Wellcare No Premium Open (PPO)
Wellcare No Premium Open (PPO) H6713-001 Plan Details
Wellcare No Premium Open (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by WellCare Health Plans, Inc..
Plan ID: H6713-001.
$0.00
Monthly Premium
Wellcare No Premium Open (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by WellCare Health Plans, Inc..
Plan ID: H6713-001.
Wellcare No Premium Open (PPO) H6713-001 Plan Details
Wellcare No Premium Open (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by WellCare Health Plans, Inc..
Plan ID: H6713-001.
$0.00
Monthly Premium
Illinois Counties Served
Bond
Boone
Brown
Bureau
Calhoun
Cass
Champaign
Clark
Coles
Cook
Cumberland
De Witt
DeKalb
Douglas
DuPage
Edgar
Effingham
Ford
Fulton
Greene
Grundy
Hancock
Henderson
Henry
Iroquois
Jasper
Jersey
Kane
Kankakee
Kendall
Knox
La Salle
Lee
Livingston
Logan
Macoupin
Madison
Marshall
Mason
McHenry
McLean
Mercer
Monroe
Morgan
Moultrie
Ogle
Peoria
Piatt
Pike
Putnam
Rock Island
Schuyler
Scott
Shelby
Stark
Stephenson
Tazewell
Vermilion
Warren
Whiteside
Will
Winnebago
Woodford
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $0 |
| Out of Pocket Max |
In-Network: $3450 Out-of-Network: 5150 |
| Initial Coverage Limit | $4430 |
| Catastrophic Coverage Limit | $7,050 |
| Primary Care Doctor Visit | $0 copay Out-of-Network $20 |
| Specialty Doctor Visit | $30 Out-of-Network $50 |
| Inpatient Hospital Care | $350 copay per day for days 1-6 and a $0 copay per day for days 7-90 Out-of-Network 35% of the total cost for days 1-90 |
| Urgent Care | $0 copay Out-of-Network $0 copay |
| Emergency Room Visit | $120 Out-of-Network $120 |
| Ambulance Transportation | $350 Out-of-Network $350 |
Health Care Services and Medical Supplies
Wellcare No Premium Open (PPO) 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 Out-of-Network Medicare Covered Chiropractic Services: 35% per visit |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | Diabetes Supplies: $0 / Diabetes Self-Management Training: $0 / Diabetic Therapeutic Shoes or Inserts: 20% Out-of-Network Diabetes Supplies: 35% / Diabetes Self-Management Training: $0 / Diabetic Therapeutic Shoes or Inserts: 35% |
| Durable Medical Eqipment (DME) | 20% Out-of-Network 35% |
| 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. Out-of-Network X-Ray Services: 35% / Lab Services: 35%. $0 for COVID-related testing. For other services, please refer to the Evidence of Coverage for more information. |
| Home Health Care | 20% Out-of-Network 35% |
| Mental Health Inpatient Care | $350 copay per day for days 1-6 and a $0 copay per day for days 7-90 Out-of-Network 35% of the total cost for days 1-90 |
| Mental Health Outpatient Care | $40 for individual or group Out-of-Network 35% for individual or group |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $300.00 Prior Authorization Required for Outpatient Hospital Services Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $120.00 to $300.00 Prior Authorization Required for Outpatient Observation Services Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $250.00 Prior Authorization Required for Ambulatory Surgical Center Services Prior authorization required Out-of-Network: Outpatient Hospital and ASC Services: Coinsurance for Medicare Covered Outpatient Hospital Services 35% Coinsurance for Medicare Covered Ambulatory Surgical Center Services 35% |
| Outpatient Substance Abuse Care | $40 for individual or group Out-of-Network 35% for individual or group |
| Over-the-counter (OTC) Items | $70 every quarter OTC Retail/Catalog. Unused amounts do not carry over to the next month/quarter. Out-of-Network $70 every quarter OTC Retail/Catalog. Unused amounts do not carry over to the next month/quarter. |
| Podiatry Services | Medicare Covered Podiatry Services: $30 Out-of-Network Medicare Covered Podiatry Services: $50 |
| Skilled Nursing Facility Care | $0 copay per day for days 1-20 and a $184 copay per day for days 21-100 Out-of-Network $0 copay per day for days 1-20 and a $250 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 and comprehensive services up to $3000, including but not limited to cleanings, x-ray(s), oral exams, fluoride treatments, fillings, dentures or a bridge or a crown and a root canal with a $0 member co-pay. Out-of-Network The dental benefits on this plan include coverage of preventive and comprehensive services up to $3000, including but not limited to cleanings, x-ray(s), oral exams, fluoride treatments, fillings, dentures or a bridge or a crown and a root canal with a 50% member cost-share. |
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 and up to $300 for unlimited contacts, glasses, lenses, and/or frames per year Out-of-Network The vision benefits on this plan cover routine eye exams and up to $300 with a 40% coinsurance for all services and eyewear received OON, for unlimited contacts, glasses, lenses, and/or frames per year |
Hearing Benefits
The following hearing services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Hearing Benefits | The hearing benefits on this plan include, but are not limited to, an annual exam, hearing aid fitting and evaluation, and up to $1,500 a year towards hearing aids A maximum of one hearing aid per ear will apply Out-of-Network The hearing benefits on this plan include, but are not limited to, an annual exam, hearing aid fitting and evaluation with a 40% coinsurance OON, and up to $1,500 a year towards hearing aids A maximum of one hearing aid per ear will apply |
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. Out-of-Network Most services offered at $0 cost share, please refer to your Evidence of Coverage for more information. |
