2027 Medicare Advantage plan

Wellpoint Full Dual Advantage Support (HMO D-SNP): 2027 benefits and costs

Wellpoint HMO D-SNP Special Needs Plan

CMS plan ID: H5828-001-0 · Plan year: 2027

Wellpoint Full Dual Advantage Support (HMO D-SNP) is a 2027 Medicare Advantage plan offered by Wellpoint. It is listed in Tennessee.

2027 plan costs at a glance

Monthly plan premium$0.00

Drug deductible$105.00

In-network medical out-of-pocket maximum$9,850.00

Costs shown are before Medicaid or Extra Help; your costs depend on your eligibility and assistance.

Organization: Wellpoint
Plan organization: WELLPOINT TENNESSEE, INC.
Parent company: Elevance Health, Inc.
Plan type: HMO D-SNP
Part C premium: $0.00
Part D premium: $0.00
Prescription drug coverage: Yes
Special Needs Plan type: Dual-Eligible
2027 CMS Star Rating

Standard monthly Medicare Part B premium: $209.50 (estimated)

You must continue to pay your Medicare Part B premium.

In-network medical deductible: Same as Medicare's Part B deductible
Applies to certain in-network Medicare-covered services.
In-network medical maximum: $9,850.00

Who can join this Special Needs Plan?

This plan is for people who qualify for both Medicare and Medicaid. The plan must confirm the required Medicaid eligibility level. Your costs can depend on your assistance level.

Plan eligibility type: Dual-Eligible

2027 benefit summary

Doctor visits and medical care

Plan-level deductibles may still apply when a service-specific deductible is listed as No.

Common medical services and member costs
Service	In-network	What to know
Primary care doctor	20% coinsurance Service-specific deductible No
Specialist visit	20% coinsurance Service-specific deductible No	Approval required Yes Referral required No
Telehealth	$0.00 copay Service-specific deductible No	Approval required No Referral required No
Emergency care	$115.00 copay
Urgent care	$20.00 copay
Home health	$0.00 copay Service-specific deductible No	Approval required Yes Referral required No
Dialysis	20% coinsurance Service-specific deductible No	Approval required No Referral required No
Part B chemotherapy and radiation drugs	0% to 20% coinsurance Deductible applies No	Approval required Yes
Other Part B drugs	0% to 20% coinsurance Deductible applies No	Approval required Yes
Kidney disease education services	$0.00 copay Service-specific deductible No	Approval required No Referral required No
Medicare-covered chiropractic	20% coinsurance Service-specific deductible No	Approval required Yes Referral required No
Medicare-covered foot care	20% coinsurance Service-specific deductible No	Approval required Yes Referral required No
Other health professionals	20% coinsurance Service-specific deductible No	Approval required Yes Referral required No

Hospital, outpatient surgery and observation care

Inpatient stays and skilled nursing care

In-network stays. Charges can depend on the number of days and the benefit period.
Care	Your share of the cost	What to know
Inpatient hospital stay	Original Medicare cost-sharing rules apply.	Approval required Yes Referral required No Benefit period Original Medicare
Inpatient mental health care	Original Medicare cost-sharing rules apply.	Approval required Yes Referral required No Benefit period Original Medicare
Skilled nursing facility	Original Medicare cost-sharing rules apply.	Approval required Yes Referral required No Benefit period Original Medicare

See plan documents for out-of-network hospital and skilled nursing costs.

Hospital, outpatient surgery and observation care and member costs
Service	In-network	What to know
Outpatient hospital care	20% coinsurance Service-specific deductible No
Hospital observation services	20% coinsurance Service-specific deductible No
Ambulatory surgical center	20% coinsurance Service-specific deductible No	Approval required Yes Referral required No
Outpatient blood	$0.00 copay Service-specific deductible No	Approval required No Referral required No

Tests, imaging and laboratory services

Tests, imaging and laboratory services and member costs
Service	In-network	What to know
Diagnostic procedures and tests	20% coinsurance Service-specific deductible No	Approval required Yes Referral required No
Laboratory services	20% coinsurance Service-specific deductible No	Approval required Yes Referral required No
Diagnostic radiology (CT, MRI)	20% coinsurance Service-specific deductible No	Approval required Yes Referral required No
Therapeutic radiology	20% coinsurance Service-specific deductible No	Approval required Yes Referral required No
X-rays	20% coinsurance Service-specific deductible No	Approval required Yes Referral required No

Mental health and substance use treatment

Mental health and substance use treatment and member costs
Service	In-network	What to know
Partial hospitalization	$115.00 copay Service-specific deductible No	Approval required Yes Referral required No
Intensive outpatient program	$115.00 copay Service-specific deductible No	Approval required Yes Referral required No
Substance use treatment, individual sessions	20% coinsurance Service-specific deductible No	Approval required Yes Referral required No
Substance use treatment, group sessions	20% coinsurance Service-specific deductible No	Approval required Yes Referral required No
Opioid treatment program	20% coinsurance Service-specific deductible No	Approval required Yes Referral required No
Mental health, individual sessions	20% coinsurance Service-specific deductible No	Approval required Yes Referral required No
Mental health, group sessions	20% coinsurance Service-specific deductible No	Approval required Yes Referral required No
Psychiatry, individual sessions	20% coinsurance Service-specific deductible No	Approval required Yes Referral required No
Psychiatry, group sessions	20% coinsurance Service-specific deductible No	Approval required Yes Referral required No

Therapy and rehabilitation

Therapy and rehabilitation and member costs
Service	In-network	What to know
Occupational therapy	20% coinsurance Service-specific deductible No	Approval required Yes Referral required No
Physical and speech therapy	20% coinsurance Service-specific deductible No	Approval required Yes Referral required No
Cardiac rehabilitation	20% coinsurance Service-specific deductible No	Approval required Yes Referral required No
Intensive cardiac rehabilitation	20% coinsurance Service-specific deductible No	Approval required Yes Referral required No
Pulmonary rehabilitation	20% coinsurance Service-specific deductible No	Approval required Yes Referral required No
Supervised exercise for peripheral artery disease	20% coinsurance Service-specific deductible No	Approval required Yes Referral required No

Ambulance, medical equipment and supplies

Ambulance, medical equipment and supplies and member costs
Service	In-network	What to know
Ground ambulance	20% coinsurance Service-specific deductible No	Approval required Yes
Air ambulance	20% coinsurance Service-specific deductible No	Approval required Yes
Durable medical equipment	20% coinsurance Service-specific deductible No	Approval required Yes
Prosthetic devices	20% coinsurance Service-specific deductible No	Approval required Yes
Medical supplies	20% coinsurance Service-specific deductible No	Approval required Yes
Diabetic supplies	$0.00 copay Service-specific deductible No	Approval required Yes
Diabetic shoes and inserts	$0.00 copay Service-specific deductible No	Approval required Yes
Diabetic monitors	$0.00 copay; 20% coinsurance Service-specific deductible No	Approval required Yes

Dental benefits

Dental benefits and member costs
Service	In-network	What to know
Medicare-covered dental	20% coinsurance
Oral examsAdditional plan benefit	$0.00 copay
Dental X-raysAdditional plan benefit	$0.00 copay
Other diagnostic dentalAdditional plan benefit	$0.00 copay
Dental cleaningAdditional plan benefit	$0.00 copay
FluorideAdditional plan benefit	$0.00 copay
Other preventive dentalAdditional plan benefit	$0.00 copay
Restorative dental careAdditional plan benefit	$0.00 copay
Root canal treatment (endodontics)Additional plan benefit	$0.00 copay
Gum treatment (periodontics)Additional plan benefit	$0.00 copay
Removable dentures (prosthodontics)Additional plan benefit	$0.00 copay
Fixed dental restorations (prosthodontics)Additional plan benefit	$0.00 copay
Oral surgeryAdditional plan benefit	$0.00 copay
Other dental servicesAdditional plan benefit	$0.00 copay

Vision benefits

Vision benefits and member costs
Service	In-network	What to know
Medicare-covered eye exams	20% coinsurance Service-specific deductible No	Approval required No Referral required No
Routine eye examsAdditional plan benefit	$0.00 copay	Approval required No Referral required No
Medicare-covered eyewear	20% coinsurance Service-specific deductible No	Approval required No Referral required No
Contact lensesAdditional plan benefit	$0.00 copay	Approval required No Referral required No
Eyeglasses, lenses and framesAdditional plan benefit	$0.00 copay	Approval required No Referral required No
Eyeglass lensesAdditional plan benefit	$0.00 copay	Approval required No Referral required No
Eyeglass framesAdditional plan benefit	$0.00 copay	Approval required No Referral required No

Hearing benefits

Hearing benefits and member costs
Service	In-network	What to know
Medicare-covered hearing exams	20% coinsurance Service-specific deductible No	Approval required Yes Referral required No
Routine hearing examsAdditional plan benefit	$0.00 copay	Approval required Yes Referral required No
Hearing aid fitting and evaluationAdditional plan benefit	$0.00 copay	Approval required Yes Referral required No
Prescription hearing aids (all types)Additional plan benefit	$0.00 copay Service-specific deductible No	Approval required Yes Referral required No
Over-the-counter hearing aidsAdditional plan benefit	$0.00 copay Service-specific deductible No	Approval required Yes Referral required No

Extra benefits

Extra benefits and member costs
Service	In-network	What to know
Over-the-counter health itemsAdditional plan benefit	$0.00 copay Service-specific deductible No
Limited-duration mealsAdditional plan benefit	$0.00 copay Service-specific deductible No	Approval required No Referral required No
Annual physical examAdditional plan benefit	$0.00 copay Service-specific deductible No	Approval required No Referral required No
Fitness benefitAdditional plan benefit	$0.00 copay Service-specific deductible No	Approval required No Referral required No

Allowances and optional benefits

Combined OTC + Other Supplemental

One shared limit covers the listed services, not a separate allowance for each service.

Services sharing this allowance: Over-the-counter health items; Home and Bathroom Safety Devices and Modifications; Additional Benefits for SSBCI
Service categories that apply to the combined supplemental benefits group for Special Supplemental Benefits for Chronically Ill (SSBCI) package(s): Food and produce (SSBCI: Non-Health Related Benefits); Support for daily living (SSBCI: Non-Health Related Benefits)
How benefits are provided: Catalogue Purchase; Claims Processing; Debit Card; Reimbursement
Advance choice of benefits required: No
Shared benefit limit: $423.00
How often this limit applies: Every one month
Are the benefits combined such that a single benefit maximum available to all enrollees in the benefit details section is extended to an SSBCI or MA UF benefit for eligible enrollees?: Yes
Shared limit on visits or trips: No

Benefits for qualifying members

Non-Health Related Benefits

The plan must confirm eligibility, including any qualifying condition.

Qualifying conditions: Chronic alcohol use disorder and other substance use disorders (SUDs); Autoimmune disorders; Cancer; Cardiovascular disorders; Chronic heart failure; Dementia; Diabetes mellitus; Overweight, obesity, and metabolic syndrome; Chronic gastrointestinal disease; Chronic kidney disease (CKD); Severe hematologic disorders; HIV/AIDS; Chronic lung disorders; Chronic and disabling mental health conditions; Neurologic disorders; Stroke; Post-organ transplantation; Immunodeficiency and Immunosuppressive disorders; Conditions associated with cognitive impairment; Conditions with functional challenges; Chronic conditions that impair vision, hearing (deafness), taste, touch, and smell; Conditions that require continued therapy services in order for individuals to maintain or retain functioning; Other 1; Other 2; Other 3; Other 4
Qualifying conditions: Chronic Hypertension
Qualifying conditions: Osteoporosis
Qualifying conditions: Chronic back pain
Qualifying conditions: Pre-diabetes: Fasting blood glucose: 100-125 mg/dl or Hgb A1C:5.7-6.4%
Included services: Food and produce; Support for daily living
Some package benefits are exempt from the deductible: No

Prescription drug coverage

Costs shown are for initial coverage.

Drug deductible exceptions: Tier 1; Tier 2 are exempt from the deductible.

Standard retail costs

On a small screen, scroll the table sideways to compare all fill lengths.

Standard retail: initial-coverage cost per prescription fill
Drug tier	30 days	60 days	90 days
Tier 1Preferred Generic	$0.00	$0.00	Not listed
Tier 2Generic	$0.00	$0.00	$0.00
Tier 3Preferred Brand	25%	25%	25%
Tier 4Non-Preferred Drug	25%	25%	25%
Tier 5Specialty Tier	32%	Not listed	Not listed

Standard retail: initial-coverage cost per prescription fill (continued: 100 days)
Drug tier	100 days
Tier 1Preferred Generic	$0.00

Mail-order and other pharmacies

Out-of-network pricing: You pay the standard retail copay or coinsurance, plus any difference between the pharmacy’s billed charge and the amount the plan allows at a standard retail pharmacy.

Standard mail order costs

On a small screen, scroll the table sideways to compare all fill lengths.

Standard mail order: initial-coverage cost per prescription fill
Drug tier	30 days	60 days	90 days
Tier 1Preferred Generic	$0.00	$0.00	Not listed
Tier 2Generic	$0.00	$0.00	$0.00
Tier 3Preferred Brand	25%	25%	25%
Tier 4Non-Preferred Drug	25%	25%	25%
Tier 5Specialty Tier	32%	Not listed	Not listed

Standard mail order: initial-coverage cost per prescription fill (continued: 100 days)
Drug tier	100 days
Tier 1Preferred Generic	$0.00

Long-term care pharmacy costs

Long-term care pharmacy: initial-coverage cost per prescription fill
Drug tier	34 days
Tier 1Preferred Generic	$0.00
Tier 2Generic	$0.00
Tier 3Preferred Brand	25%
Tier 4Non-Preferred Drug	25%
Tier 5Specialty Tier	32%

Out-of-network pharmacy costs

Out-of-network pharmacy: initial-coverage cost per prescription fill
Drug tier	30 days
Tier 1Preferred Generic	$0.00
Tier 2Generic	$0.00
Tier 3Preferred Brand	25%
Tier 4Non-Preferred Drug	25%
Tier 5Specialty Tier	32%

Drug coverage rules and exceptions

Tier 1: Preferred Generic

Drugs included in this tier: Part D Drugs Only
Longer fills available for every covered drug: Yes
Some longer-fill prescriptions require a one-month first fill: No

Tier 2: Generic

Drugs included in this tier: Part D Drugs Only
Longer fills available for every covered drug: No
Some longer-fill prescriptions require a one-month first fill: No

Tier 3: Preferred Brand

Drugs included in this tier: Part D Drugs Only
Longer fills available for every covered drug: No
Some longer-fill prescriptions require a one-month first fill: No

Tier 4: Non-Preferred Drug

Drugs included in this tier: Part D Drugs Only
Longer fills available for every covered drug: No
Some longer-fill prescriptions require a one-month first fill: No

Tier 5: Specialty Tier

Drugs included in this tier: Part D Drugs Only

Initial-coverage prices also apply to drugs exempt from the deductible: Yes

Special cost protections apply to covered insulin and recommended adult vaccines.

Where this plan is offered

CMS lists this plan in 1 state or territory. Availability can vary by county and ZIP code.

View all locations 95 county listings across 1 state or territory