Wellpoint Medicare Advantage (HMO-POS) Medicare Advantage Plan H5828-013 • 2026 • Clay County, TN

Wellpoint Medicare Advantage Overview

Plan Details for Wellpoint Medicare Advantage

This Medicare Advantage Prescription Drug (MAPD) HMO-POS plan includes hospital, medical, and prescription drug coverage under Medicare Parts A and B. The monthly premium is $19.00, and the plan provides coverage through a network of participating providers, with limited access to out-of-network services in certain situations. The annual Part D deductible is $200.00.

Primary care visits have a $0 copay | Out-of-network: $30 copay, specialist visits come with a $45 copay | Out-of-network: $50 copay, urgent care services carry a $30 copay, and ambulance transportation is $325 copay | Out-of-network: $325 copay. These costs apply toward the maximum out-of-pocket (MOOP) limit of $6750.00. Once this limit is reached, in-network services are fully covered for the remainder of the year.

This plan is listed by CMS under Plan ID H5828-013. Cost-sharing details are provided below.

Cost Sharing Expenses

Wellpoint Medicare Advantage has cost-sharing, meaning there are out-of-pocket costs when receiving covered healthcare services. The table below details the most common in-network out-of-pocket expenses for plan H5828-013.

Certain preventive services are covered 100% by Wellpoint Medicare Advantage as a Part B benefit.

Prescription Drug Coverage

Wellpoint Medicare Advantage includes a Medicare Part D prescription drug plan (PDP). Plan type and coverage level are defined by CMS and may vary between basic and enhanced benefit designs.

This plan includes an enhanced benefit Medicare Part D plan (PDP), providing coverage beyond the standard CMS-defined minimum.

Prescription Drug Plan Premium

The Part D prescription drug plan premium is included in the overall Medicare Special Needs Plan cost. Additional adjustments may apply through the Low-Income Subsidy (LIS) program, also known as Extra Help, administered by Social Security. LIS benefits are separate from Medicare Special Needs Plan coverage.

For more details, visit the Social Security Extra Help program .

Prescription Drug Plan Deductible

This plan has a $200.00 annual Part D deductible. You'll pay this deductible at the pharmacy before Wellpoint starts contributing towards your prescription costs.

Prescription Drug Plan Out-of-Pocket Costs

Beyond premiums and deductibles, Wellpoint Medicare Advantage may have additional costs at pharmacies. The table below outlines out-of-pocket expenses by drug tier.

Medicare Plan Star Ratings

Medicare Advantage (Part C) and Part D plans are rated each year by CMS on a 5-star scale. Ratings summarize plan performance across clinical care and member experience measures.