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

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  • Learn more about WellCare Patriot (PPO) H8553:002-0 Plan Details, including how much you can expect to pay for coinsurance, deductibles, premiums and copays for various services covered by the plan.

Arizona Counties Served

Pima County
Maricopa County

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
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