A non-government entity
Wellpoint Premium Savings (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Wellpoint Premium Savings (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Wellpoint Premium Savings (HMO) in 2025, please refer to our full plan details page.
Wellpoint Premium Savings (HMO) is a HMO plan offered by Elevance Health, Inc. available for enrollment in 2025 to people living in Pima County. This plan received an overall rating of 3 out of 5 stars in 2025.
It's important to know that Wellpoint Premium Savings (HMO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Wellpoint Premium Savings (HMO).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Wellpoint Premium Savings (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $0.00. This is the amount you must pay every month. Additionally, this plan comes with a Part B Premium reduction of $52.70. You must continue to pay paying your reduced Part B Premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has no drug deductible. Your prescription medication coverage will start immediately.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $3400.00 for out-of-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $0.00 for in-network covered services, the plan will pay 100% of in-network covered costs for the rest of the year.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
Sign up for Wellpoint Premium Savings (HMO)
Need help deciding? Talk with one of our licensed insurance specialists 1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
Drug Coverage
The Wellpoint Premium Savings (HMO) plan offers drug coverage with no deductible. For those who qualify for the low-income subsidy, the plan has no copay. In the initial coverage phase, you'll pay different amounts depending on the drug tier and pharmacy. Preferred Generic, and Specialty Tier drugs have no copay, while Standard Generic drugs have a $25-$30 copay. Preferred Brand and Non-Preferred drugs have a 25-33% coinsurance. Once your total drug costs reach $2000, you enter the catastrophic coverage phase, where you pay nothing for covered drugs.
Additional Benefits
The Wellpoint Premium Savings (HMO) plan offers a variety of benefits, including coverage for inpatient and outpatient hospital services, with varying copays. Emergency, primary care, and specialist services are covered with copays ranging from $0 to $120. Additional benefits include coverage for preventive, hearing, vision, and dental services, with some services having no copay. The plan also covers home health services, skilled nursing facilities, and other services, such as over-the-counter items, with various copays and coinsurance amounts.
Inpatient Hospital See details
Inpatient hospital stays are covered by the Wellpoint Premium Savings (HMO) plan, with a $225 copay for days 1-5, and no copay for days 6-90. Additional days for inpatient hospital are covered with no copay, but non-Medicare-covered stays and upgrades for inpatient hospital are not covered.
Outpatient Services See details
The Wellpoint Premium Savings (HMO) plan covers outpatient hospital services with a copay between $0 and $225, observation services with a $225 copay, and ambulatory surgical center services with no copay. Outpatient substance abuse services, including individual and group sessions, have a copay of $35, and outpatient blood services are covered with no copay.
Partial Hospitalization See details
Partial Hospitalization is covered by the Wellpoint Premium Savings (HMO) plan and requires prior authorization. The copay for this benefit is $35.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered under the Wellpoint Premium Savings (HMO) plan. Ground and Air Ambulance Services have a $195 copay, while Transportation Services to a plan-approved health-related location have no copay for 4 one-way trips per year, and transportation to any other health-related location is not covered.
Emergency Services See details
Emergency Services, including Urgently Needed Services and Worldwide Emergency Services, are covered by the Wellpoint Premium Savings (HMO) plan. For Emergency Services, there is a $120 copay, and for Urgently Needed Services, there is a $30 copay; there is also a $120 copay for Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation.
Primary Care See details
Primary Care Physician Services have a copay between $0 and $10, while Chiropractic Services have a $20 copay. Occupational Therapy Services have a $20 copay and require prior authorization, and Physician Specialist Services have a copay between $0 and $40 with a doctor referral. Mental Health Specialty Services, which include Individual and Group Sessions, have a copay between $0 and $35. Other Health Care Professional services have a copay between $0 and $20, while Psychiatric Services, also including Individual and Group Sessions, have a copay between $0 and $40. Physical Therapy and Speech-Language Pathology Services have a copay between $0 and $20 and require prior authorization. Additional Telehealth Benefits have no copay, and Opioid Treatment Program Services have a $35 copay and require prior authorization.
Preventive Services See details
Preventive Services, including Medicare-covered services, annual physical exams, and additional preventive services, are covered. Annual physical exams have no copay. Additional services such as Health Education, In-Home Safety Assessment, Personal Emergency Response System (PERS), and others are not covered.
Hearing Services See details
The Wellpoint Premium Savings (HMO) plan covers hearing exams, routine hearing exams, and fitting/evaluation for hearing aids with no copay, as well as OTC hearing aids with no copay. Prescription hearing aids are covered with a maximum benefit of $1500 every year, and all types of prescription hearing aids have no copay.
Vision Services See details
Vision Services includes coverage for eye exams with a copay of $0-$40, and eyewear with no copay, including contact lenses, eyeglasses (lenses and frames), and eyeglass lenses and frames. Upgrades are not covered.
Dental Services See details
Dental services are partially covered by the Wellpoint Premium Savings (HMO) plan, with a copay between $0 and $40 for Medicare Dental Services. Orthodontic Services, Restorative Services, Adjunctive General Services, Endodontics, Periodontics, Prosthodontics (removable and fixed), Maxillofacial Prosthetics, Implant Services, Oral and Maxillofacial Surgery, and Orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered by the Wellpoint Premium Savings (HMO) plan and require prior authorization. The plan covers Medicare Part B Insulin Drugs with a $35 copay, and covers Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs with coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Wellpoint Premium Savings (HMO) plan. You will pay 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment is covered under the Wellpoint Premium Savings (HMO) plan. Durable Medical Equipment (DME) has a coinsurance of 0% to 20%, and no copay, but Durable Medical Equipment for use outside the home is not covered. Prosthetic Devices have a coinsurance of 0% to 20%, and no copay, while Medical Supplies have a coinsurance of 0% to 20%, and no copay. Diabetic Equipment has a coinsurance of 20%, and no copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered. Diagnostic Procedures/Tests have no copay, while Lab Services have no copay. Diagnostic Radiological Services have a copay of up to $150, while Therapeutic Radiological Services have coinsurance of at most 20%. Outpatient X-Ray Services have a $15 copay.
Home Health Services See details
Home Health Services are covered by the Wellpoint Premium Savings (HMO) plan with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but the plan does not cover Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, or Additional Cardiac Rehabilitation Services. Prior authorization is required, and the plan has a copay for this benefit.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Wellpoint Premium Savings (HMO) plan, with a $0 copay for days 1-20 and a $125 copay for days 21-100. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Under the Wellpoint Premium Savings (HMO) plan, acupuncture and several other services are not covered. Over-the-counter items have no copay, and the plan offers a $100 benefit every three months. Meal benefits and other services have no copay, but a prior authorization is required for meal benefits.
Get Personalized Help from a licensed insurance agent
1-877-649-2073 / TTY 711. 8am-11pm EST. 7 days a week
*/SMID: MULTIPLAN_HCIHNMEDADVRX25_HCI_M
MedicareAdvantageRX.com is owned and operated by Dog Media Solutions LLC.
This is a promotional communication.
Every year, Medicare evaluates plans based on a 5-star rating system.
Part B premium reduction is not available with all plans. Availability varies by carrier and location. Actual Part B premium reduction could be lower. Deductibles, copays and coinsurance may apply.
* Benefit(s) mentioned may be part of a special supplemental program for chronically ill members with one of the following conditions: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure. This is not a complete list of qualifying conditions. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply.
Enrollment in Medicare/Medicare Advantage may be limited to certain times of the year unless you qualify for a Special Enrollment Period
We do not offer every plan available in your area. Currently, we represent 18 organizations, which offer 52,101 products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.
We represent Medicare Advantage HMO, PPO and PFFS organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan's contract renewal.
Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.
Please contact Medicare.gov ,1-800-MEDICARE , or your local State Health Insurance Program (SHIP) to get information on all of your options.
Medicare has neither approved nor endorsed any information on this site.
Speak with a licensed insurance agent: 1-877-649-2073 / TTY 711 | 8am - 11pm ET | 7 days a week
© 2023 Dog Media Solutions LLC. All rights reserved