WellSense Medicare Advantage (HMO)
H6851 - 001 - 0
(0 / 5)
WellSense Medicare Advantage (HMO) is a Medicare Advantage (Part C) Plan by BMC HealthNet Plan.
This page features plan details for 2022 WellSense Medicare Advantage (HMO) H6851 – 001 – 0 available in All Counties.
IMPORTANT: This page features the 2022 version of this plan. See the 2024 version using the link below:
Locations
WellSense Medicare Advantage (HMO) is offered in the following locations.
Plan Overview
WellSense Medicare Advantage (HMO) offers the following coverage and cost-sharing.
| Insurer: | BMC HealthNet Plan |
| Health Plan Deductible: | |
| MOOP: | $7,550.00 |
| Drugs Covered: | Yes |
Ready to sign up for WellSense Medicare Advantage (HMO) ?
Premium Breakdown
WellSense Medicare Advantage (HMO) has a monthly premium of $30.5. 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 |
|---|---|---|---|---|
| $170.10 | $0.00 | $30.50 | $0.00 | $200.60 |
- 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
WellSense Medicare Advantage (HMO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
| Drug Deductible: | $480.00 |
| Initial Coverage Limit: | $4,430.00 |
| Catastrophic Coverage Limit: | $7,050.00 |
| Drug Benefit Type: | Basic |
| Gap Coverage: | No |
| 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 25% | LIS 50% | LIS 75% | LIS Full |
|---|---|---|---|---|
| $30.50 | $22.90 | $15.20 | $7.60 | $0.00 |
Initial Coverage Phase
After you pay your $480.00 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 $4,430.00. Once you reach that amount, you will enter the next coverage phase.
30 Day
60 Day
90 Day
30 Day
60 Day
90 Day
Gap Coverage Phase
After your total drug costs (including what this plan has paid and what you have paid) reach $4,430.00, you will pay no more than the amounts below for any drug tier until you reach $7,050.00.
30 Day
90 Day
30 Day
90 Day
| Drug Type | Cost Share |
|---|---|
| Generic drugs | 25% |
| Brand-name drugs | 25% |
Catastrophic Coverage Phase
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $7,050.00, you will pay no more than the greater of the two amounts listed below for generic and brand-name drugs.
| Tier | Cost |
|---|---|
| Generic | $4.15 copay or 5% (whichever costs more) |
| Brand-name | $10.35 copay or 5% (whichever costs more) |
Additional Benefits
WellSense Medicare Advantage (HMO) also provides the following benefits.
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
| In-Network: No |
Dental (comprehensive)
| Diagnostic services: | 50% coinsurance (limits may apply) |
| Endodontics: | 50% coinsurance (limits may apply) |
| Extractions: | 50% coinsurance (limits may apply) |
| Non-routine services: | 50% coinsurance (limits may apply) |
| Periodontics: | 50% coinsurance (limits may apply) |
| Prosthodontics, other oral/maxillofacial surgery, other services: | 50% coinsurance (limits may apply) |
| Restorative services: | 50% coinsurance (limits may apply) |
Dental (preventive)
| Cleaning: | $0 copay (limits may apply) |
| Dental x-ray(s): | $0 copay (limits may apply) |
| Fluoride treatment: | $0 copay (limits may apply) |
| Oral exam: | $0 copay (limits may apply) |
Diagnostic procedures/lab services/imaging
| Diagnostic radiology services (e.g., MRI): | 20% coinsurance |
| Diagnostic tests and procedures: | 20% coinsurance |
| Lab services: | $0 copay |
| Outpatient x-rays: | 20% coinsurance |
Doctor visits
| Primary: | 20% coinsurance per visit |
| Specialist: | 20% coinsurance per visit |
Emergency care/Urgent care
| Emergency: | 20% coinsurance per visit (always covered) |
| Urgent care: | 20% coinsurance per visit (always covered) |
Foot care (podiatry services)
| Foot exams and treatment: | 20% coinsurance |
| Routine foot care: | Not covered |
Ground ambulance
| 20% coinsurance |
Health plan deductible
| Contact plan for details |
Health plan deductibles (other)
| In-Network: No |
Hearing
| Fitting/evaluation: | $0 copay |
| Hearing aids: | $0 copay (limits may apply) |
| Hearing exam: | 20% coinsurance |
Hospital coverage (inpatient)
| Contact plan for details (authorization required) |
Hospital coverage (outpatient)
| 20% coinsurance per visit (authorization required) |
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
| $7,550 In-network |
Medical equipment/supplies
| Diabetes supplies: | 20% coinsurance per item (authorization required) |
| Durable medical equipment (e.g., wheelchairs, oxygen): | 20% coinsurance per item (authorization required) |
| Prosthetics (e.g., braces, artificial limbs): | 20% coinsurance per item (authorization required) |
Medicare Part B drugs
| Chemotherapy: | 20% coinsurance (authorization required) |
| Other Part B drugs: | 20% coinsurance (authorization required) |
Mental health services
| Inpatient hospital – psychiatric: | Contact plan for details (authorization required) |
| Outpatient group therapy visit with a psychiatrist: | 20% coinsurance (authorization required) |
| Outpatient group therapy visit: | 20% coinsurance (authorization required) |
| Outpatient individual therapy visit with a psychiatrist: | 20% coinsurance (authorization required) |
| Outpatient individual therapy visit: | 20% coinsurance (authorization required) |
Optional supplemental benefits
| No |
Preventive care
| $0 copay (authorization required) |
Rehabilitation services
| Occupational therapy visit: | 20% coinsurance (authorization required) |
| Physical therapy and speech and language therapy visit: | 20% coinsurance (authorization required) |
Skilled Nursing Facility
| Contact plan for details (authorization required) |
Transportation
| $0 copay (limits may apply) (authorization required) |
Vision
| Contact lenses: | $0 copay (limits may apply) |
| Eyeglass frames: | $0 copay (limits may apply) |
| Eyeglass lenses: | $0 copay (limits may apply) |
| Eyeglasses (frames and lenses): | $0 copay (limits may apply) |
| Other: | Not covered |
| Routine eye exam: | $0 copay (limits may apply) |
| Upgrades: | $0 copay (limits may apply) |
Wellness programs (e.g., fitness, nursing hotline)
| Covered (authorization required) |
Ready to sign up for WellSense Medicare Advantage (HMO) ?