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2019 Medicare Advantage Plan Benefit Details for the Allwell Dual Medicare (HMO SNP)

This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.

2019 Medicare Advantage Plan Details
Medicare Plan Name:Allwell Dual Medicare (HMO SNP)
Location:Miami-Dade, Florida
Plan ID:H5190 - 004 - 0     Click to see other plans
Member Services:1-877-935-8022 TTY users 711
— This plan information is for research purposes only. —
Click here to see plans for the current plan year
Medicare Contact Information:1-800-MEDICARE (1-800-633-4227)
TTY users 1-877-486-2048
Email a copy of the Allwell Dual Medicare (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):$3,820
Health Plan Type:Local HMO
Special Needs Plan (SNP)
Eligibility Requirement:
Additional Gap Coverage?Yes, some additional gap coverage.
Total Number of Formulary Drugs:3,474 drugsBrowse the Allwell Dual Medicare (HMO SNP) Formulary
This plan has 6 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:
Number of Drugs per
Plan's Pharmacy Search:http://allwell.sunshinehealth.com/findadoctor
Plan Offers Mail Order?Yes
Number of Members enrolled in this plan in Miami-Dade, Florida:210 members
Number of Members enrolled in this plan in (H5190 - 004):211 members
Plan’s Summary Star Rating: 3.5 out of 5 Stars.
Customer Service Rating: 4 out of 5 Stars.
Member Experience Rating: Insufficient data to rate this plan.
Drug Cost Accuracy Rating: 4 out of 5 Stars.
— Plan Premium Details —
The Monthly Premium is Split as Follows:
Part C
Part D Base
Part D Supplemental
Monthly Premium with Extra Help Low-Income Subsidy (LIS): 100%
Monthly Part D Premium with LIS:$0.00$7.60$15.20$22.70
Total Monthly Premium with LIS (Parts C & D):$0.00$7.60$15.20$22.70
— Plan Health Benefits —
** Benefit Highlights **
Health plan deductible
• $0
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
• $3,400 In-network
Optional supplemental benefits
• No
Inpatient hospital coverage
• $0 copay
Outpatient hospital coverage
• $0 copay
Preventive care
• $0 copay
Other health plan deductibles?
In-Network:  No
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
In-Network:  No
Doctor visits
Primary:  $0 copay
Specialist:  $0 copay
Emergency care/Urgent care
Emergency:  $0 copay
Urgent care:  $0 copay
Skilled Nursing Facility
• $0 per day for days 1 through 20
$0 or $50 per day for days 21 through 100
Ground ambulance
• $0 copay
• $0 copay
Wellness programs (e.g., fitness, nursing hotline)
• Covered
Routine eye exam:  $0 copay
Other:  Not covered
Contact lenses:  $0 copay
Eyeglasses (frames and lenses):  $0 copay
Eyeglass frames:  Not covered
Eyeglass lenses:  Not covered
Upgrades:  Not covered
Mental health services
Inpatient hospital - psychiatric:  $0 copay
Outpatient group therapy visit with a psychiatrist:  $0 copay
Outpatient individual therapy visit with a psychiatrist:  $0 copay
Outpatient group therapy visit:  $0 copay
Outpatient individual therapy visit:  $0 copay
Rehabilitation services
Occupational therapy visit:  $0 copay
Physical therapy and speech and language therapy visit:  $0 copay
Foot care (podiatry services)
Foot exams and treatment:  $0 copay
Routine foot care:  $0 copay
Medical equipment/supplies
Durable medical equipment (e.g., wheelchairs, oxygen):  $0 copay
Prosthetics (e.g., braces, artificial limbs):  $0 copay
Diabetes supplies:  $0 copay
Medicare Part B drugs
Chemotherapy:  0% or 20%
Other Part B drugs:  0% or 20%
** Benefits Services **
Diagnostic procedures/lab services/imaging
Diagnostic tests and procedures:  $0 copay
Lab services:  $0 copay
Diagnostic radiology services (e.g., MRI):  $0 copay
Outpatient x-rays:  $0 copay
Hearing exam:  $0 copay
Fitting/evaluation:  $0 copay
Hearing aids:  $0 copay
Preventive dental
Oral exam:  $0 copay
Cleaning:  $0 copay
Fluoride treatment:  $0 copay
Dental x-ray(s):  $0 copay
Comprehensive dental
Non-routine services:  Not covered
Diagnostic services:  $0 copay
Restorative services:  $0 copay
Endodontics:  $0 copay
Periodontics:  $0 copay
Extractions:  $0 copay
Prosthodontics, other oral/maxillofacial surgery, other services:  $0 copay

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