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WellSense Choice (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for WellSense Choice (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on WellSense Choice (HMO) in 2026, please refer to our full plan details page.
WellSense Choice (HMO) is a HMO plan offered by BMC Health System, Inc. available for enrollment in 2025 to people living in Hillsborough_Choice. This plan received an overall rating of 3 out of 5 stars in 2026.
It's important to know that WellSense Choice (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 WellSense Choice (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 WellSense Choice (HMO), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $13.90. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your 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 a $495.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $4200.00 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 WellSense Choice (HMO) Medicare plan features an annual prescription drug deductible of $495. For Tier 1 preferred generic drugs, members pay no copay for a 1-month or 3-month supply at standard pharmacies and through standard mail order. Tier 2 generic medications also feature no copay for mail order, while standard retail pharmacy purchases require a $10 copay for a 1-month supply or a $25 copay for a 3-month supply. Tier 3 preferred brand drugs carry a $47 standard retail copay or a $45 mail order copay for a 1-month supply. Tier 4 non-preferred drugs require a $100 retail copay or a $97 mail order copay for 1 month, with 3-month supplies costing $280 at retail and $275 through mail order. Finally, Tier 5 specialty drugs require a 27% coinsurance for a 1-month supply at both standard pharmacies and standard mail order.
Additional Benefits
The WellSense Choice (HMO) plan offers robust coverage for essential medical needs, featuring no copays for primary care physician visits, annual physical exams, and home health services. Specialist visits, routine eye exams, and routine hearing exams are accessible with a predictable $35 copay. For hospital care, inpatient acute stays require a $450 copay for the first seven days before dropping to no copay, while emergency room visits carry a $150 copay that is waived if you are admitted. This plan also provides valuable supplemental benefits, including no copays for preventive dental care, routine eyewear, and over-the-counter items up to $50 every three months. Comprehensive dental services are covered with a 50% coinsurance up to a $4,000 annual limit, and prescription hearing aids are available with copays ranging from $699 to $999. Additionally, most durable medical equipment and dialysis services are covered with a 20% coinsurance.
Inpatient Hospital See details
Inpatient hospital services are partially covered by WellSense Choice (HMO) with no coinsurance, as additional days, upgrades, and non-Medicare-covered stays are not covered. For acute inpatient stays, there is a $450 copay for days 1 through 7 and no copay for days 8 through 90, while psychiatric stays require a $430 copay for days 1 through 6 and no copay for days 7 through 90.
Outpatient Services See details
Outpatient services are covered by WellSense Choice (HMO) with no coinsurance, featuring copays of $0 to $425 for outpatient hospital services, $450 per day for observation services, and $400 for ambulatory surgical center services which require prior authorization. Outpatient substance abuse sessions require a $45 copay with no coinsurance, while outpatient blood services are available with no copay and no coinsurance.
Partial Hospitalization See details
Partial hospitalization is covered by WellSense Choice (HMO) with a copay of $175.00 or $180.00 and no coinsurance.
Ambulance and Transportation Services See details
Ambulance services are covered by WellSense Choice (HMO) with a $350 copay and coinsurance for ground transport, and a 50% coinsurance and copay for air transport, with prior authorization required. Routine transportation services to plan-approved or health-related locations are not covered.
Emergency Services See details
Emergency services are partially covered by WellSense Choice (HMO), excluding worldwide emergency transportation. Covered emergency care carries a $150 copay and no coinsurance (waived if admitted within 24 hours), while urgently needed care requires a $65 copay and no coinsurance, with worldwide coverage limited to $50,000.
Primary Care See details
WellSense Choice (HMO) covers primary care physician services with no copay and no coinsurance, and specialist visits with a $35 copay and no coinsurance. Therapy, mental health, and select chiropractic services require copays ranging from $20 to $80 with no coinsurance, while routine chiropractic and podiatry services are not covered.
Preventive Services See details
Preventive services are covered by WellSense Choice (HMO) with no copay and no coinsurance for annual physical exams, kidney education, and select screenings. Additional preventive services are partially covered, providing remote access technologies with no copay or coinsurance, while benefits such as fitness programs, health education, and weight management are not covered.
Hearing Services See details
WellSense Choice (HMO) hearing services are partially covered, offering routine hearing exams for a $35 copay and no coinsurance with no deductible, and up to two prescription hearing aids per year for a $699 to $999 copay and no coinsurance. Over-the-counter (OTC) hearing aids, along with inner ear, outer ear, and over the ear prescription hearing aids, are not covered.
Vision Services See details
Vision services are partially covered by WellSense Choice (HMO), featuring routine eye exams with a $35 copay and no coinsurance, while other eye exam services are not covered. Eyewear, including contact lenses, eyeglasses, and upgrades, is covered with no copay and no coinsurance.
Dental Services See details
WellSense Choice (HMO) partially covers dental services, offering Medicare-covered dental for a $35 copay and no coinsurance, alongside preventive care with no copay and no coinsurance. Comprehensive services like restorative care and oral surgery are covered with no copay and a 50% coinsurance up to a $4,000 annual limit, while maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home infusion bundled services are covered by WellSense Choice (HMO) with no copay, though prior authorization and step therapy may apply. Under this benefit, Medicare Part B insulin has a $35 copay and no coinsurance, while chemotherapy and other Part B drugs carry a 0% to 20% coinsurance.
Dialysis Services See details
Dialysis Services are covered under the WellSense Choice (HMO) plan with no copay and a 20% coinsurance.
Medical Equipment See details
Medical equipment is covered by WellSense Choice (HMO) with no copay, though prior authorization is required. Most covered items, including durable medical equipment, prosthetics, and diabetic shoes, require a 20% coinsurance, while diabetic supplies carry a coinsurance ranging from 0% to 20%.
Diagnostic and Radiological Services See details
Diagnostic and radiological services are covered by WellSense Choice (HMO) with prior authorization required. Diagnostic tests carry no coinsurance and a copay of $0 to $10, lab services have no copay or coinsurance, and radiological services require a minimum $80 copay for diagnostic radiology, an $80 copay (with coinsurance) for X-rays, and a minimum 20% coinsurance for therapeutic radiology.
Home Health Services See details
WellSense Choice (HMO) covers Home Health Services with no copay and no coinsurance, though prior authorization is required.
Cardiac Rehabilitation Services See details
WellSense Choice (HMO) cardiac rehabilitation services feature no coinsurance, but only some services are covered under the plan. Specifically, cardiac rehabilitation (with a $50 copay), intensive cardiac rehabilitation (with a $65 copay), pulmonary rehabilitation (with a $40 copay), and SET for PAD services (with a $30 copay) are not covered.
Skilled Nursing Facility (SNF) See details
WellSense Choice (HMO) covers Skilled Nursing Facility (SNF) services with no coinsurance, offering no copay for days 1 through 20 and a $218 daily copay for days 21 through 100. Prior authorization is required, and additional days beyond the standard Medicare-covered limit are not covered.
Other Services See details
WellSense Choice (HMO) partially covers other services, offering no copay and no coinsurance for chronic illness meal benefits and over-the-counter (OTC) items up to $50 every three months. Acupuncture is not covered under these benefits.
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