Wellpoint Extra Help (HMO)
H5828 - 008 - 0
(3.5 / 5)
Wellpoint Extra Help (HMO) is a Medicare Advantage Plan by Amerigroup Community Care.
This page features plan details for 2024 Wellpoint Extra Help (HMO) H5828 – 008 – 0 available in Tennessee.
IMPORTANT: This page features the 2024 version of this plan. See the 2025 version using the link below:
Locations
Wellpoint Extra Help (HMO) is offered in the following locations.
Plan Overview
Wellpoint Extra Help (HMO) offers the following coverage and cost-sharing.
| Insurer: | Amerigroup Community Care |
| Health Plan Deductible: | $0.00 |
| MOOP: | $4,900 In-network |
| Drugs Covered: | Yes |
Ready to sign up for Wellpoint Extra Help (HMO) ?
Get help from a licensed insurance agent.
Call 1-877-354-4611 / TTY 711.
M-F: 8:00 am – 10:00 pm EST
Sat-Sun: 8:00 am – 9:00 pm EST
Premium Breakdown
Wellpoint Extra Help (HMO) has a monthly premium of $8.60. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.| Part B | Part C | Part D | Part B Give Back | Total |
|---|---|---|---|---|
| $174.70 | $0.00 | $8.60 | $0.00 | $ |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
- You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.
Drug Info
Wellpoint Extra Help (HMO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
| Drug Deductible: | $545.00 |
| Initial Coverage Limit: | $5,030.00 |
| Catastrophic Coverage Limit: | $8,000.00 |
| Drug Benefit Type: | Enhanced Alternative |
| Additional Gap Coverage: | |
| Formulary Link: | Formulary Link |
Part D Premium Reduction
The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs.
The table below shows how the LIS impacts the Part D premium of this plan.
| Part D | LIS Full |
|---|---|
| $8.60 | $ |
Initial Coverage Phase
After you pay your $545.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $5,030.00. Once you reach that amount, you will enter the next coverage phase.
30 Day
60 Day
90 Day
30 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $10.00 copay | $10.00 copay | $10.00 copay | |
| 2 (Generic) | $20.00 copay | $20.00 copay | $20.00 copay | |
| 3 (Preferred Brand) | $37.00 copay | $47.00 copay | $37.00 copay | |
| 4 (Non-Preferred Drug) | $90.00 copay | $100.00 copay | $90.00 copay | |
| 5 (Specialty Tier) | 25% | 25% | 25% | |
| 6 (Select Care Drugs) | $10.00 copay | $10.00 copay | $10.00 copay |
60 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | ||||
| 2 (Generic) | ||||
| 3 (Preferred Brand) | ||||
| 4 (Non-Preferred Drug) | ||||
| 5 (Specialty Tier) | ||||
| 6 (Select Care Drugs) |
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $30.00 copay | $30.00 copay | $30.00 copay | |
| 2 (Generic) | $60.00 copay | $60.00 copay | $60.00 copay | |
| 3 (Preferred Brand) | $111.00 copay | $141.00 copay | $111.00 copay | |
| 4 (Non-Preferred Drug) | $270.00 copay | $300.00 copay | $270.00 copay | |
| 5 (Specialty Tier) | ||||
| 6 (Select Care Drugs) | $30.00 copay | $30.00 copay | $30.00 copay |
Gap Coverage Phase
30 Day
90 Day
30 Day
90 Day
| Tier | Cost |
|---|---|
| All other tiers (Generic) | 25% |
| All other tiers (Brand-name) | 25% |
Catastrophic Coverage Phase
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $8,000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. Please note, that this plan has a Enhanced Alternative benefit type.
Additional Benefits
Wellpoint Extra Help (HMO) also provides the following benefits.
| $0 |
| In-network | No |
| $4,900 In-network |
| Yes |
| In-network | Yes, contact plan for further details |
| $0-275 copay per visit (Authorization is required.) (Referral is not required.) |
| Primary | $0 copay (Not applicable.) (Not applicable.) |
| Specialist | $25 copay per visit (Authorization is required.) (Referral is not required.) |
| $0 copay (Authorization is not required.) (Referral is not required.) |
| Emergency | $90 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Urgent care | $35 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Diagnostic tests and procedures | $0-90 copay (Authorization is required.) (Referral is not required.) |
| Lab services | $0-10 copay (Authorization is required.) (Referral is not required.) |
| Diagnostic radiology services (e.g., MRI) | $90-200 copay (Authorization is required.) (Referral is not required.) |
| Outpatient x-rays | $50-90 copay (Authorization is required.) (Referral is not required.) |
| Hearing exam | $25 copay (Authorization is required.) (Referral is not required.) |
| Fitting/evaluation | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Hearing aids | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Oral exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Cleaning | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Fluoride treatment | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Dental x-ray(s) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Non-routine services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Diagnostic services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Restorative services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Endodontics | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Periodontics | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Extractions | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Prosthodontics, other oral/maxillofacial surgery, other services | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Routine eye exam | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Other | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Contact lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglasses (frames and lenses) | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglass frames | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Eyeglass lenses | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Upgrades | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Occupational therapy visit | $25 copay (Authorization is required.) (Referral is not required.) |
| Physical therapy and speech and language therapy visit | $25 copay (Authorization is required.) (Referral is not required.) |
| $235 copay (Not applicable.) (Not applicable.) |
| $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Foot exams and treatment | $0-25 copay (Authorization is required.) (Referral is not required.) |
| Routine foot care | $0 copay (There are no limits.) (Authorization is required.) (Referral is not required.) |
| Durable medical equipment (e.g., wheelchairs, oxygen) | 0-20% coinsurance per item (Authorization is required.) (Not applicable.) |
| Prosthetics (e.g., braces, artificial limbs) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| Diabetes supplies | $0 copay (Authorization is not required.) (Not applicable.) |
| Covered (Authorization is not required.) (Referral is not required.) |
| Chemotherapy | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| Other Part B drugs | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| Part B Insulin drugs | $35 copay (Authorization is required.) (Not applicable.) |
| $295 per day for days 1 through 6 $0 per day for days 7 through 90 (Authorization is required.) (Referral is not required.) |
| Inpatient hospital – psychiatric | $260 per day for days 1 through 6 $0 per day for days 7 through 90 (Authorization is required.) (Referral is not required.) |
| Outpatient group therapy visit with a psychiatrist | $25 copay (Authorization is required.) (Referral is not required.) |
| Outpatient individual therapy visit with a psychiatrist | $25 copay (Authorization is required.) (Referral is not required.) |
| Outpatient group therapy visit | $25 copay (Authorization is required.) (Referral is not required.) |
| Outpatient individual therapy visit | $25 copay (Authorization is required.) (Referral is not required.) |
| $0 per day for days 1 through 20 $203 per day for days 21 through 100 (Authorization is required.) (Referral is not required.) |
| Monthly Premium | $13.00 |
| Deductible | nan |
| Monthly Premium | $26.00 |
| Deductible | nan |
| Monthly Premium | $47.00 |
| Deductible | nan |
Ready to sign up for Wellpoint Extra Help (HMO) ?
Get help from a licensed insurance agent.
Call 1-877-354-4611 / TTY 711.
M-F: 8:00 am – 10:00 pm EST
Sat-Sun: 8:00 am – 9:00 pm EST
Table of Contents
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