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WellSense Premium Savings (HMO)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for WellSense Premium Savings (HMO). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on WellSense Premium Savings (HMO) in 2025, please refer to our full plan details page.
This summary reflects 2025 plan information. Where this plan continues in 2027, the full plan details page links to its 2027 benefits and costs.
WellSense Premium Savings (HMO) is a HMO plan offered by BMC Health System, Inc. available for the 2025 plan year to people living in All Counties_Premium Savings. This plan received an overall rating of 2.5 out of 5 stars in 2025.
It's important to know that WellSense 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 WellSense 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 WellSense 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 $50.00. You must continue to pay paying your reduced Part B Premium.
Deductibles
Health deductible: information not available.
This plan has a $295.00 drug deductible that applies only to drugs in certain tiers. You pay this amount toward covered prescriptions in those tiers before the plan's cost sharing begins; drugs in the other tiers are not subject to the deductible. See the full plan details page for the tier table.
Out-of-Pocket Maximums
This plan has a Maximum Out-Of-Pocket cost of $4900.00 for in-network services. You will pay copays, coinsurance, and deductibles toward this amount. Once your out-of-pocket costs reach $4900.00 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 Premium Savings (HMO) plan has a $295 deductible for prescription drugs. After the deductible, you'll pay a copay or coinsurance depending on the drug tier and pharmacy. For example, in the initial coverage phase, you may pay $10 for preferred generic drugs at a standard pharmacy, or 29% coinsurance for non-preferred drugs. Once your total drug costs reach $2,000, you enter the catastrophic coverage phase, where you will pay nothing for covered drugs. If you qualify for the low-income subsidy, you will have no copay for Part D drugs.
Additional Benefits
The WellSense Premium Savings (HMO) plan offers a range of benefits, including inpatient hospital stays with copays, outpatient services with varying copays, and coverage for emergency services. This plan also includes coverage for primary care visits with no copay, along with benefits for hearing, vision, and dental services with copays and coinsurance. Additional benefits include home health services with no copay, and skilled nursing facility (SNF) stays with no copay for the first 20 days. The plan covers a variety of services, but it is important to note that certain services are not covered, such as some home-based services, and specific services like podiatry and maxillofacial prosthetics.
Inpatient Hospital See details
Inpatient Hospital benefits include coverage for Inpatient Hospital-Acute and Inpatient Hospital Psychiatric services. For Inpatient Hospital-Acute, there is a $425 copay for days 1-6, and no copay for days 7-90. For Inpatient Hospital Psychiatric, there is a $380 copay for days 1-6, and no copay for days 7-90.
Outpatient Services See details
Outpatient services include coverage for all outpatient hospital services, with a copay ranging from $0 to $410, and observation services with a $425 copay. Ambulatory surgical center services have a $300 copay, and outpatient substance abuse services, including individual and group sessions, have a copay of $45. Outpatient blood services are not covered.
Partial Hospitalization See details
Partial hospitalization is covered by the WellSense Premium Savings (HMO) plan, but prior authorization is required. The copay for partial hospitalization is $105.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the WellSense Premium Savings (HMO) plan, with all ambulance services requiring prior authorization. Ground ambulance services have a $295 copay, while air ambulance services have a 50% coinsurance, and transportation services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Coverage are covered by the WellSense Premium Savings (HMO) plan. Emergency Services have a $125 copay, Urgently Needed Services have a $55 copay, and Worldwide Emergency Coverage has a $125 copay; all services have no coinsurance. Worldwide Emergency Transportation is not covered.
Primary Care See details
The WellSense Premium Savings (HMO) plan covers primary care physician services with no copay, and chiropractic services with a $20 copay. Occupational therapy services have a $45 copay, and physician specialist services have a $50 copay. Individual and group sessions for mental health and psychiatric services have a $60 copay. Physical therapy and speech-language pathology services have a $65 copay, and other health care professional services have a copay between $0 and $65. Opioid Treatment Program Services have a copay between $0 and $60. Podiatry services are not covered.
Preventive Services See details
The WellSense Premium Savings (HMO) plan covers preventive services, including Medicare-covered services with prior authorization, annual physical exams, and additional preventive services, but does not cover health education, in-home safety assessments, personal emergency response systems, medical nutrition therapy, post-discharge in-home medication reconciliation, re-admission prevention, wigs for hair loss related to chemotherapy, weight management programs, alternative therapies, therapeutic massage, adult day health services, nutritional/dietary benefits, home-based palliative care, in-home support services, support for caregivers of enrollees, additional sessions of smoking and tobacco cessation counseling, enhanced disease management, telemonitoring services, home and bathroom safety devices and modifications, and counseling services. Additional services covered include fitness benefits, remote access technologies, kidney disease education services, glaucoma screenings, diabetes self-management training, barium enemas, digital rectal exams, and EKGs following a welcome visit.
Hearing Services See details
Hearing Services include coverage for hearing exams with a $50 copay, and prescription hearing aids with a copay between $699 and $999. Routine hearing exams are covered once per year, and fitting/evaluation for hearing aids is covered. Prescription hearing aids are limited to 2 per year. OTC hearing aids, and prescription hearing aids for the inner ear, outer ear, and over the ear are not covered.
Vision Services See details
Vision services include coverage for eye exams with a $50 copay. Eyewear benefits include a combined maximum of $150 per year, while contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades are also covered.
Dental Services See details
Dental Services includes coverage for Medicare dental services with a $50 copay, and for other dental services, including oral exams, dental x-rays, other diagnostic services, cleaning, and fluoride treatment. Orthodontic services are covered up to a maximum of $1500 per year, and restorative, adjunctive general, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery services are covered with 50% coinsurance. Maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered under the WellSense Premium Savings (HMO) plan, with a $35 copay for Medicare Part B Insulin Drugs. Other Medicare Part B drugs and Chemotherapy/Radiation Drugs may have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered with a coinsurance between 20% and 20%.
Medical Equipment See details
Medical Equipment is covered, including Durable Medical Equipment (DME) with 20% coinsurance, Prosthetics/Medical Supplies with 20% coinsurance, and Diabetic Equipment. Durable Medical Equipment for use outside the home is not covered.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including Diagnostic Procedures/Tests, Lab Services, and Radiological Services. Diagnostic Procedures/Tests have a copay between $0 and $10, Lab Services have no copay, Diagnostic Radiological Services have a copay between $80 and $350, Therapeutic Radiological Services have 20% coinsurance, and Outpatient X-Ray Services have a $80 copay.
Home Health Services See details
Home Health Services are covered by the WellSense Premium Savings (HMO) plan with no copay and no coinsurance, but additional hours of care and personal care services are not covered. Authorization is required for this benefit.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered by the WellSense Premium Savings (HMO) plan, but the plan does not cover any of the specific sub-services. There is a copay for the services, but the amount is not specified.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the WellSense Premium Savings (HMO) plan, with prior authorization required. There is no copay for days 1-20, and a $214 copay for days 21-100. Additional days beyond Medicare-covered and non-Medicare-covered stays for SNF are not covered.
Other Services See details
Other Services are not covered by the WellSense Premium Savings (HMO) plan, including acupuncture, over-the-counter items, 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. However, the plan covers a meal benefit for chronic illnesses.
Plan Providers
Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross and Blue Shield, Aspire Health Plan, Dean Health Plan, Devoted Health, Florida Blue Medicare, Freedom Health, Health Care Service Corporation, HealthSpringSM, HealthSun, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Medica Central Health Plan, Optimum HealthCare, Premera Blue Cross, SCAN Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint.
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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.
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