Wellcare Patriot No Premium Open (PPO)

WellCare Health Plans, Inc.
Wellcare Patriot No Premium Open (PPO) H7175-005 Plan Details
Plan too new to be measured

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 Health Plans, Inc.
Wellcare Patriot No Premium Open (PPO) H7175-005 Plan Details
Plan too new to be measured

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

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $-1
Out of Pocket Max In-Network: $5500
Out-of-Network: 10000
Initial Coverage Limit $0
Catastrophic Coverage Limit $7,050
Primary Care Doctor Visit
$0 copay

Out-of-Network
$0 copay
Specialty Doctor Visit
$30

Out-of-Network
$30
Inpatient Hospital Care
$300 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
$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 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
Medicare Covered Chiropractic Services: $20 per visit. $20 / 24 visits every year in addition to Medicare covered.

Out-of-Network
Medicare Covered Chiropractic Services: $20 per visit. $20 / 24 visits every year in addition to Medicare covered.
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: $0 / Diabetes Self-Management Training: $0 / Diabetic Therapeutic Shoes or Inserts: 20%
Durable Medical Eqipment (DME)
20%

Out-of-Network
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.

Out-of-Network
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

Out-of-Network
$0 copay
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
$25 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:
Copayment for Medicare Covered Outpatient Hospital Services $0.00 to $250.00
Copayment for Medicare Covered Ambulatory Surgical Center Services $0.00 to $250.00
Outpatient Substance Abuse Care
$25 for individual or group

Out-of-Network
$25 for individual or group
Over-the-counter (OTC) Items
$60 every quarter OTC Retail/Catalog. Unused amounts do not carry over to the next month/quarter.

Out-of-Network
$60 every quarter OTC Retail/Catalog. Unused amounts do not carry over to the next month/quarter.
Podiatry Services
Medicare Covered Podiatry Services: $30 / Routine Podiatry Services: $20 for 6 visits every year.

Out-of-Network
Medicare Covered Podiatry Services: $30 / Routine Podiatry Services: $20 for 6 visits every year.
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 $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 for preventive and a 20% cost-share on comprehensive services.

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 $2000 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 $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.

Out-of-Network
Most services offered at $0 cost share, please refer to your Evidence of Coverage for more information.