WellCare Premier (PPO) H8553:001-0 Plan Details

Arizona Counties Served

Plan Details and Plan Costs

WellCare Premier (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered in Arizona by WellCare Premier (PPO). The plan ID is H8553:001-0.

Monthly Premium: $0
Plan Deductible: $0.00
Out of Pocket Spending Max: $5000

Primary Care Doctor Visit

In Network: $0 Copayment
Out of Network: 40% Coinsurance

Specialist Doctor Visit

In Network:

$35 Copayment for Physician Specialist Office Visit

Out of Network:

40% Coinsurance

Inpatient Hospital Care

In Network:

$300.00 per day for days 1 to 5
$0.00 per day for days 6 to 90

Out of Network:

Out of Network: 20% of the total cost for days 1-90

Urgent Care

In Network:

In-Network: $40 Copayment

Emergency Room (ER) Visits

In Network:

In Network: $90 Copayment

Ambulance Transportation

In Network: $250 Copayment

Additional Covered Health Care Services and Medical Supplies

WellCare Premier (PPO) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).

Home Health Care

In Network: $0.00 Copay

Out of Network: 40% Coinsurance

Skilled Nursing Facility (SNF) Care

In Network: $0 co-pay per day for days 1-20 and a $184.00 co-pay per day for days 21-100

Out of Network: 20% of the total cost for days 1-100

Medical Diagnostic Tests, Labs and Radiology Services

Outpatient Diagnostic Procedures, Tests and Lab Services: X-Ray Services: $0 / Lab Services: $0
Outpatient Diagnostic and Therapeutic Radiology Services: X-Ray Services: 40% / Lab Services: 40%. For other services, please refer to your Evidence of Coverage for more information.

Diabetes Supplies, Training, Nutrition Therapy and Monitoring

In Network:

Diabetes Supplies: $0 / Diabetes Self-Management Training: $0 /
Diabetic Therapeutic Shoes or Inserts: 20%

Out of Network:

Diabetes Supplies: 20% / Diabetes Self-Management Training: $0 /
Diabetic Therapeutic Shoes or Inserts: 20%

Durable Medical Equipment (DME)

In Network: 20% Coinsurance

Chiropractic Services

In Network:

Copayment for Medicare-covered Chiropractic Services: $20 per visit
Copayment for Routine Care: $20 for 12 visits every year

Out of Network:

Coinsurance for Medicare Covered Chiropractic Services: 40% per visit
Copayment for Routine Care: 40% for 12 visits every year

Mental Health Inpatient Care

In Network: $300 co-pay per day for days 1-5 and a $0 co-pay per day for days 6-90
Out of Network: Out of Network: 40% of the total cost for days 1-90

Mental Health Outpatient Care

In Network: $40 for individual or group
Out of Network: 40% Copayment for individual or group

Outpatient Substance Abuse Care

In Network: $40 for individual or group

Out of Network: 40% Copayment for individual or group

Podiatry Services

In Network:

Medicare Covered Podiatry Services: $35 per visit / Routine Podiatry Services: $20 per visit for 6 visits every year
Medicare Covered Podiatry Services: 40% per visit / Routine Podiatry Services: 40% per visit for 6 visits every year

Out of Network:

Medicare Covered Podiatry Services: 40% per visit / Routine Podiatry Services: 40% per visit for 6 visits every year

Over-the-Counter (OTC) Items

$100 every quarter OTC Retail/Catalog. Unused amounts do not carry over to the next quarter.

Dental Benefits

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

Preventive Dental Care

In Network: The dental benefits on this plan include coverage of preventive and comprehensive services up to $1,500 Copayment, 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.
Out of Network: The dental benefits on this plan include coverage of preventive and comprehensive services up to $1,500 Copayment with a coinsurance on services performed OON, 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.

Vision Benefits

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

In Network: The vision benefits on this plan cover routine eye exams and up to $200 Copayment 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 $200 Copayment with a 40% coinsurance for all services and eyewear received OON, for unlimited contacts, glasses, lenses, and/or frames per year.

Hearing Benefits

In Network: The hearing benefits on this plan cover, but are not limited to: routine hearing exams, hearing aid fittings and evaluations, and up to $2,000 Copayment for 2 hearing aids per year with a maximum of $1,000 Copayment per ear.
Out of Network: The hearing benefits on this plan cover, but are not limited to: routine hearing exams, hearing aid fittings and evaluations, and up to $2,000 Copayment for 2 hearing aids per year with a maximum of $1,000 Copayment per ear with a 40% coinsurance for all services and hearing aids received OON.

Preventive Services and Health/Wellness Education Programs

The following preventive services and wellness education programs are covered from in-network providers with [Most services offered at $0 Copayment cost share, please refer to your Evidence Of Coverage for more information] required.

Prescription Drug Costs and Coverage

The WellCare Premier plan offers the following prescription drug coverage in Arizona, with an annual drug deductible of [$150 Copayment per year for Part D prescription drugs except for $0 Copayment for drugs listed on the following tiers: Tier1; Tier2] per year.

Preferred Generic Drugs

Preferred Mail Order Cost Sharing (90 Day Supply) $0.00 Copayment
Standard Retail Cost Sharing (30 Day Supply) $0.00 Copayment
Standard Mail Order Cost Sharing (90 Day Supply) $0.00 Copayment

Generic Drugs

Preferred Mail Order Cost Sharing (90 Day Supply) $0.00 Copayment
Standard Retail Cost Sharing (30 Day Supply) $5.00 Copayment
Standard Mail Order Cost Sharing (90 Day Supply) $15.00 Copayment

Preferred Brand Name Drugs

Preferred Mail Order Cost Sharing (90 Day Supply) $94.00 Copayment
Standard Retail Cost Sharing (30 Day Supply) $47.00 Copayment
Standard Mail Order Cost Sharing (90 Day Supply) $141.00 Copayment

Non-Preferred Drugs

Preferred Mail Order Cost Sharing (90 Day Supply) $200.00 Copayment
Standard Retail Cost Sharing (30 Day Supply) $100.00 Copayment
Standard Mail Order Cost Sharing (90 Day Supply) $300.00 Copayment

Specialty Tier Drugs

Standard Retail Cost Sharing (30 Day Supply) 30% Coinsurance