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2016 WellCare Access (HMO SNP) in Grenada, Mississippi

Medicare Advantage Plan Benefit Details in Plain Text

The following Medicare Advantage plan benefits apply to the WellCare Access (HMO SNP) (H5698 - 134) in Grenada, Mississippi .

This plan is administered by HARMONY HEALTH PLAN, INC.. To switch to a different Medicare Advantage plan or to change your location, click here.

Click here to see the WellCare Access (HMO SNP) health and prescription benefit details in chart format

or email and view benefits chart

Plan Premium

The WellCare Access (HMO SNP) has a monthly premium of $18.70. That is $224.40 for 12 months. There are a few factors that can increase or decrease this premium. If you qualify for full or partial extra help, your premium will be lower. If you have a premium penalty, your premium will be higher. Please remember that the $18.70 montly premium is in addition to your Medicare Part B premium. If you have a premium penalty, your premium will be higher. Or if you have a higher income you would be subject to the Income Related Adjustment Amount (IRMAA).

This Medicare Advantage Plan with Prescription Drug Coverage is a Local HMO plan.

Plan Membership and Plan Ratings

The WellCare Access (HMO SNP) (H5698 - 134) currently has 9,297 members. There are 63 members enrolled in this plan in Grenada, Mississippi, and 9,261 members in Mississippi.

The Centers for Medicare and Medicaid Services (CMS) has given this plan carrier a summary rating of 2.5 stars. The detail CMS plan carrier ratings are as follows:

Customer Service Rating of 4 out of 5 stars
Member Experience Rating of 2 out of 5 stars
Drug Cost Information Accuracy Rating of 3 out of 5 stars

Prescription Drug Coverage: Deductible, Cost-sharing, Formulary

This plan has a $360 deductible. So, you are 100% responsible for the first $360 in medication costs. After you have met the deductible, the WellCare Access (HMO SNP) will share the costs of your medications with you -- see cost-sharing below. $360 is the maximum deductible for 2016. There are other plans with a lower deductible or even a $0 deductible for all formulary drugs. Click here to review plans with a $0 deductible.

The following information is about the WellCare Access (HMO SNP) formulary (or drug list). There are 2801 drugs on the WellCare Access (HMO SNP) formulary. Click here to browse the WellCare Access (HMO SNP) Formulary.

The Initial Coverage Phase (ICP) can be thought of as the cost-sharing phase of the plan. During this phase, you and the insurance company share your prescription costs. Once you have spent $360, your initial coverage phase will start. All medication are divided into tiers within the plans formulary. This helps the plan to organize and manage the prescription cost-sharing. The WellCare Access (HMO SNP)’s formulary is divided into 5 tiers. Every plan can name their tiers differently, and can place medications on any tier. The cost-sharing for this plan is divided as follows:

Tier 1 (Preferred Generic) contains 324 drugs and has a co-payment of $0.00.
Tier 2 (Generic) contains 416 drugs and has a co-payment of $18.00.
Tier 3 (Preferred Brand) contains 898 drugs and has a co-payment of $47.00.
Tier 4 (Non-Preferred Brand) contains 800 drugs and has a co-insurance of 50% of the drug cost.
Tier 5 (Specialty Tier) contains 526 drugs and has a co-insurance of 25% of the drug cost.

Click here to browse the WellCare Access (HMO SNP) Formulary.

The Coverage Gap, which is also known as the Donut (Doughnut) Hole is the phase of your Medicare Part D plan where you are responsible for 100% of your medication costs. Healthcare Reform mandates that the insurance carrier pay 42% of your generic drug prescription costs in the donut hole on your behalf.

The brand-name drug manufacturer will pay 50% and your plan will pay an additional 5% of the cost of your brand-name drugs purchased in the Donut Hole, for a total of 55% discount. The 50% paid by the brand-name drug manufacturer is paid on your behalf and therefore counts toward your TrOOP (or True Out-of-Pocket) costs. The portion paid by your plan, does not count toward TrOOP. Some Medicare Part D plans offer coverage during the Coverage Gap that is beyond the mandated discounts. Any drug not covered by the plan’s Gap Coverage will still receive the discounts noted above -- even if the plan has "No Gap Coverage". This plan (WellCare Access (HMO SNP)) offers No Coverage during the Coverage Gap phase.

The WellCare Access (HMO SNP) offers many Health and Prescription Drug Coverage Benefits. The following section will describe these benefits in detail.

** Cost **

Monthly premium, deductible, and limits on how much you pay for covered services

$0 per month.

This plan does not have a deductible.

This plan does not have a deductible for chemotherapy and other drugs administered in your doctor's office (Part B drugs).

This plan does not have a deductible for Part D prescription drugs.

Yes. Like all Medicare health plans our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care.

In this plan you may pay nothing for Medicare-covered services depending on your level of [insert State Medicaid plan name] eligibility.

Your yearly limit(s) in this plan:

$6 700 for services you receive from in-network providers.

If you reach the limit on out-of-pocket costs you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year.

Refer to the "Medicare & You" handbook for Medicare-covered services. For [insert State Medicaid plan name]-covered services refer to the Medicaid Coverage section in this document.

Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs.

Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply.

** Doctor and Hospital Choice **

Acupuncture

Not covered

** Extra Benefits **

Inpatient mental health care

For inpatient mental health care see the "Mental Health Care" section.

Outpatient prescription drugs

For Part B drugs such as chemotherapy drugs¹: You pay nothing

Other Part B drugs¹: You pay nothing

You pay the following:

You may get your drugs at network retail pharmacies and mail order pharmacies.

Standard Retail Cost-Sharing

Tier	One-month supply	Three-month supply
Tier 1 (Preferred Generic)	$0	$0
Tier 2 (Generic)	For generic drugs (including brand drugs treated as generic) either: $0 copay; or $1.20 copay; or $2.95 copay For all other drugs either: $0 copay; or $3.60 copay; or $7.40 copay.	For generic drugs (including brand drugs treated as generic) either: $0 copay; or $1.20 copay; or $2.95 copay For all other drugs either: $0 copay; or $3.60 copay; or $7.40 copay.
Tier 3 (Preferred Brand)	For generic drugs (including brand drugs treated as generic) either: $0 copay; or $1.20 copay; or $2.95 copay For all other drugs either: $0 copay; or $3.60 copay; or $7.40 copay.	For generic drugs (including brand drugs treated as generic) either: $0 copay; or $1.20 copay; or $2.95 copay For all other drugs either: $0 copay; or $3.60 copay; or $7.40 copay.
Tier 4 (Non-Preferred Brand)	For generic drugs (including brand drugs treated as generic) either: $0 copay; or $1.20 copay; or $2.95 copay For all other drugs either: $0 copay; or $3.60 copay; or $7.40 copay.	For generic drugs (including brand drugs treated as generic) either: $0 copay; or $1.20 copay; or $2.95 copay For all other drugs either: $0 copay; or $3.60 copay; or $7.40 copay.
Tier 5 (Specialty Tier)	For generic drugs (including brand drugs treated as generic) either: $0 copay; or $1.20 copay; or $2.95 copay For all other drugs either: $0 copay; or $3.60 copay; or $7.40 copay.	Not Offered

Standard Mail Order Cost-Sharing

Tier	One-month supply	Three-month supply
Tier 1 (Preferred Generic)	$0	$0
Tier 2 (Generic)	For generic drugs (including brand drugs treated as generic) either: $0 copay; or $1.20 copay; or $2.95 copay For all other drugs either: $0 copay; or $3.60 copay; or $7.40 copay.	For generic drugs (including brand drugs treated as generic) either: $0 copay; or $1.20 copay; or $2.95 copay For all other drugs either: $0 copay; or $3.60 copay; or $7.40 copay.
Tier 3 (Preferred Brand)	For generic drugs (including brand drugs treated as generic) either: $0 copay; or $1.20 copay; or $2.95 copay For all other drugs either: $0 copay; or $3.60 copay; or $7.40 copay.	For generic drugs (including brand drugs treated as generic) either: $0 copay; or $1.20 copay; or $2.95 copay For all other drugs either: $0 copay; or $3.60 copay; or $7.40 copay.
Tier 4 (Non-Preferred Brand)	For generic drugs (including brand drugs treated as generic) either: $0 copay; or $1.20 copay; or $2.95 copay For all other drugs either: $0 copay; or $3.60 copay; or $7.40 copay.	For generic drugs (including brand drugs treated as generic) either: $0 copay; or $1.20 copay; or $2.95 copay For all other drugs either: $0 copay; or $3.60 copay; or $7.40 copay.
Tier 5 (Specialty Tier)	For generic drugs (including brand drugs treated as generic) either: $0 copay; or $1.20 copay; or $2.95 copay For all other drugs either: $0 copay; or $3.60 copay; or $7.40 copay.	Not Offered

Preferred Mail Order Cost-Sharing

Tier	One-month supply	Three-month supply
Tier 1 (Preferred Generic)	$0	$0
Tier 2 (Generic)	For generic drugs (including brand drugs treated as generic) either: $0 copay; or $1.20 copay; or $2.95 copay For all other drugs either: $0 copay; or $3.60 copay; or $7.40 copay.	For generic drugs (including brand drugs treated as generic) either: $0 copay; or $1.20 copay; or $2.95 copay For all other drugs either: $0 copay; or $3.60 copay; or $7.40 copay.
Tier 3 (Preferred Brand)	For generic drugs (including brand drugs treated as generic) either: $0 copay; or $1.20 copay; or $2.95 copay For all other drugs either: $0 copay; or $3.60 copay; or $7.40 copay.	For generic drugs (including brand drugs treated as generic) either: $0 copay; or $1.20 copay; or $2.95 copay For all other drugs either: $0 copay; or $3.60 copay; or $7.40 copay.
Tier 4 (Non-Preferred Brand)	For generic drugs (including brand drugs treated as generic) either: $0 copay; or $1.20 copay; or $2.95 copay For all other drugs either: $0 copay; or $3.60 copay; or $7.40 copay.	For generic drugs (including brand drugs treated as generic) either: $0 copay; or $1.20 copay; or $2.95 copay For all other drugs either: $0 copay; or $3.60 copay; or $7.40 copay.
Tier 5 (Specialty Tier)	For generic drugs (including brand drugs treated as generic) either: $0 copay; or $1.20 copay; or $2.95 copay For all other drugs either: $0 copay; or $3.60 copay; or $7.40 copay.	Not Offered

If you reside in a long-term care facility you pay the same as at a retail pharmacy.

You may get drugs from an out-of-network pharmacy but may pay more than you pay at an in-network pharmacy.

You pay nothing

** Important Information **

Monthly premium, deductible, and limits on how much you pay for covered services

$0 per month.

This plan does not have a deductible.

This plan does not have a deductible for chemotherapy and other drugs administered in your doctor's office (Part B drugs).

This plan does not have a deductible for Part D prescription drugs.

Yes. Like all Medicare health plans our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care.

In this plan you may pay nothing for Medicare-covered services depending on your level of [insert State Medicaid plan name] eligibility.

Your yearly limit(s) in this plan:

$6 700 for services you receive from in-network providers.

If you reach the limit on out-of-pocket costs you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year.

Refer to the "Medicare & You" handbook for Medicare-covered services. For [insert State Medicaid plan name]-covered services refer to the Medicaid Coverage section in this document.

Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs.

Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply.

** Outpatient Care and Services **

Acupuncture

Not covered

Ambulance

You pay nothing

Chiropractic care

Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position): You pay nothing

Routine chiropractic visit (for up to 12 every year): $5 copay

Dental services

Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth): You pay nothing

Preventive dental services:

Cleaning (for up to 2 every year): You pay nothing

Dental x-ray(s) (for up to 1 every year): You pay nothing

Fluoride treatment (for up to 2 every year): You pay nothing

Oral exam (for up to 2 every year): You pay nothing

Diabetes supplies and services

Diabetes monitoring supplies: You pay nothing

Diabetes self-management training: You pay nothing

Therapeutic shoes or inserts: You pay nothing

Diagnostic tests, lab and radiology services, and x-rays (Costs for these services may be different if received in an outpatient surgery setting)

Diagnostic radiology services (such as MRIs CT scans): You pay nothing

Diagnostic tests and procedures: You pay nothing

Lab services: You pay nothing

Outpatient x-rays: You pay nothing

Therapeutic radiology services (such as radiation treatment for cancer): You pay nothing

Doctor's office visits

Primary care physician visit: You pay nothing

Specialist visit: You pay nothing

Durable medical equipment (wheelchairs, oxygen, etc.)

You pay nothing

Emergency care

You pay nothing

Foot care (podiatry services)

Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: You pay nothing

Routine foot care (for up to 6 visit(s) every year): $5 copay

Hearing services

Exam to diagnose and treat hearing and balance issues: You pay nothing

Routine hearing exam (for up to 1 every year): You pay nothing

Hearing aid fitting/evaluation (for up to 1 every year): You pay nothing

Hearing aid: You pay nothing

Our plan pays up to $350 every year for hearing aids.

Home health care

You pay nothing

Mental health care

Inpatient visit:

Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital.

Our plan covers 90 days for an inpatient hospital stay.

Our plan also covers 60 "lifetime reserve days." These are "extra" days that we cover. If your hospital stay is longer than 90 days you can use these extra days. But once you have used up these extra 60 days your inpatient hospital coverage will be limited to 90 days.

You pay nothing

Outpatient group therapy visit: You pay nothing

Outpatient individual therapy visit: You pay nothing

Outpatient rehabilitation

Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks): You pay nothing

Occupational therapy visit: You pay nothing

Physical therapy and speech and language therapy visit: You pay nothing

Outpatient substance abuse

Group therapy visit: You pay nothing

Individual therapy visit: You pay nothing

Outpatient surgery

Ambulatory surgical center: You pay nothing

Outpatient hospital: You pay nothing

Over-the-counter items

Please visit our website to see our list of covered over-the-counter items.

Prosthetic devices (braces, artificial limbs, etc.)

Prosthetic devices: You pay nothing

Related medical supplies: You pay nothing

Renal dialysis

You pay nothing

Transportation

You pay nothing

Urgently needed services

You pay nothing

Vision services

Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening): You pay nothing

Routine eye exam (for up to 1 every year): You pay nothing

Contact lenses (for up to 1 every year): You pay nothing

Eyeglasses (frames and lenses) (for up to 1 every year): You pay nothing

Eyeglass frames (for up to 1 every year): You pay nothing

Eyeglass lenses (for up to 1 every year): You pay nothing

Eyeglasses or contact lenses after cataract surgery: You pay nothing

Our plan pays up to $200 every year for eyewear.

** Hospice **

Hospice

You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the cost for drugs and respite care.

** Preventive Care **

Preventive care

You pay nothing

Our plan covers many preventive services including:

Abdominal aortic aneurysm screening
Alcohol misuse counseling
Bone mass measurement
Breast cancer screening (mammogram)
Cardiovascular disease (behavioral therapy)
Cardiovascular screenings
Cervical and vaginal cancer screening
Colorectal cancer screenings (Colonoscopy Fecal occult blood test Flexible sigmoidoscopy)
Depression screening
Diabetes screenings
HIV screening
Medical nutrition therapy services
Obesity screening and counseling
Prostate cancer screenings (PSA)
Sexually transmitted infections screening and counseling
Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease)
Vaccines including Flu shots Hepatitis B shots Pneumococcal shots
"Welcome to Medicare" preventive visit (one-time)
Yearly "Wellness" visit

Any additional preventive services approved by Medicare during the contract year will be covered.

Annual physical exam: You pay nothing

** Inpatient Care **

Inpatient hospital care

Our plan covers 90 days for an inpatient hospital stay.

You pay nothing

Inpatient mental health care

For inpatient mental health care see the "Mental Health Care" section.

Skilled Nursing Facility (SNF)

Our plan covers up to 100 days in a SNF.

You pay nothing

Outpatient prescription drugs

For Part B drugs such as chemotherapy drugs¹: You pay nothing

Other Part B drugs¹: You pay nothing

You pay the following:

You may get your drugs at network retail pharmacies and mail order pharmacies.

Standard Retail Cost-Sharing

Tier	One-month supply	Three-month supply
Tier 1 (Preferred Generic)	$0	$0
Tier 2 (Generic)	For generic drugs (including brand drugs treated as generic) either: $0 copay; or $1.20 copay; or $2.95 copay For all other drugs either: $0 copay; or $3.60 copay; or $7.40 copay.	For generic drugs (including brand drugs treated as generic) either: $0 copay; or $1.20 copay; or $2.95 copay For all other drugs either: $0 copay; or $3.60 copay; or $7.40 copay.
Tier 3 (Preferred Brand)	For generic drugs (including brand drugs treated as generic) either: $0 copay; or $1.20 copay; or $2.95 copay For all other drugs either: $0 copay; or $3.60 copay; or $7.40 copay.	For generic drugs (including brand drugs treated as generic) either: $0 copay; or $1.20 copay; or $2.95 copay For all other drugs either: $0 copay; or $3.60 copay; or $7.40 copay.
Tier 4 (Non-Preferred Brand)	For generic drugs (including brand drugs treated as generic) either: $0 copay; or $1.20 copay; or $2.95 copay For all other drugs either: $0 copay; or $3.60 copay; or $7.40 copay.	For generic drugs (including brand drugs treated as generic) either: $0 copay; or $1.20 copay; or $2.95 copay For all other drugs either: $0 copay; or $3.60 copay; or $7.40 copay.
Tier 5 (Specialty Tier)	For generic drugs (including brand drugs treated as generic) either: $0 copay; or $1.20 copay; or $2.95 copay For all other drugs either: $0 copay; or $3.60 copay; or $7.40 copay.	Not Offered

Standard Mail Order Cost-Sharing

Tier	One-month supply	Three-month supply
Tier 1 (Preferred Generic)	$0	$0
Tier 2 (Generic)	For generic drugs (including brand drugs treated as generic) either: $0 copay; or $1.20 copay; or $2.95 copay For all other drugs either: $0 copay; or $3.60 copay; or $7.40 copay.	For generic drugs (including brand drugs treated as generic) either: $0 copay; or $1.20 copay; or $2.95 copay For all other drugs either: $0 copay; or $3.60 copay; or $7.40 copay.
Tier 3 (Preferred Brand)	For generic drugs (including brand drugs treated as generic) either: $0 copay; or $1.20 copay; or $2.95 copay For all other drugs either: $0 copay; or $3.60 copay; or $7.40 copay.	For generic drugs (including brand drugs treated as generic) either: $0 copay; or $1.20 copay; or $2.95 copay For all other drugs either: $0 copay; or $3.60 copay; or $7.40 copay.
Tier 4 (Non-Preferred Brand)	For generic drugs (including brand drugs treated as generic) either: $0 copay; or $1.20 copay; or $2.95 copay For all other drugs either: $0 copay; or $3.60 copay; or $7.40 copay.	For generic drugs (including brand drugs treated as generic) either: $0 copay; or $1.20 copay; or $2.95 copay For all other drugs either: $0 copay; or $3.60 copay; or $7.40 copay.
Tier 5 (Specialty Tier)	For generic drugs (including brand drugs treated as generic) either: $0 copay; or $1.20 copay; or $2.95 copay For all other drugs either: $0 copay; or $3.60 copay; or $7.40 copay.	Not Offered

Preferred Mail Order Cost-Sharing

Tier	One-month supply	Three-month supply
Tier 1 (Preferred Generic)	$0	$0
Tier 2 (Generic)	For generic drugs (including brand drugs treated as generic) either: $0 copay; or $1.20 copay; or $2.95 copay For all other drugs either: $0 copay; or $3.60 copay; or $7.40 copay.	For generic drugs (including brand drugs treated as generic) either: $0 copay; or $1.20 copay; or $2.95 copay For all other drugs either: $0 copay; or $3.60 copay; or $7.40 copay.
Tier 3 (Preferred Brand)	For generic drugs (including brand drugs treated as generic) either: $0 copay; or $1.20 copay; or $2.95 copay For all other drugs either: $0 copay; or $3.60 copay; or $7.40 copay.	For generic drugs (including brand drugs treated as generic) either: $0 copay; or $1.20 copay; or $2.95 copay For all other drugs either: $0 copay; or $3.60 copay; or $7.40 copay.
Tier 4 (Non-Preferred Brand)	For generic drugs (including brand drugs treated as generic) either: $0 copay; or $1.20 copay; or $2.95 copay For all other drugs either: $0 copay; or $3.60 copay; or $7.40 copay.	For generic drugs (including brand drugs treated as generic) either: $0 copay; or $1.20 copay; or $2.95 copay For all other drugs either: $0 copay; or $3.60 copay; or $7.40 copay.
Tier 5 (Specialty Tier)	For generic drugs (including brand drugs treated as generic) either: $0 copay; or $1.20 copay; or $2.95 copay For all other drugs either: $0 copay; or $3.60 copay; or $7.40 copay.	Not Offered

If you reside in a long-term care facility you pay the same as at a retail pharmacy.

You may get drugs from an out-of-network pharmacy but may pay more than you pay at an in-network pharmacy.

You pay nothing

** Outpatient Care **

Diabetes supplies and services

Diabetes monitoring supplies: You pay nothing

Diabetes self-management training: You pay nothing

Therapeutic shoes or inserts: You pay nothing

Foot care (podiatry services)

Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions: You pay nothing

Routine foot care (for up to 6 visit(s) every year): $5 copay

Hearing services

Exam to diagnose and treat hearing and balance issues: You pay nothing

Routine hearing exam (for up to 1 every year): You pay nothing

Hearing aid fitting/evaluation (for up to 1 every year): You pay nothing

Hearing aid: You pay nothing

Our plan pays up to $350 every year for hearing aids.

** Outpatient Medical Services and Supplies **

Outpatient substance abuse

Group therapy visit: You pay nothing

Individual therapy visit: You pay nothing

Prosthetic devices (braces, artificial limbs, etc.)

Prosthetic devices: You pay nothing

Related medical supplies: You pay nothing

** Additional Benefits **

Inpatient mental health care

For inpatient mental health care see the "Mental Health Care" section.

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