Wellcare Premium Ultra (HMO)
Wellcare Premium Ultra (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by WellCare Health Plans, Inc..
Plan ID: H0562-084.
$165.00
Monthly Premium
Wellcare Premium Ultra (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by WellCare Health Plans, Inc..
Plan ID: H0562-084.
California Counties Served
Basic Costs and Coverage
Coverage | Cost |
---|---|
Monthly Deductible | $0 |
Out of Pocket Max |
In-Network: $5000 Out-of-Network: N/A |
Initial Coverage Limit | $4430 |
Catastrophic Coverage Limit | $7,050 |
Primary Care Doctor Visit | $15 |
Specialty Doctor Visit | $20 |
Inpatient Hospital Care | $275 copay per day for days 1-4 and a $0 copay per day for days 5-90 |
Urgent Care | $20 |
Emergency Room Visit | $90 |
Ambulance Transportation | $220 |
Health Care Services and Medical Supplies
Wellcare Premium Ultra (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: $20 per visit |
Diabetes Supplies, Training, Nutrition Therapy and Monitoring | Diabetes Supplies: $0 / Diabetes Self-Management Training: $0 / Diabetic Therapeutic Shoes or Inserts: 20% |
Durable Medical Eqipment (DME) | 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. |
Home Health Care | $0 copay |
Mental Health Inpatient Care | $900 copay per stay |
Mental Health Outpatient Care | $25 for individual or group |
Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $275.00 Prior Authorization Required for Outpatient Hospital Services Referral Required for Outpatient Hospital Services Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $90.00 to $275.00 Prior Authorization Required for Outpatient Observation Services Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $125.00 Prior Authorization Required for Ambulatory Surgical Center Services Referral Required for Ambulatory Surgical Center Services Prior authorization required |
Outpatient Substance Abuse Care | $25 for individual or group |
Podiatry Services | Medicare Covered Podiatry Services: $20 |
Skilled Nursing Facility Care | $0 copay per day for days 1-100 |
Dental Benefits
The following dental services are covered from in-network providers.
Coverage | Cost |
---|---|
Dental Care | No Max allowance for comprehensive 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 only |
Hearing Benefits
The following hearing services are covered from in-network providers.
Coverage | Cost |
---|---|
Hearing Benefits | The hearing benefits on this plan cover hearing exams only |
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. |