2021 WellCare Prime (PPO) H5199-013 By WellCare.

Summary of Benefits for
2021 WellCare Prime (PPO)


WellCare Prime (PPO) H5199-013 is a 2021 Medicare Advantage Plan or Medicare Part-C plan by WellCare available to residents in Florida. This plan includes additional Medicare prescription drug (Part-D) coverage. The WellCare Prime (PPO) has a monthly premium of $90.00 and has an in-network Maximum Out-of-Pocket limit of $1,700 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $1,700 out of pocket. This can be a extremely nice safety net.

WellCare Prime (PPO) is a Local PPO. A preferred provider organization (PPO) is a Medicare plan that has created contracts with a network of "preferred" providers for you to choose from at reduced rates. You do not need to select a primary care physician and you do not need referrals to see other providers in the network. Offering you a little more flexibility overall. You can get medical attention from a provider outside of the network but you will have to pay the difference between the out-of-network bill and the PPOs discounted rate.

WellCare works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for WellCare Prime (PPO) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from WellCare and not Original Medicare. With Medicare Advantage Plans you are always covered for urgently needed and emergency care. Plus you receive all of the benefits of Original Medicare from WellCare except hospice care. Original Medicare still provides you with hospice care even if you sign up for a Medicare Advantage Plan.




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2021 WellCare Medicare Advantage Plan Costs

Name:
WellCare Prime (PPO)
Plan ID:
H5199-013
Provider:WellCare
Year:2021
Type: Local PPO
Monthly Premium C+D: $90.00
Part C Premium: $63.30
MOOP: $1,700
Part D (Drug) Premium: $26.70
Part D Supplemental Premium $0
Total Part D Premium: $26.70
Drug Deductible: $0
Tiers with No Deductible:0
Gap Coverage:Yes
Benchmark:not below the regional benchmark
Type of Medicare Health:Enhanced Alternative
Drug Benefit Type:Enhanced
Similar Plan: H5199-014




WellCare Prime (PPO) Part-C Premium

WellCare plan charges a $63.30 Part-C premium. The Part C premium covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.



H5199-013 Part-D Deductible and Premium

WellCare Prime (PPO) has a monthly drug premium of $26.70 and a $0 drug deductible. This WellCare plan offers a $26.70 Part D Basic Premium that is not below the regional benchmark. This covers the basic prescription benefit only and does not cover enhanced drug benefits such as medical benefits or hospital benefits. The Part D Supplemental Premium is $0 this Premium covers any enhanced plan benefits offered by WellCare above and beyond the standard PDP benefits. This can include additional coverage in the gap, lower co-payments and coverage of non-Part D drugs. The Part D Total Premium is $26.70. The Part D Total Premium is the addition of the supplemental and basic premiums for some plans this amount can be lower due to negative basic or supplemental premiums.



WellCare Gap Coverage

In 2021 once you and your plan provider have spent $4130 on covered drugs. (combined amount plus your deductible) You will be in the coverage gap. (AKA "donut hole") You will be required to pay 25% for prescription drugs unless your plan offers additional coverage. This WellCare plan does offer additional coverage through the gap.



Premium Assistance

The Low Income Subsidy (LIS) helps people with Medicare pay for prescription drugs, and lowers the costs of Medicare prescription drug coverage. Depending on your income level you may be eligible for full 75%, 50%, 25% premium assistance. The WellCare Prime (PPO) medicare insurance offers a $0 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $6.70 for 75% low income subsidy $13.30 for 50% and $20.00 for 25%.



Full LIS Premium: $0
75% LIS Premium: $6.70
50% LIS Premium: $13.30
25% LIS Premium: $20.00


H5199-013 Formulary or Drug Coverage

WellCare Prime (PPO) formulary is divided into tiers or levels of coverage based on usage and according to the medication costs. Each tier will have a defined copay that you must pay to receive the drug. Drugs in lower tiers will usually cost less than those in higher tiers. By reviewing different Medicare Drug formularies, you can pick a Medicare Advantage plan that covers your medications. Additionally, you can choose a plan that has your drugs listed at a lower price.

Drug Tier Copay
Preferred
Pharmacy
Copay
Nonpreferred
Pharmacy
Tier 1 NA $0
Tier 2 NA $5
Tier 3 NA $47
Tier 4 NA $100
Tier 5 NA 33%
*Initial Coverage Phase and 30 day supply







2021 WellCare Prime (PPO) Summary of Benefits




Additional Benefits


No



Comprehensive Dental


Diagnostic services 50% coinsurance (Out-of-Network)
Diagnostic services $0 copay
Endodontics 50% coinsurance (Out-of-Network)
Endodontics $0 copay
Extractions $0 copay
Extractions 50% coinsurance (Out-of-Network)
Non-routine services 50% coinsurance (Out-of-Network)
Non-routine services $0 copay
Periodontics $0 copay
Periodontics 50% coinsurance (Out-of-Network)
Prosthodontics, other oral/maxillofacial surgery, other services 50% coinsurance (Out-of-Network)
Prosthodontics, other oral/maxillofacial surgery, other services $0 copay
Restorative services $0 copay
Restorative services 50% coinsurance (Out-of-Network)



Deductible


$0



Diagnostic Tests and Procedures


Diagnostic radiology services (e.g., MRI) $0-125 copay
Diagnostic radiology services (e.g., MRI) $0-125 copay (Out-of-Network)
Diagnostic tests and procedures $0-50 copay (Out-of-Network)
Diagnostic tests and procedures $0-50 copay
Lab services $0 copay
Lab services $0 copay (Out-of-Network)
Outpatient x-rays $0 copay
Outpatient x-rays $0 copay (Out-of-Network)



Doctor Visits


Primary $0 copay (Out-of-Network)
Primary $0 copay
Specialist $15 copay per visit
Specialist $15 copay per visit (Out-of-Network)



Emergency care/Urgent Care


Emergency $120 copay per visit (always covered)
Urgent care $15 copay per visit (always covered)



Foot Care (podiatry services)


Foot exams and treatment $15 copay (Out-of-Network)
Foot exams and treatment $15 copay
Routine foot care Not covered



Ground Ambulance


$275 copay (Out-of-Network)
$275 copay



Hearing


Fitting/evaluation 40% coinsurance (Out-of-Network)
Fitting/evaluation $0 copay
Hearing aids $0 copay
Hearing aids 40% coinsurance (Out-of-Network)
Hearing exam $15 copay
Hearing exam $15 copay (Out-of-Network)



Inpatient Hospital Coverage


$125 per day for days 1 through 6
$0 per day for days 7 through 90
$125 per day for days 1 through 6
$0 per day for days 7 and beyond (Out-of-Network)



Medical Equipment/Supplies


Diabetes supplies $0 copay per item
Diabetes supplies 20-50% coinsurance per item (Out-of-Network)
Durable medical equipment (e.g., wheelchairs, oxygen) 20% coinsurance per item
Durable medical equipment (e.g., wheelchairs, oxygen) 20-50% coinsurance per item (Out-of-Network)
Prosthetics (e.g., braces, artificial limbs) 20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs) 20-50% coinsurance per item (Out-of-Network)



Medicare Part B Drugs


Chemotherapy 20-50% coinsurance (Out-of-Network)
Chemotherapy 20% coinsurance
Other Part B drugs 20% coinsurance
Other Part B drugs 20-50% coinsurance (Out-of-Network)



Mental Health Services


Inpatient hospital - psychiatric $125 per day for days 1 through 6
$0 per day for days 7 through 90 (Out-of-Network)
Inpatient hospital - psychiatric $125 per day for days 1 through 6
$0 per day for days 7 through 90
Outpatient group therapy visit $15 copay (Out-of-Network)
Outpatient group therapy visit $15 copay
Outpatient group therapy visit with a psychiatrist $15 copay
Outpatient group therapy visit with a psychiatrist $15 copay (Out-of-Network)
Outpatient individual therapy visit $15 copay
Outpatient individual therapy visit $15 copay (Out-of-Network)
Outpatient individual therapy visit with a psychiatrist $15 copay (Out-of-Network)
Outpatient individual therapy visit with a psychiatrist $15 copay



MOOP


$5,100 In and Out-of-network
$1,700 In-network



Option


No



Optional supplemental benefits


No



Outpatient Hospital Coverage


$125 copay per visit (Out-of-Network)
$125 copay per visit



Preventive Care


$0 copay (Out-of-Network)
$0 copay



Preventive Dental


Cleaning $0 copay
Cleaning 50% coinsurance (Out-of-Network)
Dental x-ray(s) 50% coinsurance (Out-of-Network)
Dental x-ray(s) $0 copay
Fluoride treatment $0 copay
Fluoride treatment 50% coinsurance (Out-of-Network)
Oral exam $0 copay
Oral exam 50% coinsurance (Out-of-Network)



Rehabilitation Services


Occupational therapy visit $15 copay
Occupational therapy visit $15 copay (Out-of-Network)
Physical therapy and speech and language therapy visit $15 copay (Out-of-Network)
Physical therapy and speech and language therapy visit $15 copay



Skilled Nursing Facility


$0 per day for days 1 through 20
$178 per day for days 21 through 100
$0 per day for days 1 through 20
$178 per day for days 21 through 100 (Out-of-Network)



Transportation


Not covered



Vision


Contact lenses 40% coinsurance (Out-of-Network)
Contact lenses $0 copay
Eyeglass frames $0 copay
Eyeglass frames 40% coinsurance (Out-of-Network)
Eyeglass lenses $0 copay
Eyeglass lenses 40% coinsurance (Out-of-Network)
Eyeglasses (frames and lenses) 40% coinsurance (Out-of-Network)
Eyeglasses (frames and lenses) $0 copay
Other Not covered
Routine eye exam $0 copay
Routine eye exam 40% coinsurance (Out-of-Network)
Upgrades $0 copay
Upgrades 40% coinsurance (Out-of-Network)



Wellness Programs (e.g. fitness nursing hotline)


Covered





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Sun 9am-6pm EST




Coverage Area for WellCare Prime (PPO)

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Source: CMS.
Data as of September 9, 2020.
Notes: Data are subject to change as contracts are finalized. For 2021, enhanced alternative may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part D benefit. Includes 2021 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.

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