2015 Piedmont WellStar Medicare Choice (HMO) Benefits

The Piedmont WellStar Medicare Choice (HMO) Plan is a Medicare Advantage health plan designed to help you stay well and live better. In addition to all Original Medicare services, Piedmont WellStar Medicare Choice (HMO) includes additional benefits, health services, and tools to help you maintain the healthy life you deserve.

Our Medicare Advantage HMO Plan offers:

  • Comprehensive annual physical exam
  • Routine vision care and allowance for eyeglasses/contact lenses
  • Routine dental care
  • Silver&Fit Exercise & Healthy Aging program
  • Care advisory services to coordinate care
  • Nurse advice line available 24 hours a day, seven days a week
  • Prescription Drug coverage for brand name and generic drugs

Some of the most important plan benefits and copay details for Piedmont WellStar Medicare Choice (HMO) are highlighted in the table below.

Medicare Advantage Plan Benefit
Piedmont WellStar Medicare Choice (HMO)
Monthly Plan Premium
$0 in addition to your Medicare Part B premium
Annual Out-of-Pocket Maximum
The total amount you will have to pay each year for copays and coinsurance for covered services that you receive at in-network providers.
$3,900 for all Medicare-covered charges
Primary Care and Specialty Physician Visits
$5 for each primary care physician visit
$40 for each specialist visit
Urgent Care
$40 for each visit
Emergency Care
$65 for each visit
Inpatient Hospital and Inpatient Mental Health Care
$225 per day (days 1-7) / Acute
$215 per day (days 1-7) / Mental Health
Skilled Nursing Facility (SNF)
$0 each day (days 1-20)
$150 each day (days 21-100)
Outpatient Rehabilitation
$40 for each visit
Outpatient Surgery
$200 for each procedure
Ambulatory Surgery Center (ASC)
$150 for each visit
Durable Medical Equipment
20% of the cost of each item
Diabetes Supplies
20% of the cost for diabetes supplies
Lab Services, X-rays and Advanced Imaging
$0 for lab services;
$15 copay for general X-rays or ultra-sound;
$125 copay for Medicare-covered diagnostic and therapeutic radiology services
Preventive Services
$0 for annual wellness exam, routine physical exam, immunizations (e.g., flu and pneumonia), and preventive screenings, including mammograms, Pap, pelvic, prostate, colorectal exams and bone mass measurement.
Routine Vision
$0 for one routine eye exam per year
$100 allowance toward the cost of glasses or contacts per year
Routine Dental
$0 for routine oral exam and cleaning every six months
$0 for one fluoride treatment per year
$0 for one X-ray per year
Membership at a local participating fitness facility
Nurse Advice Line
Free access to healthcare advice and information from registered nurses, 24 hours a day, 7 days a week
Care Advisory Services
Free support to coordinate care for complex health conditions
You must continue to pay your Part B premium. Not all benefits are listed. For complete benefit information, please see the Summary of Benefits. Learn more about about our additional benefits (fitness, dental, and vision). To find plan providers, search our Directory of Piedmont WellStar Medicare Choice (HMO) Doctors and Locations.

Piedmont WellStar Medicare Choice (HMO) Pharmacy Benefits

A prescription drug formulary is a list of drugs a Medicare Advantage plan covers. The Piedmont WellStar Medicare Choice formulary includes thousands of brand name and generic prescription drug medications. Piedmont WellStar Medicare Choice gives you access to a large network of retail chain and independent pharmacies.

In-Network Retail Pharmacy / Mail-Order Pharmacy Benefits
Prescription Drug Level (Tier)
30 day supply
90 day supply
Preferred Generic Drugs
Non‐preferred Generic Drugs
Preferred Brand Drugs
Non‐preferred Brand Drugs
Specialty Drugs
33% of the cost
Not Available
Coverage Gap: After your total yearly drug costs reach $2,960, you will pay 65% of the costs for generic drugs. You will receive a discount on brand-name drugs and generally pay no more than 45% (plus dispensing fee).

You pay your normal copay ($3 for 30 day supply) for preferred generic drugs.
Catastrophic Coverage: After your yearly out-of-pocket drug costs reach $4,700, you pay the greater of:

- $2.65 copay for generic drugs (including brand drugs treated as generic)
- $6.60 copay for all other drugs
- Or 5% of the cost

Piedmont WellStar Medicare Choice is a Medicare Advantage HMO organization with a Medicare Contract. Enrollment in Piedmont WellStar Medicare Choice depends on contract renewal.

The benefit information provided is a brief summary, not a complete description of benefits. For more information, contact the plan. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, provider network, premium and/or copayments/coinsurance] may change on January 1 of each year.

*Our hours of operation change throughout the year. We are available to take your call: Oct. 1 through Feb. 14 Monday through Sunday: 8 a.m. to 8 p.m., and Feb.15 through Sept. 30 Monday through Friday: 8 a.m. to 8 p.m. and Saturday: 8 a.m. to 3 p.m.