Wellpoint Dual Advantage (HMO D-SNP)
Wellpoint Dual Advantage (HMO D-SNP) is a HMO Medicare Advantage (Medicare Part C) plan offered by Wellpoint
Plan ID: H1894-011
HelpAdvisor Editorial Team analysis of data from the 2025 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
Wellpoint Dual Advantage (HMO D-SNP) is a HMO Medicare Advantage (Medicare Part C) plan offered by Wellpoint
Plan ID: H1894-011
HelpAdvisor Editorial Team analysis of data from the 2025 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $0 |
| Out of Pocket Max |
In-Network: $9350 Out-of-Network: N/A |
| Initial Coverage Limit | $2000 |
| Catastrophic Coverage Limit | $2,000 |
| Primary Care Doctor Visit | In-Network: $0.00 copay |
| Specialty Doctor Visit | In-Network: $0.00 copay |
| Inpatient Hospital Care | In-Network: Medicare-defined Cost Share |
| Urgent Care | Urgent Care: $45.00 copay |
| Emergency Room Visit | Emergency Care: $90.00 copay Copay waived if admitted to hospital within 24 hours Worldwide Coverage: This plan covers urgent care and emergency services when traveling outside of the United States for less than six months. This benefit is limited to $100,000 per year. |
| Ambulance Transportation | Ground Ambulance: 20% coinsurance Per Trip Air Ambulance: 20% coinsurance |
Health Care Services and Medical Supplies
Wellpoint Dual Advantage (HMO D-SNP) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).
| Coverage | Cost |
|---|---|
| Chiropractic Services | In-Network: Medicare Covered Chiropractic Services: 20% coinsurance Routine Chiropractic Services: $0.00 copay 24 visits each year |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network: Diabetic Supplies: $0.00 copay |
| Durable Medical Eqipment (DME) | In-Network: 20% coinsurance |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | In-Network: Lab Services: 20% coinsurance X-Rays: 20% coinsurance Therapeutic Radiological Services: 20% coinsurance Outpatient Diagnostic Procedures/Tests: 20% coinsurance Diagnostic Radiological Services: 20% coinsurance |
| Home Health Care | In-Network: $0.00 copay |
| Mental Health Inpatient Care | In-Network: Medicare-defined Cost Share |
| Mental Health Outpatient Care | In-Network: Individual and Group Sessions: 20% coinsurance |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital - Surgery: 20% coinsurance Observation Services: 20% coinsurance Ambulatory Surgical Center: 20% coinsurance |
| Outpatient Substance Abuse Care | In-Network: Individual and Group Sessions: 20% coinsurance |
| Podiatry Services | In-Network: Medicare Covered Podiatry Services: 20% coinsurance Routine Foot Care: $0.00 copay Unlimited routine foot care visits each year. |
| Skilled Nursing Facility Care | In-Network: Medicare-defined cost share |
Dental Benefits
The following dental services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Dental Care | In-Network: Preventive Dental Services: $0.00 copay Medicare Covered Dental: 20% coinsurance Comprehensive Dental Services: $0.00 copay This plan covers up to a $2,500 allowance for covered preventive and comprehensive dental services every year. |
Vision Benefits
The following vision services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Vision Benefits | In-Network: Medicare Covered Eye Exam: 20% coinsurance Routine Eye Exam: $0.00 copay This plan covers 1 routine eye exam(s) every year. Medicare Covered Eye Wear: 20% coinsurance Routine Eye Wear: $0.00 copay This plan covers up to $200 for eyeglasses or contact lenses every year. |
Hearing Benefits
The following hearing services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Hearing Benefits | In-Network: Medicare Covered Hearing Exam: 20% coinsurance Routine Hearing Exam: $0.00 copay for routine hearing exam(s). $0.00 copay for hearing aids up to the maximum plan benefit amount. This plan covers 1 routine hearing exam every year. $300 maximum plan benefit for over-the-counter hearing aids OR 1 routine hearing aid fitting evaluation and a $3,000 maximum plan benefit for prescribed hearing aids every year. |
Preventive Services and Health/Wellness Education Programs
The following services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Preventive Services and Health/Wellness Education Programs | In-Network: $0.00 copay for Medicare Covered Preventive Services |
