Wellcare Plus Sapphire I (HMO)

WellCare Health Plans, Inc.
Wellcare Plus Sapphire I (HMO) H0562-122 Plan Details
4 out of 5 stars

Wellcare Plus Sapphire I (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by WellCare Health Plans, Inc..
Plan ID: H0562-122.

$33.20
Monthly Premium

Wellcare Plus Sapphire I (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by WellCare Health Plans, Inc..
Plan ID: H0562-122.

WellCare Health Plans, Inc.
Wellcare Plus Sapphire I (HMO) H0562-122 Plan Details
4 out of 5 stars

Wellcare Plus Sapphire I (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by WellCare Health Plans, Inc..
Plan ID: H0562-122.

$33.20
Monthly Premium

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $480
Out of Pocket Max In-Network: $3450
Out-of-Network: N/A
Initial Coverage Limit $4430
Catastrophic Coverage Limit $7,050
Primary Care Doctor Visit
$0 copay
Specialty Doctor Visit
$0 copay
Inpatient Hospital Care
$2,524 copay per stay
Urgent Care
$65
Emergency Room Visit
$120
Ambulance Transportation
20%

Health Care Services and Medical Supplies

Wellcare Plus Sapphire I (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: $0 per visit. $0 / 36 visits every year in addition to Medicare covered.
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
Diabetes Supplies: $0 / Diabetes Self-Management Training: 20% / Diabetic Therapeutic Shoes or Inserts: 20%
Durable Medical Eqipment (DME)
20%
Diagnostic Tests, Lab and Radiology Services, and X-Rays
X-Ray Services: 20% / Lab Services: $0. $0 for COVID-related testing. For other services, please refer to the Evidence of Coverage for more information.
Home Health Care
20%
Mental Health Inpatient Care
$90 copay per day for days 1-15 and a $0 copay per day for days 16-90
Mental Health Outpatient Care
20% for individual or group
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Coinsurance for Medicare Covered Outpatient Hospital Services 20%
Prior Authorization Required for Outpatient Hospital Services
Referral Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $120.00
Coinsurance for Medicare Covered Observation Services - Per stay 20%
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Coinsurance for Ambulatory Surgical Center Services 20%
Prior Authorization Required for Ambulatory Surgical Center Services
Referral Required for Ambulatory Surgical Center Services
Prior authorization required
Outpatient Substance Abuse Care
20% for individual or group
Over-the-counter (OTC) Items
$140 every quarter OTC Retail/Catalog. Unused amounts do not carry over to the next month/quarter.
Podiatry Services
Medicare Covered Podiatry Services: $0 / Routine Podiatry Services: $0 for 12 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

Dental Benefits

The following dental services are covered from in-network providers.

Coverage Cost
Dental Care
$1,000 for comprehensive dental services including dentures

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 $400 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 $1,500 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 Plus Sapphire I (HMO) plan offers the following prescription drug coverage, with an annual drug deductible of $480 (excludes Tiers 1 and 6) per year.

Coverage
Cost
Coverage & Cost
Annual Drug Deductible $480 (excludes Tiers 1 and 6)
Preferred Generic
  • Standard retail $0.00
  • Preferred mail order $0.00
  • Standard mail order $0.00
Select Care Drugs
  • Standard retail $0.00
  • Preferred mail order $0.00
  • Standard mail order $0.00
Annual Drug Deductible $480 (excludes Tiers 1 and 6)
Preferred Generic
  • Standard retail $0.00
  • Preferred mail order $0.00
  • Standard mail order $0.00
Select Care Drugs
  • Standard retail $0.00
  • Preferred mail order $0.00
  • Standard mail order $0.00
Annual Drug Deductible $480 (excludes Tiers 1 and 6)
Preferred Generic
  • Standard retail $0.00
  • Preferred mail order $0.00
  • Standard mail order $0.00
Select Care Drugs
  • Standard retail $0.00
  • Preferred mail order $0.00
  • Standard mail order $0.00