Wellpoint Dual Advantage (HMO D-SNP)
Available to residents of Pend Oreille County, WA for 2026. Contract H1894, plan 011, segment 0.
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- Plan health benefits
- Benefits in plain text
- Rx cost-sharing for all pharmacies and tiers
- Other plans in Pend Oreille County
- Plan website
- Browse the Wellpoint Dual Advantage (HMO D-SNP) formulary
Renewed, service area expanded for 2026. CMS carries this plan forward from 2025.
Plan details
| Monthly premium (Part C + D) | $0.00 |
|---|---|
| — medical (Part C) part | $0.00 |
| — drug (Part D) part | $0.00? |
| Monthly premium with full Extra Help (LIS) | $0.00? |
| Part B premium reduction (giveback) | None |
| Health plan deductible (in-network) | None |
| In-network out-of-pocket maximum | $9,250.00? |
| Drug deductible | $615.00Tier 1 and 6 exempt |
| Drug out-of-pocket threshold | $2,100.00 |
| Plan type | HMO D-SNP? |
| Special needs plan | Dual-eligible SNP |
| Contract / plan | H1894-011-0 |
| Offered by | Wellpoint |
| Parent organization | Elevance Health, Inc. |
| Formulary drugs | 3,554 |
| Formulary exception tier | 4? |
| Pharmacy search | www.myamerigroup.com/medicare |
| Member services | (833)668-0684TTY 711 |
CMS star ratings
- Overall
- 3 out of 5 stars for Overall
- Health plan (Part C)
- 2.5 out of 5 stars for Health plan (Part C)
- Drug plan (Part D)
- 3 out of 5 stars for Drug plan (Part D)
Published per contract — every plan under contract H1894 shares this rating.
Plan health benefits
| Service | In-network |
|---|---|
| Doctor visits | |
| Primary care doctor | $0 copay |
| Specialist | $0 copay(authorization and referral required) |
| Other health care professional | $0 copay(authorization and referral required) |
| Additional telehealth services | $0 copay |
| Preventive care | |
| Medicare-covered preventive services | $0 copay |
| Annual physical exam | $0 copay |
| Kidney disease education | $0 copay(referral required) |
| Glaucoma screening | 20% coinsurance(referral required) |
| Diabetes self-management training | 20% coinsurance(referral required) |
| Diagnostic tests, labs and imaging | |
| Diagnostic tests and procedures | 20% coinsurance(authorization and referral required) |
| Lab services | 20% coinsurance(authorization and referral required) |
| Diagnostic radiology (e.g. MRI, CT) | 20% coinsurance(authorization and referral required) |
| Therapeutic radiology | 20% coinsurance(authorization and referral required) |
| Outpatient x-rays | 20% coinsurance(authorization and referral required) |
| Emergency and urgent care | |
| Emergency room | $115 copay |
| Urgent care | $40 copay |
| Worldwide emergency coverage | $0 copay · $100,000 plan limit |
| Worldwide urgent care | $0 copay · $100,000 plan limit |
| Worldwide emergency transportation | $0 copay |
| Hospital care | |
| Inpatient hospital stay | Original Medicare cost-sharing(authorization required) |
| Outpatient hospital services | 20% coinsurance(authorization and referral required) |
| Outpatient observation | 20% coinsurance(authorization and referral required) |
| Ambulatory surgical center | 20% coinsurance(authorization and referral required) |
| Outpatient blood services | $0 copay(referral required) |
| Skilled nursing and home health | |
| Skilled nursing facility | Original Medicare cost-sharing(authorization required) |
| Home health care | $0 copay(authorization and referral required) |
| Kidney dialysis | 20% coinsurance |
| Rehabilitation | |
| Occupational therapy | 20% coinsurance(authorization and referral required) |
| Physical therapy and speech-language therapy | 20% coinsurance(authorization and referral required) |
| Cardiac rehabilitation | 20% coinsurance(authorization required) |
| Pulmonary rehabilitation | 20% coinsurance(authorization required) |
| Mental health and substance use | |
| Inpatient psychiatric hospital stay | Original Medicare cost-sharing(authorization required) |
| Outpatient mental health, individual session | 20% coinsurance(authorization and referral required) |
| Outpatient mental health, group session | 20% coinsurance(authorization and referral required) |
| Psychiatrist, individual session | 20% coinsurance(authorization and referral required) |
| Psychiatrist, group session | 20% coinsurance(authorization and referral required) |
| Partial hospitalization | $60 copay(authorization required) |
| Intensive outpatient program | $60 copay(authorization required) |
| Outpatient substance use, individual session | 20% coinsurance(authorization and referral required) |
| Outpatient substance use, group session | 20% coinsurance(authorization and referral required) |
| Opioid treatment program | 20% coinsurance(authorization and referral required) |
| Ambulance and transportation | |
| Ground ambulance | 20% coinsurance(authorization required) |
| Air ambulance | 20% coinsurance(authorization required) |
| Transportation to plan-approved locations | $0 copay(limits apply) |
| Medical equipment and supplies | |
| Durable medical equipment (e.g. wheelchairs, oxygen) | 0%–20% coinsurance(authorization required) |
| Prosthetics (e.g. braces, artificial limbs) | 20% coinsurance(authorization required) |
| Medical supplies | 20% coinsurance(authorization required) |
| Diabetes supplies | $0 copay |
| Diabetic therapeutic shoes or inserts | $0 copay |
| Chiropractic, acupuncture and foot care | |
| Chiropractic (Medicare-covered) | 20% coinsurance(authorization and referral required) |
| Routine chiropractic care | $0 copay(authorization and referral required, limits apply) |
| Acupuncture | $0 copay(authorization required) |
| Foot exams and treatment (Medicare-covered) | 20% coinsurance(authorization and referral required) |
| Routine foot care | $0 copay(authorization and referral required) |
| Dental? | |
| Medicare-covered dental services | 20% coinsurance(authorization required) |
| Preventive dental plan limit | $2,400 plan limit every year |
| Oral exams | $0 copay |
| Cleanings | $0 copay |
| Fluoride treatment | $0 copay |
| Dental x-rays | $0 copay |
| Other diagnostic dental services | $0 copay |
| Other preventive dental services | $0 copay |
| Restorative services (fillings, crowns) | $0 copay(authorization required, limits apply) |
| Endodontics (root canals) | $0 copay(authorization required) |
| Periodontics (gum disease) | $0 copay(authorization required, limits apply) |
| Dentures and other removable prosthodontics | $0 copay(authorization required, limits apply) |
| Maxillofacial prosthetics | $0 copay(authorization required) |
| Implants | Not covered |
| Bridges and other fixed prosthodontics | $0 copay(authorization required, limits apply) |
| Oral and maxillofacial surgery | $0 copay(authorization required) |
| Orthodontics | Not covered |
| Adjunctive general services | $0 copay(authorization required) |
| Vision? | |
| Eye exam (Medicare-covered) | 20% coinsurance |
| Routine eye exam | $0 copay(limits apply) |
| Eyewear after cataract surgery (Medicare-covered) | 20% coinsurance(limits apply) |
| Eyewear plan limit | $200 plan limit every year |
| Contact lenses | $0 copay(limits apply) |
| Eyeglasses (frames and lenses) | $0 copay(limits apply) |
| Eyeglass lenses | $0 copay(limits apply) |
| Eyeglass frames | $0 copay(limits apply) |
| Eyewear upgrades | Not covered |
| Hearing? | |
| Hearing exam (Medicare-covered) | 20% coinsurance(authorization and referral required) |
| Routine hearing exam | $0 copay(authorization and referral required, limits apply) |
| Hearing aid fitting and evaluation | $0 copay(authorization and referral required, limits apply) |
| Hearing aid plan limit | $3,000 plan limit every year |
| Hearing aids (all types) | $0 copay(authorization required, limits apply) |
| Hearing aids, inner ear | Not covered |
| Hearing aids, outer ear | Not covered |
| Hearing aids, over the ear | Not covered |
| Medicare Part B drugs | |
| Part B insulin | $35 copay(authorization required, step therapy may apply) |
| Chemotherapy and radiation drugs | 0%–20% coinsurance(authorization required, step therapy may apply) |
| Other Part B drugs | 0%–20% coinsurance(authorization required, step therapy may apply) |
| Other extra benefits? | |
| Over-the-counter (OTC) allowance | Covered (allowance not stated) |
| Meals after a hospital stay or for a chronic condition | $0 copay |
| Fitness benefit | $0 copay |
| Health education | Not covered |
| Nutritional / dietary benefit | Not covered |
| Extra smoking and tobacco cessation counseling | Not covered |
| Enhanced disease management | Not covered |
| Telemonitoring | Not covered |
| Remote access technologies (web/phone, nurse line) | $0 copay |
| Home and bathroom safety devices | $0 copay |
| Counseling services | Not covered |
| In-home safety assessment | Not covered |
| Personal emergency response system (PERS) | $0 copay |
| Medical nutrition therapy | Not covered |
| Post-discharge in-home medication reconciliation | Not covered |
| Re-admission prevention | Not covered |
| Wigs for hair loss from chemotherapy | Not covered |
| Weight management programs | Not covered |
| Alternative therapies | Not covered |
| Therapeutic massage | Not covered |
| Adult day health services | Not covered |
| Home-based palliative care | Not covered |
| In-home support services | Not covered |
| Support for caregivers | Not covered |
In-network cost-sharing as the plan filed it with CMS (CMS plan benefit package (PBP) files, CY2026). A range means the cost depends on the service or setting. Rows the filing does not state are left out rather than guessed. Contact the plan for the full Evidence of Coverage.
Drug tiers — preferred pharmacy, initial coverage
| Tier | Cost-sharing |
|---|---|
| Tier 1 | $0.00 |
| Tier 2 | 25% |
| Tier 3 | 25% |
| Tier 4 | 25% |
| Tier 5 | 25% |
| Tier 6 | $0.00 |
Rx cost-sharing by coverage phase
| Tier | 30-day supply | 90-day supply | ||||
|---|---|---|---|---|---|---|
| Preferred | Standard | Mail Order | Preferred | Standard | Mail Order | |
| Initial deductible phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 6: Select Care Drugs | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Initial coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 2: Generic | 25% | 25% | 25% | 25% | 25% | 25% |
| Tier 3: Preferred Brand | 25% | 25% | 25% | 25% | 25% | 25% |
| Tier 4: Non-Preferred Drug | 25% | 25% | 25% | 25% | 25% | 25% |
| Tier 5: Specialty Tier | 25% | 25% | 25% | n/a | n/a | n/a |
| Tier 6: Select Care Drugs | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Catastrophic coverage phase | ||||||
| Tier 1: Preferred Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 2: Generic | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 3: Preferred Brand | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 4: Non-Preferred Drug | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 5: Specialty Tier | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
| Tier 6: Select Care Drugs | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
Also available in 34 other WA counties
Benefits in plain text
Wellpoint Dual Advantage (HMO D-SNP) (H1894-011-0) is a 2026 HMO D-SNP Medicare Advantage plan offered by Wellpoint, available to residents of Pend Oreille County, WA.
The monthly premium is $0.00 (Part C and Part D together).
With full Extra Help (the Low-Income Subsidy), the total monthly premium is $0.00.
There is no in-network deductible for health services.
Its in-network out-of-pocket maximum is $9,250.00.
The drug deductible is $615.00. Tier 1 and 6 exempt.
It is a special needs plan (Dual-eligible SNP).
The plan's formulary lists 3,554 drugs.
At a preferred pharmacy in the initial coverage phase, a 30-day supply costs tier 1: $0.00; tier 2: 25%; tier 3: 25%; tier 4: 25%; tier 5: 25%; tier 6: $0.00.
CMS gives the plan's contract (H1894) an overall rating of 3 out of 5 stars.
Email a copy of the plan benefit details
Plan facts come from the CMS quarterly prescription drug plan public use files; the premium split, Extra Help premium, MOOP and plan type from the CMS Landscape file; the Part B giveback and health benefits from the CMS plan benefit package (PBP) files.