Wellcare No Premium Open (PPO)

WellCare Health Plans, Inc.
Wellcare No Premium Open (PPO) H7175-001 Plan Details
Plan too new to be measured

Wellcare No Premium Open (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by WellCare Health Plans, Inc..
Plan ID: H7175-001.

$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: H7175-001.

WellCare Health Plans, Inc.
Wellcare No Premium Open (PPO) H7175-001 Plan Details
Plan too new to be measured

Wellcare No Premium Open (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by WellCare Health Plans, Inc..
Plan ID: H7175-001.

$0.00
Monthly Premium

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $150
Out of Pocket Max In-Network: $5500
Out-of-Network: 10000
Initial Coverage Limit $4430
Catastrophic Coverage Limit $7,050
Primary Care Doctor Visit
$0 copay

Out-of-Network
$25
Specialty Doctor Visit
$25

Out-of-Network
$50
Inpatient Hospital Care
$350 copay per day for days 1-5 and a $0 copay per day for days 6-90

Out-of-Network
35% of the total cost for days 1-90
Urgent Care
$30

Out-of-Network
$30
Emergency Room Visit
$90

Out-of-Network
$90
Ambulance Transportation
$250

Out-of-Network
$250

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: 30% / Diabetes Self-Management Training: $0 / Diabetic Therapeutic Shoes or Inserts: 30%
Durable Medical Eqipment (DME)
20%

Out-of-Network
30%
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
$0 copay

Out-of-Network
35%
Mental Health Inpatient Care
$350 copay per day for days 1-5 and a $0 copay per day for days 6-90

Out-of-Network
35% of the total cost for days 1-90
Mental Health Outpatient Care
$25 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 $100.00 to $250.00
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $90.00 to $250.00
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $200.00
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
$25 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: $25

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 $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 and comprehensive services up to $1000, 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 for preventive and 20% cost-share for comprehensive services.

Out-of-Network
The dental benefits on this plan include coverage of preventive and comprehensive services up to $1000, 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 $100 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 $100 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 $1000 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 $1000 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.

Prescription Drug Costs and Coverage

The Wellcare No Premium Open (PPO) plan offers the following prescription drug coverage, with an annual drug deductible of $150 (excludes Tiers 1, 2 and 6) per year.

Coverage
Cost
Coverage & Cost
Annual Drug Deductible $150 (excludes Tiers 1, 2 and 6)
Preferred Generic
  • Preferred retail $0.00
  • Standard retail $0.00
  • Preferred mail order $0.00
  • Standard mail order $0.00
Generic
  • Preferred retail $0.00
  • Standard retail $5.00
  • Preferred mail order $0.00
  • Standard mail order $5.00
Select Care Drugs
  • Preferred retail $0.00
  • Standard retail $0.00
  • Preferred mail order $0.00
  • Standard mail order $0.00
Annual Drug Deductible $150 (excludes Tiers 1, 2 and 6)
Preferred Generic
  • Preferred retail $0.00
  • Standard retail $0.00
  • Preferred mail order $0.00
  • Standard mail order $0.00
Generic
  • Preferred retail $0.00
  • Standard retail $10.00
  • Preferred mail order $0.00
  • Standard mail order $10.00
Select Care Drugs
  • Preferred retail $0.00
  • Standard retail $0.00
  • Preferred mail order $0.00
  • Standard mail order $0.00
Annual Drug Deductible $150 (excludes Tiers 1, 2 and 6)
Preferred Generic
  • Preferred retail $0.00
  • Standard retail $0.00
  • Preferred mail order $0.00
  • Standard mail order $0.00
Generic
  • Preferred retail $0.00
  • Standard retail $15.00
  • Preferred mail order $0.00
  • Standard mail order $15.00
Select Care Drugs
  • Preferred retail $0.00
  • Standard retail $0.00
  • Preferred mail order $0.00
  • Standard mail order $0.00