calendar year no charge
Hearing: 2 hearing aids total, 1 per ear every calendar year no charge
Transportation to approved locations: up to 16 one-way trips no charge
Dental services: $3,000 every calendar year no charge
Meals after Hospital Stay: 2 meals per day for 14 days no charge
Over-the-Counter allowance on approved health products $200 per quarter
24 hour Nurse Line no charge
Fitness Program no charge
Physician Network
** Check with the plan to determine if your physician is in their network.
Preferred pharmacies
If your plan has preferred pharmacies, using those pharmacies may save you money.
Albertsons Bashas Cigna
Costco CVS Fry's
Osco Safeway Walgreen's
Walmart
Hospital Networks
Abrazo St. Lukes BannerWest Campus (Goodyear) Tempe Baywood
Central Campus Phoenix Boswell
Maryvale Del Webb
Phoenix (PV-Bell) Dignity Health Desert
Arrowhead Arizona General Estrella
Chandler Regional Gateway
Honor Health Mercy Gilbert Goldfield (Apache Junction)
Scottsdale Healthcare Osborn St Joseph’s Hospital University Medical Center
Scottsdale Healthcare Shea St Joseph’s Westgate Ironwood
Scottsdale Heallthcare Thompson Peak Thunderbird
John C Lincoln Deer Valley
John C Lincoln Phoenix Maricopa Medical Center
Banner-University Care Advantage (HMO D-SNP) Page 5
Plan Number 4931-007 877 874-3938
STAR Rating TBA www.banneruca.com
Monthly Plan Premium $0
Maximum-out-of-Pocket Limit (MOOP) $0
Out-of-Network Services Not covered
Physician/Provider Services Copayments
Primary Care $0
Specialist $0
Mental Health / Substance Abuse $0
PT, OT, Speech Therapy $0
Chiropractic (limited services) $0
Podiatrist $0
Hospital (Inpatient) Care - Copayments
Hospital inpatient Per Days 1 - 7 $0
Hospital inpatient Per Days 8 - beyond $0
Skilled Nursing Facility (SNF) Per Days 1 - 20 $0
Skilled Nursing Facility (SNF) Per Days 21 - 100 $0
Oupatient Care - Copayments
Hospital Surgery Center $0
Ambulatory Surgery Center $0
Emergency/Urgent Care Services - Copayments
Emergency Room $0
Urgent Care $0
Ambulance per Trip $0
Diagnostic Testing
Radiology Tests and Imaging $0
Lab Tests $0
Durable Medical Equipment (DME)
Diabetes Supplies and Self-Management Training $0
Diabetes therapeutic shoes and inserts $0
Equipment (e.g. wheelchairs, oxygen) and Prosthetics (e.g. braces) $0
Prescription Drugs
Part D drugs - Deductible $0
Call Plan or consult Medicare.gov Plan Finder to determine your estimated drug cost
Part B Immunizations - Flu, pheumonia, and hepititis B vacinnations $0
Transplant drug and facility based infusions such as chemotherapy $0
Banner-University Care Advantage (HMO D-SNP) Page 6
Additional Benefits, Physician Network, Preferred Pharmacies and Hospital Networks
Additional Benefits
Vision (Exams, lenses, glasses): $150 per year no charge
Hearing Aid Appliance: $1,500 every 3 years no charge
Transportation to approved locations not covered
Dental Preventive and Comprehensive: up to $3,000 per year no charge
Meals after Hospital Stay not covered
Over-the-Counter allowance on approved health products $40 per month
24 hour Nurse Line no charge
Fitness Program not covered
Physician Network
** Check with the plan to determine if your physician is in their network.
Preferred pharmacies
If your plan has preferred pharmacies, using those pharmacies may save you money.
Bashas Cigna Medical Group CVS
Fry's Safeway Walgreens
Hospital Networks
Honor Health Dignity Health BannerScottsdale Healthcare Osborn Arizona General Baywood
Scottsdale Healthcare Shea Chandler Regional Boswell
Scottsdale Heallthcare Thmpson Pk Mercy Gilbert Del Webb
John C Lincoln Deer Valley St Joseph’s Hospital Desert
John C Lincoln Phoenix St Joseph’s Westgate Estrella
Gateway
St Luke’s Goldfield (Apache Junction)
Tempe University Medical Center
Phoenix Ironwood
Thunderbird
Magellan Complete Care of Arizona (HMO D-SNP) Page 7
Plan Number H8845-2020 800-424-4505
STAR Rating TBA www.mccofaz.com/dsnp
Monthly Plan Premium $0
Maximum-out-of-Pocket Limit (MOOP) $0
Out-of-Network Services Not covered
Physician/Provider Services Copayments
Primary Care $0
Specialist $0
Mental Health / Substance Abuse $0
PT, OT, Speech Therapy $0
Chiropractic (limited services) $0
Podiatrist $0
Hospital (Inpatient) Care - Copayments
Hospital inpatient Per Days 1 - 7 $0
Hospital inpatient Per Days 8 - beyond $0
Skilled Nursing Facility (SNF) Per Days 1 - 20 $0
Skilled Nursing Facility (SNF) Per Days 21 - 100 $0
Oupatient Care - Copayments
Hospital Surgery Center $0
Ambulatory Surgery Center $0
Emergency/Urgent Care Services - Copayments
Emergency Room $0
Urgent Care $0
Ambulance per Trip $0
Diagnostic Testing
Radiology Tests and Imaging $0
Lab Tests $0
Durable Medical Equipment (DME)
Diabetes Supplies and Self-Management Training $0
Diabetes therapeutic shoes and inserts $0
Equipment (e.g. wheelchairs, oxygen) and Prosthetics (e.g. braces) $0
Prescription Drugs
Part D drugs - Deductible $0
Call Plan or consult Medicare.gov Plan Finder to determine your estimated drug cost
Part B Immunizations - Flu, pheumonia, and hepititis B vacinnations $0
Transplant drug and facility based infusions such as chemotherapy $0
Magellan Complete Care of Arizona (HMO D-SNP) Page 8
Additional Benefits, Physician Network, Preferred Pharmacies and Hospital Networks
Additional Benefits
Eyewear: up to $200 every 2 years no charge
Hearing Aid allowance of $1,250 for both ears combined every 3 years no charge
Transportation to approved locations not covered
Dental services not covered
Meals after Hospital Stay no information
Over-the-Counter allowance on approved health products no information
24 hour Nurse Line no charge
Fitness Program no information
Adult Day Care no information
In home support services no information
Physician Network
** Check with the plan to determine if your physician is in their network.
Preferred pharmacies
If your plan has preferred pharmacies, using those pharmacies may save you money.
** The pharmacy network for this plan is not available at this time.
Hospital Networks
Abrazo Dignity Health BannerWest Campus (Goodyear) Arizona General Baywood
Central Campus Chandler Regional Boswell
Maryvale Mercy Gilbert Del Webb
Phoenix (PV-Bell) St Joseph’s Desert
Arrowhead St Joseph’s Westgate Estrella
Gateway
Honor Health St Luke’s Goldfield (Apache Junction)
Scottsdale Healthcare Osborn Tempe University Medical Center
Scottsdale Healthcare Shea Phoenix Ironwood
Scottsdale Heallthcare Thompson Peak Thunderbird
John C Lincoln Deer Valley
John C Lincoln Phoenix
Mercy Care Advantage (HMO D-SNP) Page 9
Plan Number H5580-001 866 571-5781
STAR Rating TBA www.mercycareadvantage.com
Monthly Plan Premium $0
Maximum-out-of-Pocket Limit (MOOP) $0
Out-of-Network Services Not covered
Physician/Provider Services Copayments
Primary Care $0
Specialist $0
Mental Health / Substance Abuse $0
PT, OT, Speech Therapy $0
Chiropractic (limited services) $0
Podiatry $0
Hospital (Inpatient) Care - Copayments
Hospital inpatient Per Days 1 - 7 $0
Hospital inpatient Per Days 8 - beyond $0
Skilled Nursing Facility (SNF) Per Days 1 - 20 $0
Skilled Nursing Facility (SNF) Per Days 21 - 51 $0
Oupatient Care - Copayments
Hospital Surgery Center $0
Ambulatory Surgery Center $0
Emergency/Urgent Care Services - Copayments
Emergency Room $0
Urgent Care $0
Ambulance per Trip $0
Diagnostic Testing
Radiology Tests and Imaging $0
Lab Tests $0
Durable Medical Equipment (DME)
Diabetes Supplies and Self-Management Training $0
Diabetes therapeutic shoes and inserts $0
Equipment (e.g. wheelchairs, oxygen) and Prosthetics (e.g. braces) $0
Prescription Drugs
Part D drugs - Deductible $0
Call Plan or consult Medicare.gov Plan Finder to determine your estimated drug cost
Part B Immunizations - Flu, pheumonia, and hepititis B vacinnations $0
Transplant drug and facility based infusions such as chemotherapy $0
Mercy Care Advantage (HMO D-SNP) Page 10
Additional Benefits, Physician Network, Preferred Pharmacies and Hospital Networks
Additional Benefits
Vision (Exams, lenses, glasses): up to $275 every 2 years no charge
Hearing Aid Appliance: up to $1,700 every 2 years no charge
Transportation to approved locations: up to 26 one-way trips no charge
Dental: Comprehensive up to $4,000 every year, Prevent no charge no charge
Meals after Hospital Stay: 14 meals no charge
Over-the-Counter allowance on approved health products $60 per month
24 hour Nurse Line no charge
Fitness Program no charge
Physician Network
** Check with the plan to determine if your physician is in their network.
Preferred pharmacies
If your plan has preferred pharmacies, using those pharmacies may save you money.
Albertsons Bashas Fry's
Cigna Center Pharmacy CVS Walgreen's
Walmart Safeway
Hospital Networks
Abrazo Dignity Health BannerWest Campus (Goodyear) Arizona General Baywood
Central Campus Chandler Regional Boswell
Maryvale Mercy Gilbert Del Webb
Phoenix (PV-Bell) St Joseph’s Desert
Arrowhead St Joseph’s Westgate Estrella
Gateway
St. Lukes Goldfield (Apache Junction)
Tempe University Medical Center
Phoenix Ironwood
Thunderbird
Maricopa Medical Center
Steward Health Choice Generations (HMO D-SNP) Page 11
Plan Number H5587-002 800-656-8991
STAR Rating TBA www.StewardHCGenerations.org
Monthly Plan Premium $0
Maximum-out-of-Pocket Limit (MOOP) $0
Out-of-Network Services Not covered
Physician/Provider Services Copayments
Primary Care $0
Specialist $0
Mental Health / Substance Abuse $0
PT, OT, Speech Therapy $0
Chiropractic (limited services) $0
Podiatrist $0
Hospital (Inpatient) Care - Copayments
Hospital inpatient Per Days 1 - 7 $0
Hospital inpatient Per Days 8 - beyond $0
Skilled Nursing Facility (SNF) Per Days 1 - 20 $0
Skilled Nursing Facility (SNF) Per Days 21 - 51 $0
Oupatient Care - Copayments
Hospital Surgery Center $0
Ambulatory Surgery Center $0
Emergency/Urgent Care Services - Copayments
Emergency Room $0
Urgent Care $0
Ambulance per Trip $0
Diagnostic Testing
Radiology Tests and Imaging $0
Lab Tests $0
Durable Medical Equipment (DME)
Diabetes Supplies and Self-Management Training $0
Diabetes therapeutic shoes and inserts $0
Equipment (e.g. wheelchairs, oxygen) and Prosthetics (e.g. braces) $0
Prescription Drugs
Part D drugs - Deductible $0
Call Plan or consult Medicare.gov Plan Finder to determine your estimated drug cost
Part B Immunizations - Flu, pheumonia, and hepititis B vacinnations $0
Transplant drug and facility based infusions such as chemotherapy $0
Steward Health Choice Generations (HMO D-SNP) Page 12
Additional Benefits, Physician Network, Preferred Pharmacies and Hospital Networks
Additional Benefits
Eyewear: up to $300 every year for contact lenses or eyeglasses no charge
Hearing: up to $1,500 per ear every 3 years for hearing aid and fitting no charge
Transportation to approved locations: up to 24 one-way trips no charge
Preventive and Comprehensive Dental: up to $3,000 per year no charge
Meals after Hospital Stay: 10 meals per admission, once per calendar year no charge
Over-the-Counter allowance on approved health products: $150 every 3 months no charge
24 hour Nurse Line not covered
Fitness Program no charge
Physician Network
** Check with the plan to determine if your physician is in their network.
Preferred pharmacies
If your plan has preferred pharmacies, using those pharmacies may save you money.
CVS Costco Fry's
Safeway Walgreen's Walmart
Osco Bashas
Hospital Networks
Abrazo Dignity Health St Luke’sWest Campus (Goodyear) Arizona General Tempe
Central Campus Chandler Regional Phoenix
Maryvale Mercy Gilbert
Phoenix (PV-Bell) St Joseph’s
Arrowhead St Joseph’s Westgate
Honor Health Maricopa Medical Center
Scottsdale Healthcare Osborn
Scottsdale Healthcare Shea
Scottsdale Heallthcare Thompson Peak
John C Lincoln Deer Valley
John C Lincoln Phoenix
UnitedHealthcare Dual Complete (HMO D-SNP) Page 13
Plan Number H0321-002 844 560-4944
STAR Rating TBA www.UHCCommunityPlan.com
Monthly Plan Premium $0
Maximum-out-of-Pocket Limit (MOOP) $0
Out-of-Network Services Not covered
Physician/Provider Services Copayments
Primary Care $0
Specialist $0
Mental Health / Substance Abuse $0
PT, OT, Speech Therapy $0
Chiropractic (limited services) $0
Podiatry $0
Hospital (Inpatient) Care - Copayments
Hospital inpatient Per Days 1 - 7 $0
Hospital inpatient Per Days 8 - beyond $0
Skilled Nursing Facility (SNF) Per Days 1 - 20 $0
Skilled Nursing Facility (SNF) Per Days 21 - 51 $0
Oupatient Care - Copayments
Hospital Surgery Center $0
Ambulatory Surgery Center $0
Emergency/Urgent Care Services - Copayments
Emergency Room $0
Urgent Care $0
Ambulance per Trip $0
Diagnostic Testing
Radiology Tests and Imaging $0
Lab Tests $0
Durable Medical Equipment (DME)
Diabetes Supplies and Self-Management Training $0
Diabetes therapeutic shoes and inserts $0
Equipment (e.g. wheelchairs, oxygen) and Prosthetics (e.g. braces) $0
Prescription Drugs
Part D drugs - Deductible $0
Call Plan or consult Medicare.gov Plan Finder to determine your estimated drug cost
Part B Immunizations - Flu, pheumonia, and hepititis B vacinnations $0
Transplant drug and facility based infusions such as chemotherapy 0%
UnitedHealthcare Dual Complete (HMO D-SNP) Page 14
Additional Benefits, Physician Network, Preferred Pharmacies and Hospital Networks
Additional Benefits
Eyewear: lenses, frames, and contacts up to $200 every 2 years no charge
Hearing Aid Appliance up to $2,500 for 2 aids every 2 years no charge
Transportation to approved locations: 24 one-way trips no charge
Dental services up to $3,500 no charge
Meals after Hospital Stay see Plan Documentation
Over-the-Counter allowance on approved health products $275 per quarter
24 hour Nurse Line no charge
Fitness Program no charge
Physician Network
** Check with the plan to determine if your physician is in their network.
Preferred pharmacies
If your plan has preferred pharmacies, using those pharmacies may save you money.
Sam's Pharmacy Bashas Cigna
Costco CVS Fry's
Osco Safeway Walgreen's
Walmart
Hospital Networks
Abrazo Dignity Health BannerWest Campus (Goodyear) Arizona General Baywood
Central Campus Chandler Regional Boswell
Maryvale Mercy Gilbert Del Webb
Scottsdale St Joseph’s Desert
Arrowhead St Joseph’s Westgate Estrella
Gateway
Maricopa Integrated Health St Luke’s Goldfield (Apache Junction)
Tempe University Medical Center
Phoenix Ironwood
Thunderbird
Wellcare Liberty (HMO D-SNP) Page 15
Plan Number H5430-001 866 527-0056
STAR Rating TBA www.wellcare.com/medicare
Monthly Plan Premium $0
Maximum-out-of-Pocket Limit (MOOP) $0
Out-of-Network Services Not covered
Physician/Provider Services Copayments
Primary Care $0
Specialist $0
Mental Health / Substance Abuse $0
PT, OT, Speech Therapy $0
Chiropractic (limited services) $0
Podiatry $0
Hospital (Inpatient) Care - Copayments
Hospital inpatient Per Days 1 - 7 $0
Hospital inpatient Per Days 8 - beyond $0
Skilled Nursing Facility (SNF) Per Days 1 - 20 $0
Skilled Nursing Facility (SNF) Per Days 21 - 51 $0
Oupatient Care - Copayments
Hospital Surgery Center $0
Ambulatory Surgery Center $0
Emergency/Urgent Care Services - Copayments
Emergency Room $0
Urgent Care $0
Ambulance per Trip $0
Diagnostic Testing
Radiology Tests and Imaging $0
Lab Tests $0
Durable Medical Equipment (DME)
Diabetes Supplies and Self-Management Training $0
Diabetes therapeutic shoes and inserts $0
Equipment (e.g. wheelchairs, oxygen) and Prosthetics (e.g. braces) $0
Prescription Drugs
Part D drugs - Deductible $0
Call Plan or consult Medicare.gov Plan Finder to determine your estimated drug cost
Part B Immunizations - Flu, pheumonia, and hepititis B vacinnations $0
Transplant drug and facility based infusions such as chemotherapy $0
Wellcare Liberty (HMO D-SNP) Page 16
Additional Benefits, Physician Network, Preferred Pharmacies and Hospital Networks
Additional Benefits
Eyewear: lenses, frames, contacts up to $350 per year no charge
Hearing Aid Appliance up to $2,000 for 2 hearing aids per year no charge
Transportation to approved locations: 36 one-way trips no charge
Dental services up to $2,000 per year beginning October 1 each year no charge
Meals after Hospital Stay or due to Chronic Condition see plan documentation
Over-the-Counter allowance on approved health products $150 per quarter
24 hour Nurse Line no charge
Fitness Program no charge
Physician Network
** Check with the plan to determine if your physician is in their network.
Preferred pharmacies
If your plan has preferred pharmacies, using those pharmacies may save you money.
Albertsons Bashas Cigna
Costco CVS Fry's
Safeway Walgreen's Walmart
Hospital Networks
Abrazo St. Lukes BannerWest Campus (Goodyear) Tempe Baywood
Central Campus Phoenix Boswell
Maryvale Del Webb
Phoenix (PV-Bell) Desert
Arrowhead Estrella
Gateway
Honor Health Goldfield (Apache Junction)
Scottsdale Healthcare Osborn University Medical Center
Scottsdale Healthcare Shea Ironwood
Scottsdale Heallthcare Thompson Peak Thunderbird
John C Lincoln Deer Valley
John C Lincoln Phoenix
