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Wellpoint I Carelon Home Care (HMO I-SNP)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Wellpoint I Carelon Home Care (HMO I-SNP). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Wellpoint I Carelon Home Care (HMO I-SNP) in 2025, please refer to our full plan details page.
Wellpoint I Carelon Home Care (HMO I-SNP) is a HMO I-SNP 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 I Carelon Home Care (HMO I-SNP) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Important:
Wellpoint I Carelon Home Care (HMO I-SNP)is a Special Needs Type (SNP) plan. This means you can only enroll in this plan if you meet specific criteria. See our full plan details page for more information.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Wellpoint I Carelon Home Care (HMO I-SNP).
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 I Carelon Home Care (HMO I-SNP), 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 $20.00. 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 $2700.00 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:
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Drug Coverage
The Wellpoint I Carelon Home Care (HMO I-SNP) plan has an enhanced alternative drug benefit. The plan has no deductible for prescription drugs. During the initial coverage phase, you'll pay varying costs depending on the drug tier and pharmacy. For example, you'll pay a $7.50 copay for a standard pharmacy, preferred generic drug, or 25% coinsurance for a standard pharmacy, standard generic drug. After your total drug costs reach $2000, you enter the catastrophic coverage phase where you pay nothing for covered drugs.
Additional Benefits
The Wellpoint I Carelon Home Care (HMO I-SNP) plan offers a wide range of benefits with varying costs. Hospital stays have a $175 copay for days 1-5, and no copay for days 6-90. Many services, including outpatient substance abuse, preventive services, and dental services, have no copay. The plan also covers emergency services with a $120 copay, and transportation to plan-approved health-related locations with no copay. Hearing services, including exams and hearing aids, are covered with no copay, and vision services include eye exams and eyewear with no copay. Dialysis services have a 20% coinsurance, while home health and skilled nursing facility services have no copay.
Inpatient Hospital See details
Inpatient Hospital services are covered, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric. For Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, you'll pay a $175 copay for days 1-5, and no copay for days 6-90.
Outpatient Services See details
Outpatient Services includes coverage for outpatient hospital services with a copay of $0-$125, observation services with a copay of $125, ambulatory surgical center services with no copay, outpatient substance abuse services with no copay, and outpatient blood services with no copay. Outpatient blood services include an enhanced benefit with a three-pint deductible waived.
Partial Hospitalization See details
Partial Hospitalization is covered by the Wellpoint I Carelon Home Care (HMO I-SNP) plan with no copay. Prior authorization is required for this benefit.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered, including ground and air ambulance services with a $225 copay, and transportation to plan-approved health-related locations with no copay, up to 12 one-way trips per year. Transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, including Worldwide Emergency Services, are covered by the Wellpoint I Carelon Home Care (HMO I-SNP) plan. Emergency Services have a $120 copay, and Urgently Needed Services have no copay; Worldwide Emergency Coverage, Worldwide Urgent Coverage, and Worldwide Emergency Transportation each have a $120 copay.
Primary Care See details
The Wellpoint I Carelon Home Care (HMO I-SNP) plan covers primary care physician services, chiropractic services (with prior authorization), occupational therapy services (with no coinsurance, but a copay), physician specialist services (with a doctor referral), mental health specialty services (with a copay), podiatry services (with a copay), other health care professional services (with a copay), psychiatric services (with a copay), physical therapy and speech-language pathology services (with no copay), additional telehealth benefits (with no copay), and opioid treatment program services (with a copay). Routine chiropractic care is not covered.
Preventive Services See details
Preventive Services include coverage for Medicare-covered services, annual physical exams with no copay, and additional preventive services, although some services like health education, in-home safety assessments, and others are not covered. Other preventive services like glaucoma screenings, diabetes self-management training, and others have no copay.
Hearing Services See details
Hearing Services include hearing exams with no copay, routine hearing exams with no copay, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids are covered up to $3,000 per year, and OTC hearing aids are covered with no copay, up to $300 per year. Prescription hearing aids for inner ear, outer ear, and over the ear are not covered.
Vision Services See details
Vision services include eye exams and eyewear. Eye exams have no copay. Eyewear has no copay, with a combined maximum plan benefit coverage of $300 per year, and upgrades are not covered.
Dental Services See details
The Wellpoint I Carelon Home Care (HMO I-SNP) plan covers a variety of dental services, including oral exams, x-rays, and cleanings with no copay, as well as other diagnostic, preventive, restorative, and surgical services, all with a $0 copay. The plan has a maximum benefit of $500 per year for other dental services.
Home Infusion bundled Services See details
Home Infusion bundled Services, including Medicare Part B Insulin Drugs, Chemotherapy/Radiation Drugs, and Other Medicare Part B Drugs, are covered. For Medicare Part B Insulin Drugs, there is a $35 copay. For Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs, coinsurance ranges from 0% to 20%.
Dialysis Services See details
Dialysis Services are covered by the Wellpoint I Carelon Home Care (HMO I-SNP) plan. There is a 20% coinsurance for these services.
Medical Equipment See details
Medical Equipment is covered, including Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. DME has a coinsurance of 0% to 20%, while Diabetic Supplies and Diabetic Therapeutic Shoes/Inserts have no copay.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services include coverage for all diagnostic services with a copay, and lab services with no copay. Diagnostic Radiological Services have a copay of up to $150, while Therapeutic Radiological Services have a coinsurance of at least 20%. Outpatient X-Ray Services have no copay.
Home Health Services See details
Home Health Services are covered by the Wellpoint I Carelon Home Care (HMO I-SNP) 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.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Wellpoint I Carelon Home Care (HMO I-SNP) plan, with no copay for days 1-100. Additional days beyond Medicare-covered for SNF and non-Medicare-covered stays are not covered.
Other Services See details
Other Services include coverage for Over-the-Counter (OTC) Items and "Other 1", both with no copay. Acupuncture, Meal Benefits, Dual Eligible SNPs with Highly Integrated Services, Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services, Private Duty Nursing Services, Case Management (Long Term Care), Institution for Mental Disease Services for Individuals 65 or Older, Services in an Intermediate Care Facility for Individuals with Intellectual Disabilities, Case Management, Tobacco Cessation Counseling for Pregnant Women, Freestanding Birth Center Services, Respiratory Care Services, Family Planning Services, Nursing Home Services, Home and Community Based Services, Personal Care Services, and Self-Directed Personal Assistance Services are not covered.
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