Wellcare Patriot No Premium Open (PPO)
Wellcare Patriot No Premium Open (PPO) H7175-005 Plan Details
Wellcare Patriot No Premium Open (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by WellCare Health Plans, Inc..
Plan ID: H7175-005.
$0.00
Monthly Premium
Wellcare Patriot No Premium Open (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by WellCare Health Plans, Inc..
Plan ID: H7175-005.
Wellcare Patriot No Premium Open (PPO) H7175-005 Plan Details
Wellcare Patriot No Premium Open (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by WellCare Health Plans, Inc..
Plan ID: H7175-005.
$0.00
Monthly Premium
North Carolina Counties Served
Alamance
Alexander
Alleghany
Anson
Avery
Bladen
Buncombe
Durham
Franklin
Wake
Ashe
Burke
Cabarrus
Caldwell
Caswell
Catawba
Chatham
Clay
Cleveland
Columbus
Cumberland
Davidson
Davie
Duplin
Forsyth
Gaston
Graham
Granville
Greene
Guilford
Harnett
Haywood
Henderson
Hoke
Iredell
Jackson
Johnston
Lee
Lincoln
Macon
Madison
Mcdowell
Mecklenburg
Mitchell
Montgomery
Moore
Nash
Orange
Person
Polk
Randolph
Richmond
Robeson
Rockingham
Rowan
Rutherford
Sampson
Scotland
Stanly
Stokes
Surry
Swain
Transylvania
Union
Vance
Warren
Watauga
Wilkes
Wilson
Yadkin
Yancey
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $-1 |
| Out of Pocket Max |
In-Network: $6500 Out-of-Network: N/A |
| Initial Coverage Limit | $0 |
| Catastrophic Coverage Limit | $7,400 |
| Primary Care Doctor Visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0.00 Out-of-Network: Doctor Office Visit: Copayment for Medicare Covered Primary Care Office Visit $0.00 |
| Specialty Doctor Visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $40.00 Prior Authorization Required for Doctor Specialty Visit Prior authorization required Out-of-Network: Doctor Specialty Visit: Copayment for Medicare Covered Physician Specialist Office Visit $40.00 |
| Inpatient Hospital Care | In-Network: Acute Hospital Services: $325.00 per day for days 1 to 5 $0.00 per day for days 6 to 90 Prior Authorization Required for Acute Hospital Services Prior authorization required Out-of-Network: 35% per day for days 1 to 90 |
| Urgent Care | Copayment for Urgent Care $30.00 Copayment for Medicare Covered Urgent Care waived if you are admitted to hospital within 24 hours Worldwide Coverage: Copayment for Worldwide Urgent Coverage $95.00 Maximum Plan Benefit of $50,000 |
| Emergency Room Visit | Copayment for Emergency Care $95.00 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $95.00 Maximum Plan Benefit of $50,000 |
| Ambulance Transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $250.00 Air Ambulance: Copayment for Air Ambulance Services $250.00 Please see Evidence of Coverage for Prior Authorization rules Prior authorization required Out-of-Network: Ambulance Services: Copayment for Medicare Covered Ambulance Services - Ground $250.00 Copayment for Medicare Covered Ambulance Services - Air $250.00 |
Health Care Services and Medical Supplies
Wellcare Patriot 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 | In-Network: Copayment for Medicare-covered Chiropractic Services $20.00 Prior Authorization Required for Chiropractic Services Prior authorization required Out-of-Network: Copayment for Medicare Covered Chiropractic Services $20.00 |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network: Copayment for Medicare-covered Diabetic Supplies $0.00 Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20% Prior Authorization Required for Diabetic Supplies and Services Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage) Prior authorization required Out-of-Network: Coinsurance for Medicare Covered Diabetic Supplies and Services 20% to 35% |
| Durable Medical Eqipment (DME) | In-Network: Coinsurance for Medicare-covered Durable Medical Equipment 20% Prior Authorization Required for Durable Medical Equipment Prior authorization required Out-of-Network: Coinsurance for Medicare Covered Durable Medical Equipment 20% to 35% |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | In-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare-covered Diagnostic Procedures/Tests $0.00 to $75.00 Copayment for Medicare-covered Lab Services $0.00 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $0.00 to $200.00 Coinsurance for Medicare-covered Therapeutic Radiological Services 20% Copayment for Medicare-covered X-Ray Services $0.00 Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services Prior authorization required Out-of-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare Covered Diagnostic Procedures/Tests $0.00 to $350.00 Copayment for Medicare Covered Lab Services $0.00 Copayment for Medicare Covered Diagnostic Radiological Services $0.00 to $350.00 Coinsurance for Medicare Covered Therapeutic Radiological Services 20% to 35% Copayment for Medicare Covered Outpatient X-Ray Services $0.00 |
| Home Health Care | In-Network: Copayment for Medicare-covered Home Health Services $0.00 Prior Authorization Required for Home Health Services Prior authorization required Out-of-Network: Copayment for Medicare Covered Home Health $0.00 |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: $370.00 per day for days 1 to 5 $0.00 per day for days 6 to 90 Prior Authorization Required for Psychiatric Hospital Services Prior authorization required Out-of-Network: 35% per day for days 1 to 90 |
| Mental Health Outpatient Care | In-Network: Copayment for Medicare-covered Individual Sessions $25.00 Copayment for Medicare-covered Group Sessions $25.00 Prior Authorization Required for Outpatient Mental Health Services Prior authorization required Out-of-Network: Copayment for Medicare Covered Individual Sessions $25.00 Copayment for Medicare Covered Group Sessions $25.00 |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $200.00 to $350.00 Prior Authorization Required for Outpatient Hospital Services Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $95.00 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 Out-of-Network: Outpatient Hospital and ASC Services: Copayment for Medicare Covered Outpatient Hospital Services $0.00 to $350.00 Copayment for Medicare Covered Ambulatory Surgical Center Services $250.00 |
| Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $25.00 Copayment for Medicare-covered Group Sessions $25.00 Prior Authorization Required for Outpatient Substance Abuse Services Prior authorization required Out-of-Network: Copayment for Medicare Covered Individual or Group Sessions $25.00 |
| Over-the-counter (OTC) Items | In-Network: Over-The-Counter (OTC) Items: Copayment for Over-The-Counter (OTC) Items $0.00 Maximum Plan Benefit of $50.00 every three months Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit Out-of-Network: Over-The-Counter (OTC) Items: Copayment for Non-Medicare Covered Over-The-Counter (OTC) Items $0.00 Maximum Plan Benefit of $50.00 |
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $40.00 Prior Authorization Required for Podiatry Services Prior authorization required Out-of-Network: Copayment for Medicare Covered Podiatry Services $40.00 |
| Skilled Nursing Facility Care | In-Network: Skilled Nursing Facility Services: $0.00 per day for days 1 to 20 $196.00 per day for days 21 to 60 $0.00 per day for days 61 to 100 Prior Authorization Required for Skilled Nursing Facility Services Prior authorization required Out-of-Network: 35% per day for days 1 to 100 |
Dental Benefits
The following dental services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Dental Care | In-Network: Preventive Dental: Copayment for Oral Exams $0.00
Comprehensive Dental: Copayment for Medicare-covered Benefits $40.00 Coinsurance for Non-routine Services 40%
Prior Authorization Required for Comprehensive Dental Prior authorization required Out-of-Network: Medicare Covered Dental Services: Copayment for Medicare Covered Comprehensive Dental $40.00 Non-Medicare Covered Dental Services: Coinsurance for Non-Medicare Covered Preventive Dental 70% Coinsurance for Non-Medicare Covered Comprehensive Dental 70% |
Vision Benefits
The following vision services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Vision Benefits | In-Network: Eye Exams: Copayment for Medicare Covered Benefits $0.00 to $40.00 Copayment for Routine Eye Exams $0.00
Eyewear: Copayment for Medicare-Covered Benefits $0.00 Maximum Plan Allowance of $200.00 every year for all Non-Medicare covered eyewear for in and out of network services combined Prior Authorization Required for Eyewear Prior authorization required Out-of-Network: Medicare Covered Vision Services: Copayment for Medicare Covered Eye Exams $0.00 to $350.00 Copayment for Medicare Covered Eyewear $40.00 Non-Medicare Covered Vision Services: Coinsurance for Non-Medicare Covered Eye Exams 40% Coinsurance for Non-Medicare Covered Eyewear 40% |
Hearing Benefits
The following hearing services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Hearing Benefits | In-Network: Hearing Exams: Copayment for Medicare Covered Benefits $40.00 Copayment for Routine Hearing Exams $0.00
Hearing Aids: Copayment for Hearing Aids $0.00
Prior Authorization Required for Hearing Aids Prior authorization required Out-of-Network: Medicare Covered Hearing Services: Copayment for Medicare Covered Hearing Exams $40.00 Non-Medicare Covered Hearing Services: Coinsurance for Non-Medicare Covered Hearing Exams 40% Coinsurance for Non-Medicare Covered Hearing Aids 40% |
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 | In-Network: $0.00 copay for Medicare Covered Preventive Services: Abdominal aortic aneurysm screening Alcohol misuse screenings & counseling Bone mass measurements (bone density) Cardiovascular disease screenings Cardiovascular disease (behavioral therapy) Cervical & vaginal cancer screening Colorectal cancer screenings Depression screenings Diabetes screenings Diabetes self-management training Glaucoma tests Hepatitis B (HBV) infection screening Hepatitis C screening test HIV screening Lung cancer screening Mammograms (screening) Nutrition therapy services Obesity screenings & counseling One-time Welcome to Medicare preventive visit Prostate cancer screenings(PSA) Sexually transmitted infections screening & counseling Shots:
Yearly "Wellness" visit Out-of-Network: Medicare-covered Zero Dollar Preventive Services: Copayment for Medicare Covered Medicare-covered Preventive Services $0.00 |
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