Wellcare Giveback (HMO)

WellCare Health Plans, Inc.
Wellcare Giveback (HMO) H5475-031 Plan Details
3.5 out of 5 stars

Wellcare Giveback (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by WellCare Health Plans, Inc..
Plan ID: H5475-031.

$0.00
Monthly Premium

Wellcare Giveback (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by WellCare Health Plans, Inc..
Plan ID: H5475-031.

WellCare Health Plans, Inc.
Wellcare Giveback (HMO) H5475-031 Plan Details
3.5 out of 5 stars

Wellcare Giveback (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by WellCare Health Plans, Inc..
Plan ID: H5475-031.

$0.00
Monthly Premium

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $480
Out of Pocket Max In-Network: $3450
Out-of-Network: N/A
Initial Coverage Limit $4430
Catastrophic Coverage Limit $7,050
Primary Care Doctor Visit
20%
Specialty Doctor Visit
20%
Inpatient Hospital Care
$1,500 copay per stay
Urgent Care
$65
Emergency Room Visit
$120
Ambulance Transportation
20%

Health Care Services and Medical Supplies

Wellcare Giveback (HMO) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).

Coverage Cost
Chiropractic Services
Medicare Covered Chiropractic Services: 20% per visit
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
Diabetes Supplies: $0 / Diabetes Self-Management Training: $0 / Diabetic Therapeutic Shoes or Inserts: 20%
Durable Medical Eqipment (DME)
20%
Diagnostic Tests, Lab and Radiology Services, and X-Rays
X-Ray Services: $0 / Lab Services: $0. $0 for COVID-related testing. For other services, please refer to the Evidence of Coverage for more information.
Home Health Care
20%
Mental Health Inpatient Care
$2,339 copay per stay
Mental Health Outpatient Care
20% for individual or group
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Coinsurance for Medicare Covered Outpatient Hospital Services 20%
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $120.00
Coinsurance for Medicare Covered Observation Services - Per stay 20%
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Coinsurance for Ambulatory Surgical Center Services 20%
Prior Authorization Required for Ambulatory Surgical Center Services
Prior authorization required
Outpatient Substance Abuse Care
20% for individual or group
Over-the-counter (OTC) Items
$15 every quarter OTC Retail/Catalog. Unused amounts do not carry over to the next month/quarter.
Podiatry Services
Medicare Covered Podiatry Services: 20%
Skilled Nursing Facility Care
$0 copay per day for days 1-20 and a $184 copay per day for days 21-100

Dental Benefits

The following dental services are covered from in-network providers.

Coverage Cost
Dental Care
The dental benefits on this plan include coverage of preventive, diagnostic and non-routine services with no max allowance, including but not limited to cleanings, x-ray(s), oral exams, and fluoride treatments offered at a $0 co-pay.

Vision Benefits

The following vision services are covered from in-network providers.

Coverage Cost
Vision Benefits
The vision benefits on this plan cover Routine Eye exams only

Hearing Benefits

The following hearing services are covered from in-network providers.

Coverage Cost
Hearing Benefits
The hearing benefits on this plan cover hearing exams only

Preventive Services and Health/Wellness Education Programs

The following services are covered from in-network providers.

Coverage Cost
Preventive Services and Health/Wellness Education Programs
Most services offered at $0 cost share, please refer to your Evidence of Coverage for more information.

Prescription Drug Costs and Coverage

The Wellcare Giveback (HMO) plan offers the following prescription drug coverage, with an annual drug deductible of $480 (excludes Tiers 1 and 6) per year.

Coverage
Cost
Coverage & Cost
Annual Drug Deductible $480 (excludes Tiers 1 and 6)
Preferred Generic
  • Preferred retail $0.00
  • Standard retail $0.00
  • Preferred mail order $0.00
  • Standard mail order $0.00
Select Care Drugs
  • Preferred retail $0.00
  • Standard retail $0.00
  • Preferred mail order $0.00
  • Standard mail order $0.00
Annual Drug Deductible $480 (excludes Tiers 1 and 6)
Preferred Generic
  • Preferred retail $0.00
  • Standard retail $0.00
  • Preferred mail order $0.00
  • Standard mail order $0.00
Select Care Drugs
  • Preferred retail $0.00
  • Standard retail $0.00
  • Preferred mail order $0.00
  • Standard mail order $0.00
Annual Drug Deductible $480 (excludes Tiers 1 and 6)
Preferred Generic
  • Preferred retail $0.00
  • Standard retail $0.00
  • Preferred mail order $0.00
  • Standard mail order $0.00
Select Care Drugs
  • Preferred retail $0.00
  • Standard retail $0.00
  • Preferred mail order $0.00
  • Standard mail order $0.00