Wellcare 'Ohana No Premium (HMO)

WellCare Health Plans, Inc.
Wellcare 'Ohana No Premium (HMO) H2491-015 Plan Details
3 out of 5 stars

Wellcare 'Ohana No Premium (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Aetna.
Plan ID: H2491-015.

$0.00
Monthly Premium

Wellcare 'Ohana No Premium (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Aetna.
Plan ID: H2491-015.

WellCare Health Plans, Inc.
Wellcare 'Ohana No Premium (HMO) H2491-015 Plan Details
3 out of 5 stars

Wellcare 'Ohana No Premium (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Aetna.
Plan ID: H2491-015.

$0.00
Monthly Premium

Hawaii Counties Served

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $200
Out of Pocket Max In-Network: $6700
Out-of-Network: N/A
Initial Coverage Limit $4430
Catastrophic Coverage Limit $7,050
Primary Care Doctor Visit
$0 copay
Specialty Doctor Visit
$35
Inpatient Hospital Care
$350 copay per day for days 1-5 and a $0 copay per day for days 6-90
Urgent Care
$65
Emergency Room Visit
$90
Ambulance Transportation
$250

Health Care Services and Medical Supplies

Wellcare 'Ohana No Premium (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
$0 copay
Mental Health Inpatient Care
$350 copay per day for days 1-5 and a $0 copay per day for days 6-90
Mental Health Outpatient Care
$25 for individual or group
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $350.00
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $90.00 to $350.00
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
Outpatient Substance Abuse Care
$25 for individual or group
Over-the-counter (OTC) Items
$125 every quarter OTC Retail/Catalog. Unused amounts do not carry over to the next month/quarter.
Podiatry Services
Medicare Covered Podiatry Services: $35
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 and comprehensive services up to $2000, 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.

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

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 $2000 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.

Prescription Drug Costs and Coverage

The Wellcare 'Ohana No Premium (HMO) plan offers the following prescription drug coverage, with an annual drug deductible of $200 (excludes Tiers 1, 2 and 6) per year.

Coverage
Cost
Coverage & Cost
Annual Drug Deductible $200 (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 $10.00
  • Standard retail $15.00
  • Preferred mail order $10.00
  • 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
Annual Drug Deductible $200 (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 $20.00
  • Standard retail $30.00
  • Preferred mail order $20.00
  • Standard mail order $30.00
Select Care Drugs
  • Preferred retail $0.00
  • Standard retail $0.00
  • Preferred mail order $0.00
  • Standard mail order $0.00
Annual Drug Deductible $200 (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 $30.00
  • Standard retail $45.00
  • Preferred mail order $0.00
  • Standard mail order $45.00
Select Care Drugs
  • Preferred retail $0.00
  • Standard retail $0.00
  • Preferred mail order $0.00
  • Standard mail order $0.00