2027 Medicare Advantage plan

Wellcare Giveback (HMO-POS): 2027 benefits and costs

Wellcare HMO-POS

CMS plan ID: H1215-003-0 · Plan year: 2027

Wellcare Giveback (HMO-POS) is a 2027 Medicare Advantage plan offered by Wellcare. It is listed in Nebraska.

2027 plan costs at a glance

Monthly plan premium$0.00
Drug deductible$700.00
In-network medical out-of-pocket maximum$8,850.00
Organization
Wellcare
Plan organization
NEBRASKA TOTAL CARE, INC.
Parent company
Centene Corporation
Plan type
HMO-POS
Part C premium
$0.00
Part D premium
$0.00
Prescription drug coverage
Yes
2027 CMS Star Rating
Standard monthly Medicare Part B premium
$209.50 (estimated)
Monthly Part B premium after plan reduction
$189.50 (estimated)$209.50 standard premium less $20.00 plan reduction.

You must continue to pay your Medicare Part B premium.

In-network medical deductible
$375.00

Applies to certain in-network Medicare-covered services.

Combined in/out-of-network medical deductible
None
Out-of-network medical deductible
None
In-network medical maximum
$8,850.00
Combined in/out-of-network medical maximum
Not applicable
Out-of-network medical maximum
Not applicable
Part B premium reduction
$20.00

2027 benefit summary

Doctor visits and medical care

Plan-level deductibles may still apply when a service-specific deductible is listed as No.

Common medical services and member costs
ServiceIn-networkWhat to know
Primary care doctor

$0.00 copay

Service-specific deductible
No
Specialist visit

$55.00 copay

Service-specific deductible
No
Approval required
Yes
Referral required
Yes
Telehealth

$0.00 to $55.00 copay

Service-specific deductible
No
Approval required
Yes
Referral required
Yes
Emergency care

$115.00 copay

Urgent care

$35.00 copay

Home health

$0.00 copay

Service-specific deductible
No
Approval required
Yes
Referral required
Yes
Dialysis

20% coinsurance

Service-specific deductible
No
Approval required
No
Referral required
Yes
Part B chemotherapy and radiation drugs

0% to 20% coinsurance

Deductible applies
No
Approval required
Yes
Other Part B drugs

0% to 20% coinsurance

Deductible applies
No
Approval required
Yes
Kidney disease education services

20% coinsurance

Service-specific deductible
No
Approval required
No
Referral required
Yes
Medicare-covered chiropractic

$15.00 copay

Service-specific deductible
No
Approval required
Yes
Referral required
Yes
Medicare-covered foot care

$55.00 copay

Service-specific deductible
No
Approval required
Yes
Referral required
Yes
Other health professionals

$0.00 to $55.00 copay

Service-specific deductible
No
Approval required
Yes
Referral required
Yes

Hospital, outpatient surgery and observation care

Inpatient stays and skilled nursing care

In-network stays. Charges can depend on the number of days and the benefit period.
CareYour share of the costWhat to know
Inpatient hospital stay

$1,450.00 copay per stay

Approval required
Yes
Referral required
Yes
Benefit period
Per Admission or Per Stay
Inpatient mental health care

$1,937.00 copay per stay

Approval required
Yes
Referral required
Yes
Benefit period
Per Admission or Per Stay
Skilled nursing facility

Days 1–20: $0.00 copay per day

Days 21–70: $221.00 copay per day

Days 71–100: $0.00 copay per day

Approval required
Yes
Referral required
Yes
Benefit period
Per Admission or Per Stay

See plan documents for out-of-network hospital and skilled nursing costs.

Hospital, outpatient surgery and observation care and member costs
ServiceIn-networkWhat to know
Outpatient hospital care

$0.00 to $450.00 copay

Service-specific deductible
No
Hospital observation services

$115.00 to $450.00 copay

Service-specific deductible
No
Ambulatory surgical center

$225.00 copay

Service-specific deductible
No
Approval required
Yes
Referral required
Yes
Outpatient blood

$0.00 copay

Service-specific deductible
No
Approval required
No
Referral required
Yes

Tests, imaging and laboratory services

Tests, imaging and laboratory services and member costs
ServiceIn-networkWhat to know
Diagnostic procedures and tests

$0.00 to $50.00 copay

Service-specific deductible
No
Approval required
Yes
Referral required
Yes
Laboratory services

$0.00 to $50.00 copay

Service-specific deductible
No
Approval required
Yes
Referral required
Yes
Diagnostic radiology (CT, MRI)

$0.00 to $450.00 copay

Service-specific deductible
No
Approval required
Yes
Referral required
Yes
Therapeutic radiology

20% coinsurance

Service-specific deductible
No
Approval required
Yes
Referral required
Yes
X-rays

$50.00 copay

Service-specific deductible
No
Approval required
Yes
Referral required
Yes

Mental health and substance use treatment

Mental health and substance use treatment and member costs
ServiceIn-networkWhat to know
Partial hospitalization

$115.00 copay

Service-specific deductible
No
Approval required
Yes
Referral required
Yes
Intensive outpatient program

$120.00 copay

Service-specific deductible
No
Approval required
Yes
Referral required
Yes
Substance use treatment, individual sessions

$40.00 copay

Service-specific deductible
No
Approval required
Yes
Referral required
Yes
Substance use treatment, group sessions

$40.00 copay

Service-specific deductible
No
Approval required
Yes
Referral required
Yes
Opioid treatment program

$55.00 copay

Service-specific deductible
No
Approval required
Yes
Referral required
Yes
Mental health, individual sessions

$40.00 copay

Service-specific deductible
No
Approval required
Yes
Referral required
Yes
Mental health, group sessions

$40.00 copay

Service-specific deductible
No
Approval required
Yes
Referral required
Yes
Psychiatry, individual sessions

$40.00 copay

Service-specific deductible
No
Approval required
Yes
Referral required
Yes
Psychiatry, group sessions

$40.00 copay

Service-specific deductible
No
Approval required
Yes
Referral required
Yes

Therapy and rehabilitation

Therapy and rehabilitation and member costs
ServiceIn-networkWhat to know
Occupational therapy

$35.00 copay

Service-specific deductible
No
Approval required
Yes
Referral required
Yes
Physical and speech therapy

$35.00 copay

Service-specific deductible
No
Approval required
Yes
Referral required
Yes
Cardiac rehabilitation

$30.00 copay

Service-specific deductible
No
Approval required
No
Referral required
Yes
Intensive cardiac rehabilitation

$40.00 copay

Service-specific deductible
No
Approval required
No
Referral required
Yes
Pulmonary rehabilitation

$25.00 copay

Service-specific deductible
No
Approval required
No
Referral required
Yes
Supervised exercise for peripheral artery disease

$20.00 copay

Service-specific deductible
No
Approval required
No
Referral required
Yes

Ambulance, medical equipment and supplies

Ambulance, medical equipment and supplies and member costs
ServiceIn-networkWhat to know
Ground ambulance

$315.00 copay

Service-specific deductible
No
Approval required
Yes
Air ambulance

$315.00 copay

Service-specific deductible
No
Approval required
Yes
Durable medical equipment

20% coinsurance

Service-specific deductible
No
Approval required
Yes
Prosthetic devices

20% coinsurance

Service-specific deductible
No
Approval required
Yes
Medical supplies

20% coinsurance

Service-specific deductible
No
Approval required
Yes
Diabetic supplies

$0.00 copay

Service-specific deductible
No
Approval required
Yes
Diabetic shoes and inserts

20% coinsurance

Service-specific deductible
No
Approval required
Yes
Diabetic monitors

0% coinsurance

Service-specific deductible
No
Approval required
Yes

Dental benefits

Dental benefits and member costs
ServiceIn-networkPoint-of-serviceWhat to know
Medicare-covered dental

$55.00 copay

Not summarized. Check coverage with the plan.

Oral examsAdditional plan benefit

$0.00 copay

25% coinsurance

Deductible applies
No
Dollar benefit limit applies
No
Dental X-raysAdditional plan benefit

$0.00 copay

25% coinsurance

Deductible applies
No
Dollar benefit limit applies
No
Other diagnostic dentalAdditional plan benefit

$0.00 copay

25% coinsurance

Deductible applies
No
Dollar benefit limit applies
No
Dental cleaningAdditional plan benefit

$0.00 copay

25% coinsurance

Deductible applies
No
Dollar benefit limit applies
No
FluorideAdditional plan benefit

$0.00 copay

25% coinsurance

Deductible applies
No
Dollar benefit limit applies
No
Other preventive dentalAdditional plan benefit

$0.00 copay

25% coinsurance

Deductible applies
No
Dollar benefit limit applies
No
Other dental servicesAdditional plan benefit

$0.00 copay

25% coinsurance

Deductible applies
No
Dollar benefit limit applies
No

Vision benefits

Vision benefits and member costs
ServiceIn-networkWhat to know
Medicare-covered eye exams

$0.00 to $55.00 copay

Service-specific deductible
No
Approval required
Yes
Referral required
No
Medicare-covered eyewear

$0.00 copay

Service-specific deductible
No
Approval required
No
Referral required
No

Hearing benefits

Hearing benefits and member costs
ServiceIn-networkWhat to know
Medicare-covered hearing exams

$55.00 copay

Service-specific deductible
No
Approval required
Yes
Referral required
No
Routine hearing examsAdditional plan benefit

$0.00 copay

Approval required
Yes
Referral required
No
Hearing aid fitting and evaluationAdditional plan benefit

$0.00 copay

Approval required
Yes
Referral required
No
Prescription hearing aids (all types)Additional plan benefit

$0.00 copay

Service-specific deductible
No
Approval required
Yes
Referral required
No

Extra benefits

Extra benefits and member costs
ServiceIn-networkWhat to know
Annual physical examAdditional plan benefit

$0.00 copay

Service-specific deductible
No
Approval required
No
Referral required
No
Fitness benefitAdditional plan benefit

$0.00 copay

Service-specific deductible
No
Approval required
No
Referral required
No

Prescription drug coverage

Costs shown are for initial coverage.

Drug deductible exceptions: Tier 1; Tier 6 are exempt from the deductible.

Preferred retail costs

On a small screen, scroll the table sideways to compare all fill lengths.

Preferred retail: initial-coverage cost per prescription fill
Drug tier30 days60 days100 days
Tier 1Generic

$0.00

$0.00

$0.00

Tier 2Preferred Brand

25%

25%

25%

Tier 3Non-Preferred Drug

50%

50%

50%

Tier 4Injectable Drugs

1%

1%

1%

Tier 5Specialty Tier

25%

Not listedNot listed
Tier 6Select Care Drugs

$0.00

$0.00

$0.00

Standard retail costs

On a small screen, scroll the table sideways to compare all fill lengths.

Standard retail: initial-coverage cost per prescription fill
Drug tier30 days60 days100 days
Tier 1Generic

$10.00

$20.00

$30.00

Tier 2Preferred Brand

25%

25%

25%

Tier 3Non-Preferred Drug

50%

50%

50%

Tier 4Injectable Drugs

1%

1%

1%

Tier 5Specialty Tier

25%

Not listedNot listed
Tier 6Select Care Drugs

$0.00

$0.00

$0.00

Mail-order and other pharmacies

Out-of-network pricing: You pay the standard retail copay or coinsurance, plus any difference between the pharmacy’s billed charge and the amount the plan allows at a standard retail pharmacy.

Preferred mail order costs

Preferred mail order: initial-coverage cost per prescription fill
Drug tier60 days100 days
Tier 1Generic

$0.00

$0.00

Tier 2Preferred Brand

25%

25%

Tier 3Non-Preferred Drug

50%

50%

Tier 4Injectable Drugs

1%

1%

Tier 6Select Care Drugs

$0.00

$0.00

Standard mail order costs

Standard mail order: initial-coverage cost per prescription fill
Drug tier60 days100 days
Tier 1Generic

$20.00

$30.00

Tier 2Preferred Brand

25%

25%

Tier 3Non-Preferred Drug

50%

50%

Tier 4Injectable Drugs

1%

1%

Tier 6Select Care Drugs

$0.00

$0.00

Long-term care pharmacy costs

Long-term care pharmacy: initial-coverage cost per prescription fill
Drug tier31 days
Tier 1Generic

$10.00

Tier 2Preferred Brand

25%

Tier 3Non-Preferred Drug

50%

Tier 4Injectable Drugs

1%

Tier 5Specialty Tier

25%

Tier 6Select Care Drugs

$0.00

Out-of-network pharmacy costs

Out-of-network pharmacy: initial-coverage cost per prescription fill
Drug tier30 days
Tier 1Generic

$10.00

Tier 2Preferred Brand

25%

Tier 3Non-Preferred Drug

50%

Tier 4Injectable Drugs

1%

Tier 5Specialty Tier

25%

Tier 6Select Care Drugs

$0.00

Drug coverage rules and exceptions

Tier 1: Generic

Drugs included in this tier
Both Part D and Excluded Drugs
Longer fills available for every covered drug
Yes
Some longer-fill prescriptions require a one-month first fill
No

Tier 2: Preferred Brand

Drugs included in this tier
Part D Drugs Only
Longer fills available for every covered drug
Yes
Some longer-fill prescriptions require a one-month first fill
No

Tier 3: Non-Preferred Drug

Drugs included in this tier
Part D Drugs Only
Longer fills available for every covered drug
Yes
Some longer-fill prescriptions require a one-month first fill
No

Tier 4: Injectable Drugs

Drugs included in this tier
Part D Drugs Only
Longer fills available for every covered drug
Yes
Some longer-fill prescriptions require a one-month first fill
No

Tier 5: Specialty Tier

Drugs included in this tier
Part D Drugs Only

Tier 6: Select Care Drugs

Drugs included in this tier
Part D Drugs Only
Longer fills available for every covered drug
Yes
Some longer-fill prescriptions require a one-month first fill
No
Initial-coverage prices also apply to drugs exempt from the deductible
Yes

Special cost protections apply to covered insulin and recommended adult vaccines.

Where this plan is offered

CMS lists this plan in 1 state or territory. Availability can vary by county and ZIP code.

View all locations 54 county listings across 1 state or territory

Nebraska