WellSense Signature Access (PPO)

New Hampshire Medicare Advantage Plan (2025 Plan)

Monthly Premium

Your Cost

by WellSense Health Plan

Additional Coverage

HearingVisionDental

Overall Government Star Rating

(coming soon)

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Plan Name

WellSense Signature Access (PPO)

Insurance Carrier

WellSense Health Plan

Plan Type

Medicare Advantage Plan With Part D Prescription Drug Coverage

Network Type

PPO

WellSense Signature Access (PPO) is a Medicare Advantage Plan With Part D Prescription Drug Coverage, which is available in New Hampshire and offered by the health insurance company WellSense Health Plan. This plan’s network type is PPO which determines in-network doctors who accept the health plan and whether a referral is needed.

Monthly Premium

Annual Deductible

Max Out-of-Pocket

$4,900

Primary doctor visit

$0 copay

Specialist visit

$30 copay per visit

ER visit

$125 copay per visit (always covered)

Ambulance

$295 copay

WellSense Signature Access (PPO) has a monthly premium cost of $0 per month, with an annual deductible of $0 and a maximum out of pocket cost sharing of $9,900 In and Out-of-network $4,900 In-network. The most common benefit costs which people evaluate when choosing a plan are costs for a primary doctor visit, specialist doctor visit, emergency room visit, and ambulance. These costs are listed in this summary section and a full list of benefit costs for WellSense Signature Access (PPO) are defined below.

Yes

Part D Prescription Drug Coverage

Yes

Dental

Yes

Vision

Yes

Hearing

WellSense Signature Access (PPO) is a Medicare Advantage plan which does include Medicare Part D Prescription Drug coverage. Other common benefits included with Medicare Advantage plans are coverage for dental, vision, and hearing. WellSense Signature Access (PPO) includes coverage for hearing, vision, dental.

Medicare Advantage health plans can offer even more additional benefits. WellSense Signature Access (PPO) includes coverage for the following additional benefits:

Other benefits

Fitness benefit

Limited coverage

Over the counter drug benefits

Limited coverage

In-home support services

Not covered

Home and bathroom safety devices

Not covered

Meals for short duration

Limited coverage

Annual physical exams

Limited coverage

Telehealth

Limited coverage

Monthly Premium

Health Portion of Premium

Drug Portion of Premium

Health Plan Deductible

Health Plan Max Out-of-Pocket

$9,900 In and Out-of-network
$4,900 In-network

Nationwide Coverage included

Hearing Coverage included

Yes

Vision Coverage included

Yes

Dental Coverage included

Yes

Doctor Lookup Link

http://wellsense.org/medicare

Plan Link

http://wellsense.org/medicare

Doctor Services

Primary doctor visit

In-network: $0 copay
Out-of-network: $20 copay per visit

Specialist visit

In-network: $30 copay per visit
Out-of-network: $50 copay per visit

Tests, labs, & imaging

Diagnostic tests & procedures

In-network: $0-10 copay
Out-of-network: 40% coinsurance

Lab services

In-network: $0-10 copay
Out-of-network: 40% coinsurance

Diagnostic radiology services (like MRI)

In-network: $80-350 copay
Out-of-network: 40% coinsurance

Outpatient x-rays

In-network: $80 copay
Out-of-network: 40% coinsurance

Emergency care

$125 copay per visit (always covered)

Urgent care

$40 copay per visit (always covered)

Hospital Services

Inpatient hospital coverage

In-network: $370 per day for days 1 through 6
$0 per day for days 7 through 90
Out-of-network: 40% per stay

Outpatient hospital coverage

In-network: $0-365 copay per visit
Out-of-network: 40% coinsurance per visit

Skilled nursing facility

In-network: $0 per day for days 1 through 20
$214 per day for days 21 through 100
Out-of-network: 40% per stay

Preventive services

In-network: $0 copay
Out-of-network: 40% coinsurance

Ambulance

Ground ambulance

In-network: $295 copay
Out-of-network: $295 copay

Therapy services

Occupational therapy visit

In-network: $45 copay
Out-of-network: 40% coinsurance

Physical therapy & speech & language therapy visit

In-network: $65 copay
Out-of-network: 40% coinsurance

Mental health services

Outpatient group therapy with a psychiatrist

In-network: $60 copay
Out-of-network: 40% coinsurance

Outpatient individual therapy with a psychiatrist

In-network: $60 copay
Out-of-network: 40% coinsurance

Outpatient group therapy visit

In-network: $60 copay
Out-of-network: 40% coinsurance

Outpatient individual therapy visit

In-network: $60 copay
Out-of-network: 40% coinsurance

Opioid treatment services

Covered

Other services

Durable medical equipment (like wheelchairs & oxygen)

In-network: 20% coinsurance per item
Out-of-network: 40% coinsurance per item

Prosthetics (like braces, artificial limbs)

In-network: 20% coinsurance per item
Out-of-network: 40% coinsurance per item

Diabetes supplies

In-network: 0-20% coinsurance per item
Out-of-network: 40% coinsurance per item

Tier drug costs for: Standard retail pharmacy drug cost for 1-month

Tiers	Initial coverage phase	Catastrophic coverage phase
Preferred Generic	$0.00 copay	$0 copay
Generic	$5.00 copay	$0 copay
Preferred Brand	$47.00 copay	$0 copay
Non-Preferred Drug	$100.00 copay	$0 copay
Specialty Tier	33% coinsurance	$0 copay

Part B Drugs

Chemotherapy drugs

In-network: 0-20% coinsurance
Out-of-network: 40% coinsurance

Other Part B drugs

In-network: 0-20% coinsurance
Out-of-network: 40% coinsurance

Hearing

Hearing exam

In-network: $30 copay
Out-of-network: 40% coinsurance

Fitting/evaluation

In-network: $0 copay
Out-of-network: $0 copay

Hearing aids - All types

In-network: $699-999 copay
Out-of-network: $0 copay

Preventive Dental

Oral exam

In-network: $0 copay
Out-of-network: 30% coinsurance

Cleaning

In-network: $0 copay
Out-of-network: 30% coinsurance

Fluoride treatment

In-network: $0 copay
Out-of-network: 30% coinsurance

Dental x-rays

In-network: $0 copay
Out-of-network: 30% coinsurance