WellCare RX Plus H8533-003-0 (PPO) Plan Details

In this article...
  • Learn more about HumanaChoice R7220-002 (Regional PPO) R7220:002-0 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 Rx Plus  is a PPO Medicare Advantage (Medicare Part C) plan offered in Arizona by WellCare Rx Plus. The plan ID is H8553:003-0.

  • Monthly Premium: $0
  • Plan Deductible: $0.00
  • Out of Pocket Spending Max: $6000

Primary Care Doctor Visit

In Network: Copayment for Primary Care Office Visit $0.00

Specialist Doctor Visit

In Network:

  • $40 Copayment 

Out of Network:

  • Copinsurance 20%

Inpatient Hospital Care

In Network:

  • $300.00 per day for days 1 to 6
  • $0.00 per day for days 7 to 90

Out of Network:

  • $1450 co-pay per stay

Urgent Care

Copayment for Urgent Care $40.

Emergency Room (ER) Visits

In Network:

  • Copayment for Emergency Care: $90.00

Ambulance Transportation

In Network:

  • $250 copayment

Out of Network:

  • Coinsurance 20%

Additional Covered Health Care Services and Medical Supplies

WellCare Rx Plus  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: 20% Coinsurance

Skilled Nursing Facility (SNF) Care

In Network:

  • $0.00 per day for days 1 to 20
  • $184.00 per day for days 21 to 100

Medical Diagnostic Tests, Labs and Radiology Services

Outpatient Diagnostic Procedures, Tests and Lab Services:

  • Copayment for Medicare-covered Diagnostic Procedures/Tests: $0.00
  • Coinsurance for Medicare-covered Diagnostic Procedures/Tests 20%
  • Copayment for Medicare-covered Lab Services: $0.00

Diabetes Supplies, Training, Nutrition Therapy and Monitoring

Services offered:

  • Coinsurance for Medicare-covered Diabetic Supplies $0, 20% Coinsurance
  • Diabetes Self-Management Training: $0
  • Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts: 20%

Durable Medical Equipment (DME)

In Network:

  • Coinsurance for Medicare-covered Durable Medical Equipment 20%

Chiropractic Services

In Network:

  • Copayment for Medicare-covered Chiropractic Services: $20.00

Out of Network: 20% Coinsurance per visit

Mental Health Inpatient Care

In Network:

  • $300.00 per day for days 1 to 6
  • $0.00 per day for days 7 to 90

Out of Network: $1450 Co-pay per stay

Outpatient Substance Abuse Care

In Network:

  • Copayment for Medicare-covered Individual Sessions $40.00
  • Copayment for Medicare-covered Group Sessions $40.00

Out of network: 20% for individual or group

Podiatry Services

In Network:

  • Copayment for Medicare-Covered Podiatry Services: $40.00

Out of network: 20% co-pay per visit

Over-the-Counter (OTC) Items

$65 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

Covered Benefits:

  • In Network: The dental benefits on this plan include coverage of preventive services, including but not limited to: cleanings, x-ray(s), oral exams, and fluoride treatments
  • Out Network: The dental benefits on this plan include coverage of preventive services with a coinsurance on services performed OON, including but not limited to: cleanings, x-ray(s), oral exams, and fluoride treatments

Vision Benefits

In Network: The vision benefits on this plan cover routine eye exams and up to $100 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 $100 with a 40% coinsurance for all services and eyewear received OON, for unlimited contacts, glasses, lenses, and/or frames per year.

Hearing Benefits

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

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 $700 for 2 hearing aids per year with a maximum of $350 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 $700 for 2 hearing aids per year with a maximum of $350 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 $0.00 Copayment or 0% Coinsurance required.

Most services offered at $0 cost share, please refer to your Evidence Of Coverage for more information

Prescription Drug Costs and Coverage

The WellCare Rx Plus  plan offers the following prescription drug coverage in Arizona, with an annual drug deductible of $0.00 per year.

$300 per year for Part D prescription drugs except for $0 for drugs listed on the following tiers: Tier1; Tier2

Preferred Generic Drugs

 

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

Generic Drugs

 

  • Preferred Mail Order Cost Sharing (90 Day Supply) $90.00
  • Standard Retail Cost Sharing (30 Day Supply) $45.00
  • Standard Mail Order Cost Sharing (90 Day Supply) $135.00

Preferred Brand Name Drugs

 

  • Preferred Mail Order Cost Sharing (90 Day Supply) $90.00
  • Standard Retail Cost Sharing (30 Day Supply) $47.00
  • Standard Mail Order Cost Sharing (90 Day Supply) $141.00

Non-Preferred Drugs

 

  • Preferred Mail Order Cost Sharing (90 Day Supply) 45%
  • Standard Retail Cost Sharing (30 Day Supply) $100.00
  • Standard Mail Order Cost Sharing (90 Day Supply) $300.00

Specialty Tier Drugs

 

  • Standard Retail Cost Sharing (30 Day Supply) 27%
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