Wellcare No Premium (HMO) H4073-001 is a 2023 Medicare Advantage Plan or Part-C by Wellcare available to residents in North Carolina. This plan includes additional prescription drug (Part-D) coverage. Wellcare Wellcare No Premium (HMO) has a monthly premium of $0 and has an in-network maximum out-of-pocket limit of $4,500 (MOOP). This means that if you get sick or need a high-cost procedure the co-pays are capped once you pay $4,500 out-of-pocket. This can be an extremely nice safety net.

Wellcare works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Wellcare No Premium (HMO) 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 2023 Medicare Advantage Plan 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 if you sign up for Medicare Advantage in North Carolina.

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2023 Wellcare Medicare Advantage Plan Overview

What type of plan is Wellcare No Premium (HMO)

Wellcare No Premium (HMO) is a Local HMO. With a health maintenance organization (HMO) you will be required to receive most of your health care from an in-network provider. Health maintenance organizations require that you select a primary care physician (PCP). Your primary care physician will serve as your personal doctor to provide all of your basic healthcare services. If you require specialized care or a physician specialist, your primary care physician will make the arrangements and inform you where you can go in the network. You will need your primary care physician approval, called a referral. Services received from an out-of-network provider are not typically covered.

How much does Wellcare No Premium (HMO) cost?

Monthly Premium

A monthly premium is the fee you pay to the plan in exchange for coverage. Wellcare charges a $0 consolidated premium. The Part C premium is $0 this charge covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.

Part-D Deductible and Premium

An annual deductible is the amount you pay out-of-pocket for your prescription drugs before your plan begins to pay. Wellcare No Premium (HMO) has a monthly drug premium of $0 and a $150.00 drug deductible. This Wellcare plan offers a $0 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 $0. The Part D Total Premium is the addition of supplemental and basic premiums for some plans this amount can be lowered due to negative basic or supplemental premiums.

Wellcare Gap Coverage

In 2023 once you and your plan provider have spent $4660 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 not offer additional coverage through the gap.

MOOP

The maximum out-of-pocket (MOOP) is a yearly limit on your out-of-pocket costs. Wellcare No Premium (HMO) by Wellcare MOOP is $4,500. Once you spend $4,500 you will pay nothing for Part A or Part B covered services. Copayments and coinsurance for Medicare approved services apply toward your out-of-pocket limit. Remember Original Medicare (Parts A and B) doesn’t have a MOOP.

Formulary and Drug Coverage

Wellcare No Premium (HMO) 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	$0	$5
Tier 2	$5	$15
Tier 3	$35	$45
Tier 4	45%	47%
Tier 5	30%	30%
Tier 6	$0	$0

The complete Wellcare No Premium (HMO) Formulary.
*Initial Coverage Phase and 30 day supply

2023 Summary of Benefits

The benefit information provided is a summary of what Wellcare No Premium (HMO) covers and what you pay (such as copayments and coinsurance amounts) for certain common medical events. The Summary of Benefits from Wellcare helps get an idea of how much financial protection the plan is generally expected to provide for common health conditions. This section also contains information on coverage for in-network and out-of-network providers.

Wellness programs (e.g., fitness, nursing hotline)	Covered

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Contact lenses

Vision	$0 copay

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Eyeglass frames

Vision	$0 copay

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Eyeglass lenses

Vision	$0 copay

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Eyeglasses (frames and lenses)

Vision	$0 copay

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Other

Vision	Not covered

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Routine eye exam

Vision	$0 copay

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Upgrades

Vision	$0 copay

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Transportation	Not covered
Skilled Nursing Facility	$0 per day for days 1 through 20 $196 per day for days 21 through 50 $0 per day for days 51 through 100

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Occupational therapy visit

Rehabilitation services	$25 copay

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Physical therapy and speech and language therapy visit

Rehabilitation services	$25 copay

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Cleaning

Preventive dental	$0 copay

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Dental x-ray(s)

Preventive dental	$0 copay

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Fluoride treatment

Preventive dental	$0 copay

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Oral exam

Preventive dental	$0 copay

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Preventive care	$0 copay
Outpatient hospital coverage	$250-400 copay per visit
In-Network Other health plan deductibles?	No
Optional supplemental benefits	No

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Inpatient hospital - psychiatric

Mental health services	$400 per day for days 1 through 4 $0 per day for days 5 through 90

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Outpatient group therapy visit

Mental health services	$25 copay

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Outpatient group therapy visit with a psychiatrist

Mental health services	$25 copay

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Outpatient individual therapy visit

Mental health services	$25 copay

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Outpatient individual therapy visit with a psychiatrist

Mental health services	$25 copay

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Chemotherapy

Medicare Part B drugs	20% coinsurance

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Other Part B drugs

Medicare Part B drugs	20% coinsurance

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Diabetes supplies

Medical equipment/supplies	$0 copay per item

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Durable medical equipment (e.g., wheelchairs, oxygen)

Medical equipment/supplies	20% coinsurance per item

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Prosthetics (e.g., braces, artificial limbs)

Medical equipment/supplies	20% coinsurance per item

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Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)	$4,500 In-network
Inpatient hospital coverage	$350 per day for days 1 through 5 $0 per day for days 6 through 90

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Fitting/evaluation

Hearing	$0 copay

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Hearing aids

Hearing	$0 copay

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Hearing exam

Hearing	$25 copay

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Health plan deductible	$0
Ground ambulance	$280 copay

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Foot exams and treatment

Foot care (podiatry services)	$25 copay

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Routine foot care

Foot care (podiatry services)	Not covered

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Emergency

Emergency care/Urgent care	$110 copay per visit (always covered)

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Urgent care

Emergency care/Urgent care	$45 copay per visit (always covered)

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Primary

Doctor visits	$0 copay

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Specialist

Doctor visits	$25 copay per visit

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Diagnostic radiology services (e.g., MRI)

Diagnostic procedures/lab services/imaging	$0-250 copay

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Diagnostic tests and procedures

Diagnostic procedures/lab services/imaging	$0-45 copay

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Lab services

Diagnostic procedures/lab services/imaging	$0 copay

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Outpatient x-rays

Diagnostic procedures/lab services/imaging	$0 copay

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Diagnostic services

Comprehensive dental	40% coinsurance

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Endodontics

Comprehensive dental	40% coinsurance

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Extractions

Comprehensive dental	40% coinsurance

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Non-routine services

Comprehensive dental	40% coinsurance

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Periodontics

Comprehensive dental	40% coinsurance

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Prosthodontics, other oral/maxillofacial surgery, other services

Comprehensive dental	40% coinsurance

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Restorative services

Comprehensive dental	40% coinsurance

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In-Network Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?	No

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Coverage Area

(Click county or state to compare all available Advantage plans)

The availability of Medicare Advantage Plans will vary according to your region. This is why the Coverage Area matters in terms of Medicare eligibility. You will always be eligible for Original Medicare, but eligibility for Wellcare No Premium (HMO) requires you to live in that plan’s service area. The service area is listed below:

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Source:CMS. Data as of Oct 1, 2022.

Last updated on December 03, 2022

Notes: Data are subject to change as contracts are finalized. For 2023, 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 2023 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.