2018 Medicare Advantage Plan Details | |||||
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Medicare Plan Name: | Allwell Dual Medicare Essentials (HMO SNP) | ||||
Location: | Greenville, South Carolina Click to see other locations | ||||
Plan ID: | H1436 - 006 - 0 Click to see other plans | ||||
Member Services: | |||||
— 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 |
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Email a copy of the Allwell Dual Medicare Essentials (HMO SNP) benefit details
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— 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): | $3,750 | ||||
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: | 3,662 drugs | Browse the Allwell Dual Medicare Essentials (HMO SNP) Formulary | |||
This plan has 6 drug tiers.
See cost-sharing for all pharmacies and tiers.
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Formulary Drug Details: | Tier 1 | Tier 2 | Tier 3 | Tier 4 | Tier 5 |
• Preferred Pharmacy Cost-Sharing during initial coverage phase: | $0.00 | $12.00 | $47.00 | $100.00 | 30% |
• Number of Drugs per Tier: | 282 | 762 | 855 | 872 | 745 |
Plan Offers Mail Order? | No | ||||
Number of Members enrolled in this plan in Greenville, South Carolina: | less than 10 members | ||||
Number of Members enrolled in this plan in South Carolina: | less than 10 members | ||||
Number of Members enrolled in this plan in (H1436 - 006): | 30 members | ||||
Plan’s Summary Star Rating: | New plan - No summary rating as of yet. | ||||
• Customer Service Rating: | New plan - not yet rated. | ||||
• Member Experience Rating: | New plan - not yet rated. | ||||
• Drug Cost Accuracy Rating: | New plan - not yet rated. | ||||
— Plan Premium Details — | |||||
The Monthly Premium is Split as Follows: ❔ | Total Premium | Part C Premium | Part D Base Premium | Part D Supplemental Premium | |
$0.00 | $0.00 | $0.00 | $0.00 | ||
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 | |
Total Monthly Premium with LIS (Parts C & D): | $0.00 | $0.00 | $0.00 | $0.00 |
— Plan Health Benefits — | |||||
** Benefit Highlights ** | |||||
Health plan deductible | |||||
• $0 | |||||
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs) | |||||
• $6,700 In-network | |||||
Optional supplemental benefits | |||||
• No | |||||
Inpatient hospital coverage | |||||
• $0 or $450 for days 1 through 4 $0 for days 5 through 90 | |||||
Outpatient hospital coverage | |||||
• $0 or $200 per visit | |||||
Preventive care | |||||
• $0 copay | |||||
Other health plan deductibles? | |||||
• In-Network: No | |||||
Doctor visits | |||||
• Primary: $0 copay | |||||
• Specialist: $0 or $20 per visit | |||||
Emergency care/Urgent care | |||||
• Emergency: $0 or $80 per visit (always covered) | |||||
• Urgent care: $0 or $20 per visit (always covered) | |||||
Diagnostic procedures/lab services/imaging | |||||
• Diagnostic tests and procedures: $0 or $20 | |||||
• Lab services: $0 or $20 | |||||
• Diagnostic radiology services (e.g., MRI): 0% or 20% | |||||
• Outpatient x-rays: $0 or $20 | |||||
Mental health services | |||||
• $0 or $400 for days 1 through 4 $0 for days 5 through 90 | |||||
Skilled Nursing Facility | |||||
• $0 for days 1 through 20 $0 or $160 for days 21 through 100 | |||||
Ambulance | |||||
• $0 or $250 | |||||
Transportation | |||||
• Not covered | |||||
Wellness programs (e.g., fitness, nursing hotline) | |||||
• Covered | |||||
Mental health services | |||||
• Outpatient group therapy visit with a psychiatrist: $0 or $20 | |||||
• Outpatient individual therapy visit with a psychiatrist: $0 or $20 | |||||
• Outpatient group therapy visit: $0 or $20 | |||||
• Outpatient individual therapy visit: $0 or $20 | |||||
Rehabilitation services | |||||
• Occupational therapy visit: $0 or $20 | |||||
• Physical therapy and speech and language therapy visit: $0 or $20 | |||||
Foot care (podiatry services) | |||||
• Foot exams and treatment: $0 or $20 | |||||
• Routine foot care: $15 | |||||
Medical equipment/supplies | |||||
• Durable medical equipment (e.g., wheelchairs, oxygen): 0% or 20% per item | |||||
• Prosthetics (e.g., braces, artificial limbs): 0% or 20% per item | |||||
• Diabetes supplies: 0% or 20% per item | |||||
Medicare Part B drugs | |||||
• Chemotherapy: 0% or 20% | |||||
• Other Part B drugs: 0% or 20% | |||||
** Benefits Services ** | |||||
Hearing | |||||
• Hearing exam: $0 or $20 | |||||
• Fitting/evaluation: $0 copay | |||||
• Hearing aids: $0 copay | |||||
Preventive dental | |||||
• Oral exam: Not covered | |||||
• Cleaning: Not covered | |||||
• Fluoride treatment: Not covered | |||||
• Dental x-ray(s): Not covered | |||||
Comprehensive dental | |||||
• Non-routine services: Not covered | |||||
• Diagnostic services: Not covered | |||||
• Restorative services: Not covered | |||||
• Endodontics: Not covered | |||||
• Periodontics: Not covered | |||||
• Extractions: Not covered | |||||
• Prosthodontics, other oral/maxillofacial surgery, other services: Not covered | |||||
Vision | |||||
• Routine eye exam: $10 | |||||
• Other: Not covered | |||||
• Contact lenses: $0 copay | |||||
• Eyeglasses (frames and lenses): $0 copay | |||||
• Eyeglass frames: Not covered | |||||
• Eyeglass lenses: Not covered | |||||
• Upgrades: Not covered |