Wellcare Buckeye Health Dual Reserve (HMO D-SNP)
Available to residents of Medina County, OH for 2027. Contract H4158, plan 003, segment 0.
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- Plan health benefits
- Benefits in plain text
- Rx cost-sharing for all pharmacies and tiers
- Other plans in Medina County
- Plan website
- Browse the Wellcare Buckeye Health Dual Reserve (HMO D-SNP) formulary
2027 drug-by-drug coverage is not published by CMS yet. The drug lookup covers 2026, whose formulary is live.
New for 2027. This plan has no 2026 predecessor in the CMS crosswalk. Every OH plan’s 2026–2027 changes →
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 | $6,750.00? |
| Drug deductible | $700.00Tier 1, 2, 4 and 6 exempt |
| Drug out-of-pocket threshold | $2,400.00 |
| Plan type | HMO D-SNP? |
| Special needs plan | Dual-eligible SNP |
| D-SNP integration status | Coordination Only (CO) |
| Zero-dollar cost sharing D-SNP | No |
| Contract / plan | H4158-003-0 |
| Offered by | Wellcare |
| Parent organization | Centene Corporation |
| Formulary tiers | 6 |
| Formulary exception tier | 3? |
| Pharmacy search | go.wellcare.com/BuckeyeOH |
| Member services | (844)480-0680TTY 711 |
CMS star ratings
- Overall
- —
- Health plan (Part C)
- —
- Drug plan (Part D)
- —
Published per contract — every plan under contract H4158 shares this rating.
Plan health benefits
| Service | In-network |
|---|---|
| Doctor visits | |
| Primary care doctor | $0 copay |
| Specialist | $35 copay(authorization and referral required) |
| Other health care professional | $0–$35 copay(authorization and referral required) |
| Additional telehealth services | $0–$35 copay(authorization and referral required) |
| Preventive care | |
| Medicare-covered preventive services | $0 copay |
| Annual physical exam | $0 copay |
| Kidney disease education | 20% coinsurance(referral required) |
| Glaucoma screening | $0 copay(referral required) |
| Diabetes self-management training | $0 copay(referral required) |
| Diagnostic tests, labs and imaging | |
| Diagnostic tests and procedures | $0–$100 copay(authorization and referral required) |
| Lab services | $0–$50 copay(authorization and referral required) |
| Diagnostic radiology (e.g. MRI, CT) | $0–$500 copay(authorization and referral required) |
| Therapeutic radiology | 20% coinsurance(authorization and referral required) |
| Outpatient x-rays | $50 copay(authorization and referral required) |
| Emergency and urgent care | |
| Emergency room | $130 copay |
| Urgent care | $25 copay |
| Worldwide emergency coverage | $130 copay · $50,000 plan limit |
| Worldwide urgent care | $130 copay · $50,000 plan limit |
| Worldwide emergency transportation | Not covered |
| Hospital care | |
| Inpatient hospital stay | $425 per day for days 1–7; $0 per day for days 8–90(authorization and referral required) |
| Outpatient hospital services | $0–$500 copay(authorization and referral required) |
| Outpatient observation | $130–$500 copay(referral required) |
| Ambulatory surgical center | $350 copay(authorization and referral required) |
| Outpatient blood services | $0 copay(referral required) |
| Skilled nursing and home health | |
| Skilled nursing facility | $0 per day for days 1–20; $221 per day for days 21–60; $0 per day for days 61–100(authorization and referral required) |
| Home health care | $0 copay(authorization and referral required) |
| Kidney dialysis | 20% coinsurance(referral required) |
| Rehabilitation | |
| Occupational therapy | $25 copay(authorization and referral required) |
| Physical therapy and speech-language therapy | $25 copay(authorization and referral required) |
| Cardiac rehabilitation | $40 copay(referral required) |
| Pulmonary rehabilitation | $35 copay(referral required) |
| Mental health and substance use | |
| Inpatient psychiatric hospital stay | $325 per day for days 1–7; $0 per day for days 8–90(authorization and referral required) |
| Outpatient mental health, individual session | $30 copay(authorization and referral required) |
| Outpatient mental health, group session | $30 copay(authorization and referral required) |
| Psychiatrist, individual session | $30 copay(authorization and referral required) |
| Psychiatrist, group session | $30 copay(authorization and referral required) |
| Partial hospitalization | $155 copay(authorization and referral required) |
| Intensive outpatient program | $160 copay(authorization and referral required) |
| Outpatient substance use, individual session | $30 copay(authorization and referral required) |
| Outpatient substance use, group session | $30 copay(authorization and referral required) |
| Opioid treatment program | $35 copay(authorization and referral required) |
| Ambulance and transportation | |
| Ground ambulance | $350 copay(authorization required) |
| Air ambulance | $350 copay(authorization required) |
| Transportation to plan-approved locations | $0 copay(authorization required, limits apply) |
| Medical equipment and supplies | |
| Durable medical equipment (e.g. wheelchairs, oxygen) | 20% coinsurance(authorization required) |
| Prosthetics (e.g. braces, artificial limbs) | 20% coinsurance(authorization required) |
| Medical supplies | 20% coinsurance(authorization required) |
| Diabetes supplies | $0 copay(authorization required) |
| Diabetic therapeutic shoes or inserts | 20% coinsurance(authorization required) |
| Chiropractic, acupuncture and foot care | |
| Chiropractic (Medicare-covered) | $15 copay(authorization and referral required) |
| Routine chiropractic care | Not covered |
| Acupuncture | Not covered |
| Foot exams and treatment (Medicare-covered) | $35 copay(authorization and referral required) |
| Routine foot care | Not covered |
| Dental? | |
| Medicare-covered dental services | $35 copay(authorization required) |
| Oral exams | $0 copay(authorization required, limits apply) |
| Cleanings | $0 copay(authorization required, limits apply) |
| Fluoride treatment | $0 copay(authorization required, limits apply) |
| Dental x-rays | $0 copay(authorization required, limits apply) |
| Other diagnostic dental services | $0 copay(authorization required, limits apply) |
| Other preventive dental services | $0 copay(authorization required, limits apply) |
| Comprehensive dental plan limit | $3,000 plan limit every year |
| Restorative services (fillings, crowns) | $0 copay(authorization required, limits apply) |
| Endodontics (root canals) | $0 copay(authorization required, limits apply) |
| Periodontics (gum disease) | $0 copay(authorization required, limits apply) |
| Dentures and other removable prosthodontics | $0 copay(authorization required, limits apply) |
| Maxillofacial prosthetics | Not covered |
| Implants | Not covered |
| Bridges and other fixed prosthodontics | Not covered |
| Oral and maxillofacial surgery | $0 copay(authorization required, limits apply) |
| Orthodontics | Not covered |
| Adjunctive general services | $0 copay(authorization required, limits apply) |
| Vision? | |
| Eye exam (Medicare-covered) | $0–$35 copay(authorization required) |
| Routine eye exam | $0 copay(authorization required, limits apply) |
| Eyewear after cataract surgery (Medicare-covered) | $0 copay(authorization required, limits apply) |
| Eyewear plan limit | $200 plan limit every year |
| Contact lenses | $0 copay(authorization required, limits apply) |
| Eyeglasses (frames and lenses) | $0 copay(authorization required, limits apply) |
| Eyeglass lenses | $0 copay(authorization required, limits apply) |
| Eyeglass frames | $0 copay(authorization required, limits apply) |
| Eyewear upgrades | $0 copay(authorization required, limits apply) |
| Hearing? | |
| Hearing exam (Medicare-covered) | $35 copay(authorization required) |
| Routine hearing exam | $0 copay(authorization required, limits apply) |
| Hearing aid fitting and evaluation | $0 copay(authorization required, limits apply) |
| Hearing aid plan limit | $750 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 | $38 allowance every month |
| Meals after a hospital stay or for a chronic condition | Not covered |
| 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 | Not covered |
| 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 | $0 copay |
| 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, CY2027). 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 · Generic | $0.00 |
| Tier 2 · Preferred Brand | 20% |
| Tier 3 · Non-Preferred Drug | 44% |
| Tier 4 · Injectable Drugs | 0% |
| Tier 5 · Specialty Tier | 25% |
| Tier 6 · Select Care Drugs | $0.00 |
Rx cost-sharing by coverage phase
| Tier | 30-day supply | 90-day supply | ||||
|---|---|---|---|---|---|---|
| Preferred | Standard | Mail Order | Preferred | Standard | Mail Order | |
| Initial coverage phase | ||||||
| Tier 1: Generic | $0.00 | $0.00 | n/a | $0.00 | $0.00 | $0.00 |
| Tier 2: Preferred Brand | 20% | 20% | n/a | 20% | 20% | 20% |
| Tier 3: Non-Preferred Drug | 44% | 44% | n/a | 44% | 44% | 44% |
| Tier 4: Injectable Drugs | 0% | 0% | n/a | 0% | 0% | 0% |
| Tier 5: Specialty Tier | 25% | 25% | n/a | n/a | n/a | n/a |
| Tier 6: Select Care Drugs | $0.00 | $0.00 | n/a | $0.00 | $0.00 | $0.00 |
These are the initial coverage phase amounts, as the plan filed them in its benefit package. The deductible and post-threshold phases are not stated per tier in that filing, so they are not shown here rather than being inferred; the plan's annual out-of-pocket threshold is $2,400.00.
Star rating measures
| Measure | 2027 | 2026 |
|---|---|---|
| Health Plan Customer Service | ||
| Call Center – Foreign Language Interpreter and TTY Availability · C32 | 5 out of 5 stars for Call Center – Foreign Language Interpreter and TTY Availability | too new |
| DD1: Drug Plan Customer Service | ||
| Call Center – Foreign Language Interpreter and TTY Availability · D01 | 5 out of 5 stars for Call Center – Foreign Language Interpreter and TTY Availability | too new |
Measures are paired between the two years by name, not by the C/D number: CMS reuses those numbers, and in 2027 nineteen of them refer to a different measure than they did in 2026. A measure introduced for 2027 has no 2026 score to show. Published per contract — every plan under H4158 shares it.
Also available in 87 other OH counties
- Adams
- Allen
- Ashland
- Ashtabula
- Athens
- Auglaize
- Belmont
- Brown
- Butler
- Carroll
- Champaign
- Clark
- Clermont
- Clinton
- Columbiana
- Coshocton
- Crawford
- Cuyahoga
- Darke
- Defiance
- Delaware
- Erie
- Fairfield
- Fayette
- Franklin
- Fulton
- Gallia
- Geauga
- Greene
- Guernsey
- Hamilton
- Hancock
- Hardin
- Harrison
- Henry
- Highland
- Hocking
- Holmes
- Huron
- Jackson
- Jefferson
- Knox
- Lake
- Lawrence
- Licking
- Logan
- Lorain
- Lucas
- Madison
- Mahoning
- Marion
- Meigs
- Mercer
- Miami
- Monroe
- Montgomery
- Morgan
- Morrow
- Muskingum
- Noble
Benefits in plain text
Wellcare Buckeye Health Dual Reserve (HMO D-SNP) (H4158-003-0) is a 2027 HMO D-SNP Medicare Advantage plan offered by Wellcare, available to residents of Medina County, OH.
The monthly premium is $0.00.
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 $6,750.00.
The drug deductible is $700.00. Tier 1, 2, 4 and 6 exempt.
It is a special needs plan (Dual-eligible SNP).
At a preferred pharmacy in the initial coverage phase, a 30-day supply costs tier 1 (Generic): $0.00; tier 2 (Preferred Brand): 20%; tier 3 (Non-Preferred Drug): 44%; tier 4 (Injectable Drugs): 0%; tier 5 (Specialty Tier): 25%; tier 6 (Select Care Drugs): $0.00.
Email a copy of the plan benefit details
Plan facts come from the CMS plan Landscape file and the CMS plan benefit package (PBP) files.