Wellcare Advantage No Premium (PFFS)
H2816 - 040 - 0
(4 / 5)
Wellcare Advantage No Premium (PFFS) is a Medicare Advantage (Part C) Plan by Wellcare.
This page features plan details for 2024 Wellcare Advantage No Premium (PFFS) H2816 – 040 – 0 available in Select counties in ME.
IMPORTANT: This page has been updated with plan and premium data for 2024.
Locations
Wellcare Advantage No Premium (PFFS) is offered in the following locations.
Plan Overview
Wellcare Advantage No Premium (PFFS) offers the following coverage and cost-sharing.
| Insurer: | Wellcare |
| Health Plan Deductible: | $0.00 |
| MOOP: | $6,700 In and Out-of-network |
| Drugs Covered: | No |
Ready to sign up for Wellcare Advantage No Premium (PFFS) ?
Premium Breakdown
Wellcare Advantage No Premium (PFFS) has a monthly premium of $0.00. This amount includes your Part C premium but does not include your Part B premium.| Part B | Part C | Part B Give Back | Total |
|---|---|---|---|
| $174.70 | $0.00 | $0.00 | $174.70 |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
Additional Benefits
Wellcare Advantage No Premium (PFFS) also provides the following benefits.
| $0 |
| In-network | No |
| $6,700 In and Out-of-network |
| No |
| In-network | No |
| In-network | $0-300 copay per visit (Authorization is not required.) (Referral is not required.) |
| out-of-network | 30% coinsurance per visit (Authorization is not required.) (Referral is not required.) |
| In-network Primary | $10 copay per visit (Not applicable.) (Not applicable.) |
| out-of-network Primary | $20 copay per visit (Not applicable.) (Not applicable.) |
| In-network Specialist | $35 copay per visit (Authorization is not required.) (Referral is not required.) |
| out-of-network Specialist | $50 copay per visit (Authorization is not required.) (Referral is not required.) |
| In-network | $0 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network | $0 copay (Authorization is not required.) (Referral is not required.) |
| Emergency | $100 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Urgent care | $35 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| In-network Diagnostic tests and procedures | $0 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Diagnostic tests and procedures | 30% coinsurance (Authorization is not required.) (Referral is not required.) |
| In-network Lab services | $0-50 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Lab services | 30% coinsurance (Authorization is not required.) (Referral is not required.) |
| In-network Diagnostic radiology services (e.g., MRI) | $0-250 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Diagnostic radiology services (e.g., MRI) | 30% coinsurance (Authorization is not required.) (Referral is not required.) |
| In-network Outpatient x-rays | $0 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Outpatient x-rays | 30% coinsurance (Authorization is not required.) (Referral is not required.) |
| In-network Hearing exam | $35 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Hearing exam | $50 copay (Authorization is not required.) (Referral is not required.) |
| In-network Fitting/evaluation | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Fitting/evaluation | 40% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Hearing aids – inner ear | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Hearing aids – outer ear | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Hearing aids – over the ear | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Oral exam | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Cleaning | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Fluoride treatment | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Dental x-ray(s) | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Non-routine services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Diagnostic services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Restorative services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Endodontics | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Periodontics | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Extractions | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Prosthodontics, other oral/maxillofacial surgery, other services | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| In-network Routine eye exam | $0 copay (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| out-of-network Routine eye exam | 40% coinsurance (Limits may apply.) (Authorization is not required.) (Referral is not required.) |
| Other | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Contact lenses | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Eyeglasses (frames and lenses) | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Eyeglass frames | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Eyeglass lenses | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Upgrades | Not covered (Not applicable.) (Not applicable.) |
| In-network Occupational therapy visit | $35 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Occupational therapy visit | 30% coinsurance (Authorization is not required.) (Referral is not required.) |
| In-network Physical therapy and speech and language therapy visit | $35 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Physical therapy and speech and language therapy visit | 30% coinsurance (Authorization is not required.) (Referral is not required.) |
| In-network | $300 copay (Not applicable.) (Not applicable.) |
| out-of-network | $300 copay (Not applicable.) (Not applicable.) |
| Not covered (Not applicable.) (Not applicable.) |
| In-network Foot exams and treatment | $35 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Foot exams and treatment | $50 copay (Authorization is not required.) (Referral is not required.) |
| Routine foot care | Not covered (Not applicable.) (Not applicable.) |
| In-network Durable medical equipment (e.g., wheelchairs, oxygen) | 20% coinsurance per item (Authorization is not required.) (Not applicable.) |
| out-of-network Durable medical equipment (e.g., wheelchairs, oxygen) | 20% coinsurance per item (Authorization is not required.) (Not applicable.) |
| In-network Prosthetics (e.g., braces, artificial limbs) | 20% coinsurance per item (Authorization is not required.) (Not applicable.) |
| out-of-network Prosthetics (e.g., braces, artificial limbs) | 20% coinsurance per item (Authorization is not required.) (Not applicable.) |
| In-network Diabetes supplies | $0 copay per item (Authorization is not required.) (Not applicable.) |
| out-of-network Diabetes supplies | 20% coinsurance per item (Authorization is not required.) (Not applicable.) |
| Covered (Authorization is not required.) (Referral is not required.) |
| In-network Chemotherapy | 0-20% coinsurance (Authorization is not required.) (Not applicable.) |
| out-of-network Chemotherapy | $35 copay or 0-30% coinsurance (Authorization is not required.) (Not applicable.) |
| In-network Other Part B drugs | 0-20% coinsurance (Authorization is not required.) (Not applicable.) |
| out-of-network Other Part B drugs | $35 copay or 0-30% coinsurance (Authorization is not required.) (Not applicable.) |
| In-network Part B Insulin drugs | $35 copay (Authorization is not required.) (Not applicable.) |
| out-of-network Part B Insulin drugs | $35 copay or 0-30% coinsurance (Authorization is not required.) (Not applicable.) |
| In-network | $300 per day for days 1 through 6 $0 per day for days 7 through 90 (Authorization is not required.) (Referral is not required.) |
| out-of-network | $350 per day for days 1 through 7 $0 per day for days 8 through 90 (Authorization is not required.) (Referral is not required.) |
| In-network Inpatient hospital – psychiatric | $260 per day for days 1 through 6 $0 per day for days 7 through 90 (Authorization is not required.) (Referral is not required.) |
| out-of-network Inpatient hospital – psychiatric | $300 per day for days 1 through 7 $0 per day for days 8 through 90 (Authorization is not required.) (Referral is not required.) |
| In-network Outpatient group therapy visit with a psychiatrist | $25 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Outpatient group therapy visit with a psychiatrist | 30% coinsurance (Authorization is not required.) (Referral is not required.) |
| In-network Outpatient individual therapy visit with a psychiatrist | $25 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Outpatient individual therapy visit with a psychiatrist | 30% coinsurance (Authorization is not required.) (Referral is not required.) |
| In-network Outpatient group therapy visit | $25 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Outpatient group therapy visit | 30% coinsurance (Authorization is not required.) (Referral is not required.) |
| In-network Outpatient individual therapy visit | $25 copay (Authorization is not required.) (Referral is not required.) |
| out-of-network Outpatient individual therapy visit | 30% coinsurance (Authorization is not required.) (Referral is not required.) |
| In-network | $0 per day for days 1 through 20 $203 per day for days 21 through 60 $0 per day for days 61 through 100 (Authorization is not required.) (Referral is not required.) |
| out-of-network | $0 per day for days 1 through 20 $203 per day for days 21 through 100 (Authorization is not required.) (Referral is not required.) |
Ready to sign up for Wellcare Advantage No Premium (PFFS) ?
Table of Contents
SMID: MULTIPLAN_HCIHNDOGMED01_M
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