2022 Wellcare Premium Enhanced Open (PPO)


Wellcare Premium Enhanced Open (PPO) H0111-003 is a 2022 Medicare Advantage Plan or Part-C by Wellcare available to residents in Georgia. This plan includes additional prescription drug (Part-D) coverage. The Wellcare Premium Enhanced Open (PPO) has a monthly premium of $85.00 and has an in-network maximum out-of-pocket limit of $6,000 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $6,000 out-of-pocket. This can be a extremely nice safety net.

Wellcare Premium Enhanced Open (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 Premium Enhanced Open (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 you are always covered for urgently needed and emergency care. Plus you receive all the benefits of Original Medicare from Wellcare except hospice care. Original Medicare still provides you with hospice care even if you sign up for Medicare Advantage.




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2022 Wellcare Medicare Advantage Plan Costs

Name:
Wellcare Premium Enhanced Open (PPO)
Plan ID:
H0111-003
Provider:Wellcare
Year:2022
Type: Local PPO
Monthly Premium C+D: $85.00
Part C Premium:$63.70
MOOP: $6,000
Part D (Drug) Premium:$21.30
Part D Supplemental Premium$0.00
Total Part D Premium:$21.30
Drug Deductible:$75.00
Tiers with No Deductible:1
Gap Coverage:Yes
Benchmark:not below the regional benchmark
Type of Medicare Health:Enhanced Alternative
Drug Benefit Type:Enhanced
Similar Plan: H0111-005




Wellcare Premium Enhanced Open (PPO) Part-C Premium

Wellcare charges a $63.70 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.



H0111-003 Part-D Deductible and Premium

Wellcare Premium Enhanced Open (PPO) has a monthly drug premium of $21.30 and a $75.00 drug deductible. This Wellcare plan offers a $21.30 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 $0.00 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 $21.30 . The Part D Total Premium is the addition of the supplemental and basic premiums for some plans this amount can be lowered due to negative basic or supplemental premiums.



Wellcare Gap Coverage

In 2022 once you and your plan provider have spent $4430 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 Premium Enhanced Open (PPO) medicare insurance offers a $0.00 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $5.30 for 75% low income subsidy $10.60 for 50% and $16.00 for 25%.



Full LIS Premium:$0.00
75% LIS Premium:$5.30
50% LIS Premium:$10.60
25% LIS Premium:$16.00


H0111-003 Formulary or Drug Coverage

Wellcare Premium Enhanced Open (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. You can see complete 2022 Wellcare Premium Enhanced Open (PPO) H0111-003 Formulary here.

Drug Tier Copay
Preferred
Pharmacy
Copay
Nonpreferred
Pharmacy
Tier 1 $0 $0
Tier 2 $0 $5
Tier 3 $37 $47
Tier 4 48% 50%
Tier 5 31% 31%
Tier 6 $0 $0
*Initial Coverage Phase and 30 day supply





2021 Wellcare Premium Enhanced Open (PPO) Summary of Benefits

*This will be updated with 2022 data when available.



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) $0-230 copay (Out-of-Network)
Diagnostic tests and procedures $0-50 copay
Diagnostic tests and procedures $0-230 copay (Out-of-Network)
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 $0-230 copay per visit (Out-of-Network)
Specialist $15 copay per visit



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
Foot exams and treatment $0-230 copay (Out-of-Network)
Routine foot care Not covered



Ground Ambulance


$230 copay
$0-230 copay (Out-of-Network)



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 $0-230 copay (Out-of-Network)
Hearing exam $15 copay



Inpatient Hospital Coverage


$200 per day for days 1 through 5
$0 per day for days 6 through 90
$200 per day for days 1 through 5
$0 per day for days 6 and beyond (Out-of-Network)



Medical Equipment/Supplies


Diabetes supplies $0 copay or 20% coinsurance per item (Out-of-Network)
Diabetes supplies $0 copay per item
Durable medical equipment (e.g., wheelchairs, oxygen) 20% coinsurance per item
Durable medical equipment (e.g., wheelchairs, oxygen) 20-40% coinsurance per item (Out-of-Network)
Prosthetics (e.g., braces, artificial limbs) 20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs) 20-40% coinsurance per item (Out-of-Network)



Medicare Part B Drugs


Chemotherapy 20-40% coinsurance (Out-of-Network)
Chemotherapy 20% coinsurance
Other Part B drugs 20% coinsurance
Other Part B drugs 20-40% coinsurance (Out-of-Network)



Mental Health Services


Inpatient hospital - psychiatric $2,200 per stay (Out-of-Network)
Inpatient hospital - psychiatric $2,200 per stay
Outpatient group therapy visit $25 copay
Outpatient group therapy visit $0-230 copay (Out-of-Network)
Outpatient group therapy visit with a psychiatrist $0-230 copay (Out-of-Network)
Outpatient group therapy visit with a psychiatrist $25 copay
Outpatient individual therapy visit $0-230 copay (Out-of-Network)
Outpatient individual therapy visit $25 copay
Outpatient individual therapy visit with a psychiatrist $25 copay
Outpatient individual therapy visit with a psychiatrist $0-230 copay (Out-of-Network)



MOOP


$5,100 In and Out-of-network
$2,500 In-network



Option


No



Optional supplemental benefits


No



Outpatient Hospital Coverage


$125 copay per visit
$0-230 copay per visit (Out-of-Network)



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 $0-230 copay (Out-of-Network)
Occupational therapy visit $15 copay
Physical therapy and speech and language therapy visit $15 copay
Physical therapy and speech and language therapy visit $0-230 copay (Out-of-Network)



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




CMS Star Ratings for Wellcare Premium Enhanced Open (PPO) H0111



2021 Overall Rating
Part C Summary Rating
Part-D Summary Rating
Staying Healthy: Screenings, Tests, Vaccines
Managing Chronic (Long Term) Conditions
Member Experience with Health Plan
Complaints and Changes in Plans Performance
Health Plan Customer Service
Drug Plan Customer Service
Complaints and Changes in the Drug Plan
Member Experience with the Drug Plan
Drug Safety and Accuracy of Drug Pricing


Staying Healthy, Screening, Testing, & Vaccines

Total Preventative Rating
Breast Cancer Screening
Colorectal Cancer Screening
Annual Flu Vaccine
Monitoring Physical Activity


Managing Chronic And Long Term Care for Older Adults

Total Rating
SNP Care Management
Medication Review
Functional Status Assessment
Osteoporosis Management
Diabetes Care - Eye Exam
Diabetes Care - Kidney Disease
Diabetes Care - Blood Sugar
Rheumatoid Arthritis
Reducing Risk of Falling
Improving Bladder Control
Medication Reconciliation
Statin Therapy


Member Experience with Health Plan

Total Experience Rating
Getting Needed Care
Getting Appointments
Customer Service
Health Care Quality
Rating of Health Plan
Care Coordination


Member Complaints and Changes in Wellcare Premium Enhanced Open (PPO) Plans Performance

Total Rating
Complaints about Health Plan
Members Leaving the Plan
Health Plan Quality Improvement


Health Plan Customer Service Rating for Wellcare Premium Enhanced Open (PPO)

Total Customer Service Rating
Timely Decisions About Appeals
Reviewing Appeals Decisions
Call Center, TTY, Foreign Language


Wellcare Premium Enhanced Open (PPO) Drug Plan Customer Service Ratings

Total Rating
Call Center, TTY, Foreign Language


Ratings For Member Complaints and Changes in the Drug Plans Performance

Total Rating
Complaints about the Drug Plan
Members Choosing to Leave the Plan
Drug Plan Quality Improvement


Member Experience with the Drug Plan

Total Rating
Rating of Drug Plan
Getting Needed Prescription Drugs


Drug Safety and Accuracy of Drug Pricing

Total Rating
MPF Price Accuracy
Drug Adherence for Diabetes Medications
Drug Adherence for Hypertension (RAS antagonists)
Drug Adherence for Cholesterol (Statins)
MTM Program Completion Rate for CMR
Statin with Diabetes



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Or Call
1-855-778-4180
Mon-Sat 8am-11pm EST
Sun 9am-6pm EST




Coverage Area for Wellcare Premium Enhanced Open (PPO)

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State: Georgia
County:


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Source: CMS.
Data as of September 1, 2021.
Notes: Data are subject to change as contracts are finalized. For 2022, 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 2022 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.

*Licensed Agent Disclaimer: We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE (TTY users should call 1-877-486-2048) 24 hours a day/7 days a week to get information on all of your options.

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