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2014 Medicare Advantage Plan Benefit Details for the WellCare Access (HMO SNP)
This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.

2014 Medicare Advantage Plan Details
Medicare Plan Name:WellCare Access (HMO SNP)
Location:Miami-Dade, Florida 33142     Click to see other locations
Plan ID:H1032 - 176 - 0     Click to see other plans
Member Services:1-866-637-8041 TTY users 1-877-247-6272
— This plan information is for research purposes only. —
Click here to see plans for the current plan year
Medicare Contact Information:Please go to Medicare.gov or call 1-800-MEDICARE (1-800-633-4227) to get information on all of your options.
TTY users 1-877-486-2048
or contact your local SHIP for assistance
Email a copy of the WellCare Access (HMO SNP) benefit details
— Medicare Plan Features —
Monthly Premium:$0.00 for people who qualify for both Medicare and Medicaid. (see Plan Premium Details below)
Annual Deductible:$0 for people who qualify for both Medicare and Medicaid.
Annual Initial Coverage Limit (ICL):$2,850
Health Plan Type:Local HMO
Special Needs Plan (SNP)
Eligibility Requirement:		Dual-Eligible
Additional Gap Coverage?No additional gap coverage, only the Donut Hole Discount
Total Number of Formulary Drugs:2,986 drugsBrowse the WellCare Access (HMO SNP) Formulary
This plan has 5 drug tiers. See cost-sharing for all pharmacies and tiers. 
Formulary Drug Details:Tier 1Tier 2Tier 3Tier 4Tier 5
• Preferred Pharmacy
  Cost-Sharing during
  initial coverage phase:		$0.00$7.00$35.00$84.0025%
• Number of Drugs per
  Tier:		275964796600351
Plan's Pharmacy Search:http://www.wellcare.com
Plan Offers Mail Order?Yes
Number of Members enrolled in this plan in (H1032 - 176):262 members
Plan’s Summary Star Rating: 3.5 out of 5 Stars.
• Customer Service Rating: 3 out of 5 Stars.
• Member Experience Rating: 4 out of 5 Stars.
• Drug Cost Accuracy Rating: 4 out of 5 Stars.
— Plan Premium Details —
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔100%
Subsidy		75%
Subsidy		50%
Subsidy		25%
Subsidy
Monthly Part D Premium with LIS:$0.00$0.00$0.00$0.00
— Plan Health Benefits —
** Cost **
Premium and Other Important Information
* Depending on your level of Medicaid eligibility you may not have any cost-sharing responsibility for Original Medicare services
$0 monthly plan premium*
$0 annual deductible.*
$6 700 out-of-pocket limit for Medicare-covered services. However in this plan you will have no cost sharing responsibility for Medicare-covered services based on your level of Medicaid eligibility.
** Doctor and Hospital Choice **
Doctor and Hospital Choice
You must go to network doctors specialists and hospitals.
Referral required for network specialists (for certain benefits).
** Extra Benefits **
Wellness/Education and Other Supplemental Benefits & Services
The plan covers the following supplemental education/wellness programs:
  • Health Club Membership/Fitness Classes
  • Nursing Hotline
    • Acupuncture
    This plan does not cover Acupuncture and other alternative therapies.
    Over-the-Counter Items
    Please visit our plan website to see our list of covered Over-the-Counter items. OTC items may be purchased only for the enrollee. Please contact the plan for specific instructions for using this benefit.
    ** Important Information **
    Premium and Other Important Information
    * Depending on your level of Medicaid eligibility you may not have any cost-sharing responsibility for Original Medicare services
    $0 monthly plan premium*
    $0 annual deductible.*
    $6 700 out-of-pocket limit for Medicare-covered services. However in this plan you will have no cost sharing responsibility for Medicare-covered services based on your level of Medicaid eligibility.
    Doctor and Hospital Choice
    You must go to network doctors specialists and hospitals.
    Referral required for network specialists (for certain benefits).
    ** Inpatient Care **
    Inpatient Hospital Care
    Plan covers 90 days each benefit period.
    $0 annual service category deductible*
    $0 copay*
    Plan covers 60 lifetime reserve days. $0 copay per lifetime reserve day.*
    Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital.
    Inpatient Mental Health Care
    You get up to 190 days of inpatient psychiatric hospital care in a lifetime. Inpatient psychiatric hospital services count toward the 190-day lifetime limitation only if certain conditions are met. This limitation does not apply to inpatient psychiatric services furnished in a general hospital.
    $0 annual service category deductible*
    $0 copay*
    Plan covers 60 lifetime reserve days. $0 copay per lifetime reserve day.*
    Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital.
    Skilled Nursing Facility (SNF)
    Authorization rules may apply.
    Plan covers up to 100 days each benefit period
    No prior hospital stay is required.
    $0 annual service category deductible*
    $0 copay for SNF services*
    Home Health Care
    Authorization rules may apply.
    $0 copay for Medicare-covered home health visits*
    Hospice
    You must get care from a Medicare-certified hospice. You must consult with your plan before you select hospice.
    ** Outpatient Care **
    Doctor Office Visits
    $0 copay for each Medicare-covered primary care doctor visit.*
    $0 copay for each Medicare-covered specialist visit.*
    Chiropractic Services
    $0 copay for Medicare-covered chiropractic visits*
    $0 copay for up to 24 supplemental routine chiropractic visit(s) every year
    Medicare-covered chiropractic visits are for manual manipulation of the spine to correct subluxation (a displacement or misalignment of a joint or body part).
    Podiatry Services
    $0 copay for Medicare-covered podiatry visits*
    Medicare-covered podiatry visits are for medically necessary foot care.
    Outpatient Mental Health Care
    Authorization rules may apply.
    $0 copay for:
    • each Medicare-covered individual therapy visit*
  • each Medicare-covered group therapy visit*
    • $0 copay for:
    • each Medicare-covered individual therapy visit with a psychiatrist*
  • each Medicare-covered group therapy visit with a psychiatrist*
    • $0 copay for Medicare-covered partial hospitalization program services*
    Outpatient Substance Abuse Care
    Authorization rules may apply.
    $0 copay for:
    • each Medicare-covered individual substance abuse outpatient treatment visit*
  • each Medicare-covered group substance abuse outpatient treatment visit*
    • Outpatient Services
    Authorization rules may apply.
    $0 copay for each Medicare-covered ambulatory surgical center visit*
    $0 copay for each Medicare-covered outpatient hospital facility visit*
    Ambulance Services
    Authorization rules may apply.
    $0 copay for Medicare-covered ambulance benefits.*
    Emergency Care
    $0 annual service category deductible*
    $0 copay for Medicare-covered emergency room visits*
    Not covered outside the U.S. and its territories except under limited circumstances. Contact plan for details.
    If you are admitted to the hospital within 24-hour(s) for the same condition you pay $0 for the emergency room visit.
    Urgently Needed Care
    $0 copay for Medicare-covered urgently-needed-care visits*
    If you are admitted to the hospital within 24-hour(s) for the same condition you pay $0 for the urgently-needed-care visit.
    Outpatient Rehabilitation Services
    Authorization rules may apply.
    Medically necessary physical therapy occupational therapy and speech and language pathology services are covered.
    $0 copay for Medicare-covered Occupational Therapy visits*
    $0 copay for Medicare-covered Physical Therapy and/or Speech and Language Pathology visits*
    ** Outpatient Medical Services and Supplies **
    Durable Medical Equipment
    $0 annual service category deductible*
    Authorization rules may apply.
    $0 copay for Medicare-covered durable medical equipment*
    Prosthetic Devices
    Authorization rules may apply.
    $0 copay for Medicare-covered:
    • prosthetic devices*
  • medical supplies related to prosthetics splints and other devices*
    • Diabetes Programs and Supplies
    Authorization rules may apply.
    $0 copay for Medicare-covered Diabetes self-management training*
    $0 copay for Medicare-covered:
    • Diabetes monitoring supplies*
  • Therapeutic shoes or inserts*
    • Diabetic Supplies and Services are limited to specific manufacturers products and/or brands. Contact the plan for a list of covered supplies.
    Diagnostic Tests, X-Rays, Lab Services, and Radiology Services
    Authorization rules may apply.
    $0 copay for Medicare-covered:
    • lab services*
  • diagnostic procedures and tests*
  • X-rays*
  • diagnostic radiology services (not including X-rays)*
  • therapeutic radiology services*
    • ** Preventive Services **
    Cardiac and Pulmonary Rehabilitation Services
    $0 copay for:
    • Medicare-covered Cardiac Rehabilitation Services*
  • Medicare-covered Intensive Cardiac Rehabilitation Services*
  • Medicare-covered Pulmonary Rehabilitation Services*
    • Preventive Services
    $0 copay for all preventive services covered under Original Medicare at zero cost sharing. Any additional preventive services approved by Medicare mid-year will be covered by the plan or by Original Medicare.
    Plan covers a physical exam annually.
    Kidney Disease and Conditions
    $0 copay for Medicare-covered renal dialysis*
    $0 copay for Medicare-covered kidney disease education services*
    Outpatient Prescription Drugs
    $0 yearly deductible for Medicare Part B drugs.*
    $0 copay for Part B chemotherapy drugs and other Part-B drugs.*
    This plan uses a formulary. The plan will send you the formulary. You can also see the formulary at http://www.wellcare.com on the web.
    Different out-of-pocket costs may apply for people who
    • have limited incomes
    • live in long term care facilities or
    • have access to Indian/Tribal/Urban (Indian Health Service) providers.
    The plan offers national in-network prescription coverage (i.e. this would include 50 states and the District of Columbia). This means that you will pay the same cost-sharing amount for your prescription drugs if you get them at an in-network pharmacy outside of the plan's service area (for instance when you travel).
    Total yearly drug costs are the total drug costs paid by you the plan and Medicare.
    The plan may require you to first try one drug to treat your condition before it will cover another drug for that condition.
    Some drugs have quantity limits.
    Your provider must get prior authorization from WellCare Access (HMO SNP) for certain drugs.
    You must go to certain pharmacies for a very limited number of drugs due to special handling provider coordination or patient education requirements that cannot be met by most pharmacies in your network. These drugs are listed on the plan's website formulary printed materials as well as on the Medicare Prescription Drug Plan Finder on Medicare.gov.
    If the actual cost of a drug is less than the normal cost-sharing amount for that drug you will pay the actual cost not the higher cost-sharing amount.
    The plan charges a minimum cost sharing amount for certain low-cost drugs.
    If you request a formulary exception for a drug and WellCare Access (HMO SNP) approves the exception you will pay the generic cost share for generic drugs and the brand cost share for brand drugs.
    You pay a $0 annual deductible.
    Depending on your income and institutional status you pay the following: For generic drugs (including brand drugs treated as generic) either:
    • A $0 copay; or
    • A $1.20 copay; or
    • A $2.55 copay
    For all other drugs either:
    • A $0 copay; or
    • A $3.60 copay; or
    • A $6.35 copay.
    Tier 1: Preferred Generic $0 copay for drugs in this tier
    Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed.
    You can get drugs from a preferred and non-preferred pharmacy the following way(s):
    • one-month (31-day) supply
  • two-month (62-day) supply
  • three-month (93-day) supply
    • Long term care pharmacies must dispense brand name drugs in amounts less than a 14 days supply at a time. They may also dispense less than a month's supply of generic drugs at a time. Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed.
    You can get drugs the following way(s):
    • one-month (31-day) supply of drugs
    Contact your plan if you have questions about cost-sharing or billing when less than a one-month supply is dispensed.
    You can get drugs from a preferred and non-preferred mail order pharmacy the following way(s):
    • one-month (31-day) supply
  • two-month (62-day) supply
  • three-month (93-day) supply
    • You pay a $0 copay.
    Plan drugs may be covered in special circumstances for instance illness while traveling outside of the plan's service area where there is no network pharmacy. You may have to pay more than your normal cost-sharing amount if you get your drugs at an out-of-network pharmacy. In addition you will likely have to pay the pharmacy's full charge for the drug and submit documentation to receive reimbursement from WellCare Access (HMO SNP).
    You can get out-of-network drugs the following way:
    • one-month (31-day) supply
    Depending on your income and institutional status you will be reimbursed by WellCare Access (HMO SNP) up to the plan's cost of the drug minus the following: For generic drugs purchased out-of-network (including brand drugs treated as generic) either:
    • A $0 copay; or
    • A $1.20 copay; or
    • A $2.55 copay
    For all other drugs purchased out-of-network either:
    • A $0 copay; or
    • A $3.60 copay; or
    • A $6.35 copay.
    Tier 1: Preferred Generic $0 copay for drugs in this tier
    You will be reimbursed in full for drugs purchased out-of-network.
    Dental Services
    $0 copay for Medicare-covered dental benefits*
    $0 copay for up to 1 supplemental oral exam(s) every six months
    $0 copay for up to 1 supplemental cleaning(s) every six months
    $0 copay for up to 1 supplemental fluoride treatment(s) every year
    $0 copay for up to 1 supplemental dental x-ray(s)
    Plan offers additional supplemental comprehensive dental benefits.
    $750 plan coverage limit for supplemental dental benefits every year
    Hearing Services
    Authorization rules may apply.
    $0 copay for: Medicare-covered diagnostic hearing exams*
    $0 copay for up to 1 supplemental routine hearing exam(s) every year
    $0 copay for up to 1 supplemental hearing aid fitting-evaluation(s) every year
    $0 copay each for up to 1 supplemental hearing aid(s) every year
    $350 plan coverage limit for supplemental hearing aids every year.
    ** Additional Benefits **
    Vision Services
    $0 copay for: Medicare-covered diagnosis and treatment for diseases and conditions of the eye including an annual glaucoma screening for people at risk*
    $0 copay for up to 1 supplemental routine eye exam(s) every year
    $0 copay for
    • one pair of Medicare-covered eyeglasses (lenses and frames) or contact lenses after cataract surgery *
    $0 copay for up to 2 pair(s) of eyeglasses (lenses and frames) every year
    $0 copay for up to 2 pair(s) of contact lenses every year
    $0 copay for up to 2 pair(s) of eyeglass lenses every year
    $0 copay for up to 2 frame(s) every year
    $300 plan coverage limit for supplemental eyewear every year
    Wellness/Education and Other Supplemental Benefits & Services
    The plan covers the following supplemental education/wellness programs:
    • Health Club Membership/Fitness Classes
  • Nursing Hotline
    • Over-the-Counter Items
    Please visit our plan website to see our list of covered Over-the-Counter items. OTC items may be purchased only for the enrollee. Please contact the plan for specific instructions for using this benefit.
    Transportation
    $0 copay for up to 24 one-way trip(s) to plan approved location every year
    Acupuncture
    This plan does not cover Acupuncture and other alternative therapies.
    ** Inpatient Care **
    Inpatient Hospital Care
    Plan covers 90 days each benefit period.
    $0 annual service category deductible*
    $0 copay*
    Plan covers 60 lifetime reserve days. $0 copay per lifetime reserve day.*
    Except in an emergency your doctor must tell the plan that you are going to be admitted to the hospital.
    ** Outpatient Care **
    Doctor Office Visits
    $0 copay for each Medicare-covered primary care doctor visit.*
    $0 copay for each Medicare-covered specialist visit.*
    Outpatient Services
    Authorization rules may apply.
    $0 copay for each Medicare-covered ambulatory surgical center visit*
    $0 copay for each Medicare-covered outpatient hospital facility visit*
    Ambulance Services
    Authorization rules may apply.
    $0 copay for Medicare-covered ambulance benefits.*
    ** Outpatient Medical Services and Supplies **
    Durable Medical Equipment
    $0 annual service category deductible*
    Authorization rules may apply.
    $0 copay for Medicare-covered durable medical equipment*
    Diagnostic Tests, X-Rays, Lab Services, and Radiology Services
    Authorization rules may apply.
    $0 copay for Medicare-covered:
    • lab services*
  • diagnostic procedures and tests*
  • X-rays*
  • diagnostic radiology services (not including X-rays)*
  • therapeutic radiology services*
    • ** Additional Benefits **
    Wellness/Education and Other Supplemental Benefits & Services
    The plan covers the following supplemental education/wellness programs:
    • Health Club Membership/Fitness Classes
  • Nursing Hotline
    • Over-the-Counter Items
    Please visit our plan website to see our list of covered Over-the-Counter items. OTC items may be purchased only for the enrollee. Please contact the plan for specific instructions for using this benefit.




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