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
Ashe
Avery
Bladen
Buncombe
Burke
Cabarrus
Caldwell
Caswell
Catawba
Chatham
Cleveland
Columbus
Cumberland
Davidson
Davie
Duplin
Durham
Forsyth
Gaston
Graham
Granville
Guilford
Harnett
Haywood
Henderson
Hoke
Iredell
Jackson
Johnston
Lee
Lincoln
Macon
Madison
McDowell
Mecklenburg
Mitchell
Montgomery
Moore
Orange
Person
Polk
Randolph
Richmond
Robeson
Rowan
Rutherford
Scotland
Stanly
Stokes
Swain
Transylvania
Union
Vance
Wake
Warren
Watauga
Wilkes
Yadkin
Yancey
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. |
