Wellcare Premium Ultra (HMO)
Wellcare Premium Ultra (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Aetna.
Plan ID: H0562-084.
Wellcare Premium Ultra (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Aetna.
Plan ID: H0562-084.
Wellcare Premium Ultra (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Aetna.
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. |
