Wellcare Giveback Open (PPO)
H8711 - 002 - 0
(0 / 5)
Wellcare Giveback Open (PPO) is a Medicare Advantage (Part C) Plan by Wellcare.
This page features plan details for 2022 Wellcare Giveback Open (PPO) H8711 – 002 – 0 available in Select counties in NJ.
IMPORTANT: This page features the 2022 version of this plan. See the 2024 version using the link below:
No 2024 version found. You can use the location links below to find 2024 plans in your area.
Locations
Wellcare Giveback Open (PPO) is offered in the following locations.
Plan Overview
Wellcare Giveback Open (PPO) offers the following coverage and cost-sharing.
| Insurer: | Wellcare |
| Health Plan Deductible: | $0 |
| MOOP: | $7,550.00 |
| Drugs Covered: | Yes |
Please Note:
- This plan does not charge an annual deductible for all drugs. The $300.00 annual deductible only applies to drugs on certain tiers.
Ready to sign up for Wellcare Giveback Open (PPO) ?
Medicare Part B Give Back Benefit
The Part B Premium Reduction (Medicare Part B Give Back Benefit) lowers the cost of some Medicare Advantage plans.
Wellcare Giveback Open (PPO) qualifies for a monthly Medicare Give Back Benefit of $60.00.
| Premium Reduction: | $60.00 |
Premium Breakdown
Wellcare Giveback Open (PPO) has a monthly premium of $0. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.| Part B | Part C | Part D | Part B Give Back | Total |
|---|---|---|---|---|
| $170.10 | $0.00 | $0.00 | $60.00 | $110.10 |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
- You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.
Drug Info
Wellcare Giveback Open (PPO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
| Drug Deductible: | $300.00 |
| Initial Coverage Limit: | $4,430.00 |
| Catastrophic Coverage Limit: | $7,050.00 |
| Drug Benefit Type: | Enhanced |
| Gap Coverage: | No |
| Formulary Link: | Formulary Link |
Part D Premium Reduction
The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs. The table below shows how the LIS impacts the Part D premium of this plan.| Part D | LIS 25% | LIS 50% | LIS 75% | LIS Full |
|---|---|---|---|---|
| $0.00 | $0.00 | $0.00 | $0.00 | $0.00 |
Initial Coverage Phase
After you pay your $300.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $4,430.00. Once you reach that amount, you will enter the next coverage phase.
30 Day
60 Day
90 Day
30 Day
60 Day
90 Day
Gap Coverage Phase
After your total drug costs (including what this plan has paid and what you have paid) reach $4,430.00, you will pay no more than the amounts below for any drug tier until you reach $7,050.00.
30 Day
90 Day
30 Day
90 Day
| Drug Type | Cost Share |
|---|---|
| Generic drugs | 25% |
| Brand-name drugs | 25% |
Catastrophic Coverage Phase
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $7,050.00, you will pay no more than the greater of the two amounts listed below for generic and brand-name drugs.
| Drug Type | Cost Share |
|---|---|
| Generic drugs | $3.95 copay or 5% (whichever costs more) |
| Brand-name drugs | $9.85 copay or 5% (whichever costs more) |
Additional Benefits
Wellcare Giveback Open (PPO) also provides the following benefits.
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
| In-Network: No |
Dental (comprehensive)
| Diagnostic services: | In-Network: $0 copay (limits may apply) (authorization required) |
| Diagnostic services: | Out-of-Network: $0 copay or 50% coinsurance (limits may apply) (authorization required) |
| Endodontics: | Not covered |
| Extractions: | Not covered |
| Non-routine services: | In-Network: $0 copay (limits may apply) (authorization required) |
| Non-routine services: | Out-of-Network: $0 copay or 50% coinsurance (limits may apply) (authorization required) |
| Periodontics: | Not covered |
| Prosthodontics, other oral/maxillofacial surgery, other services: | Not covered |
| Restorative services: | Not covered |
Dental (preventive)
| Cleaning: | In-Network: $0 copay (limits may apply) (authorization required) |
| Cleaning: | Out-of-Network: $0 copay or 50% coinsurance (limits may apply) (authorization required) |
| Dental x-ray(s): | In-Network: $0 copay (limits may apply) (authorization required) |
| Dental x-ray(s): | Out-of-Network: $0 copay or 50% coinsurance (limits may apply) (authorization required) |
| Fluoride treatment: | In-Network: $0 copay (limits may apply) (authorization required) |
| Fluoride treatment: | Out-of-Network: $0 copay or 50% coinsurance (limits may apply) (authorization required) |
| Oral exam: | In-Network: $0 copay (limits may apply) (authorization required) |
| Oral exam: | Out-of-Network: $0 copay or 50% coinsurance (limits may apply) (authorization required) |
Diagnostic procedures/lab services/imaging
| Diagnostic radiology services (e.g., MRI): | In-Network: $0-350 copay (authorization required) |
| Diagnostic radiology services (e.g., MRI): | Out-of-Network: 50% coinsurance (authorization required) |
| Diagnostic tests and procedures: | In-Network: $0-40 copay (authorization required) |
| Diagnostic tests and procedures: | Out-of-Network: 50% coinsurance (authorization required) |
| Lab services: | In-Network: $0 copay (authorization required) |
| Lab services: | Out-of-Network: 50% coinsurance (authorization required) |
| Outpatient x-rays: | In-Network: $0 copay (authorization required) |
| Outpatient x-rays: | Out-of-Network: 50% coinsurance (authorization required) |
Doctor visits
| Primary: | In-Network: $0 copay |
| Primary: | Out-of-Network: 40% coinsurance per visit |
| Specialist: | In-Network: $50 copay per visit (authorization required) |
| Specialist: | Out-of-Network: 50% coinsurance per visit (authorization required) |
Emergency care/Urgent care
| Emergency: | $90 copay per visit (always covered) |
| Urgent care: | $40 copay per visit (always covered) |
Foot care (podiatry services)
| Foot exams and treatment: | In-Network: $50 copay (authorization required) |
| Foot exams and treatment: | Out-of-Network: 50% coinsurance (authorization required) |
| Routine foot care: | Not covered |
Ground ambulance
| In-Network: $225 copay | |
| Out-of-Network: $225 copay |
Health plan deductible
| $0.00 |
Health plan deductibles (other)
| In-Network: No |
Hearing
| Fitting/evaluation: | In-Network: $0 copay (limits may apply) (authorization required) |
| Fitting/evaluation: | Out-of-Network: 40% coinsurance (limits may apply) (authorization required) |
| Hearing aids: | In-Network: $0 copay (limits may apply) (authorization required) |
| Hearing aids: | Out-of-Network: 40% coinsurance (limits may apply) (authorization required) |
| Hearing exam: | In-Network: $50 copay (authorization required) |
| Hearing exam: | Out-of-Network: 50% coinsurance (authorization required) |
Hospital coverage (inpatient)
| In-Network: $330 per day for days 1 through 5 $0 per day for days 6 through 90 (authorization required) | |
| Out-of-Network: 20% per day for days 1 through 90 (authorization required) |
Hospital coverage (outpatient)
| In-Network: $350 copay per visit (authorization required) | |
| Out-of-Network: 50% coinsurance per visit (authorization required) |
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
| $11,300 In and Out-of-network $7,550 In-network |
Medical equipment/supplies
| Diabetes supplies: | In-Network: $0 copay per item (authorization required) |
| Diabetes supplies: | Out-of-Network: 50% coinsurance per item (authorization required) |
| Durable medical equipment (e.g., wheelchairs, oxygen): | In-Network: 20% coinsurance per item (authorization required) |
| Durable medical equipment (e.g., wheelchairs, oxygen): | Out-of-Network: 50% coinsurance per item (authorization required) |
| Prosthetics (e.g., braces, artificial limbs): | In-Network: 20% coinsurance per item (authorization required) |
| Prosthetics (e.g., braces, artificial limbs): | Out-of-Network: 50% coinsurance per item (authorization required) |
Medicare Part B drugs
| Chemotherapy: | In-Network: 20% coinsurance (authorization required) |
| Chemotherapy: | Out-of-Network: 40% coinsurance (authorization required) |
| Other Part B drugs: | In-Network: 20% coinsurance (authorization required) |
| Other Part B drugs: | Out-of-Network: 40% coinsurance (authorization required) |
Mental health services
| Inpatient hospital – psychiatric: | In-Network: $1,850 per stay (authorization required) |
| Inpatient hospital – psychiatric: | Out-of-Network: 50% per day for days 1 through 90 (authorization required) |
| Outpatient group therapy visit with a psychiatrist: | In-Network: $25 copay (authorization required) |
| Outpatient group therapy visit with a psychiatrist: | Out-of-Network: 50% coinsurance (authorization required) |
| Outpatient group therapy visit: | In-Network: $25 copay (authorization required) |
| Outpatient group therapy visit: | Out-of-Network: 50% coinsurance (authorization required) |
| Outpatient individual therapy visit with a psychiatrist: | In-Network: $25 copay (authorization required) |
| Outpatient individual therapy visit with a psychiatrist: | Out-of-Network: 50% coinsurance (authorization required) |
| Outpatient individual therapy visit: | In-Network: $25 copay (authorization required) |
| Outpatient individual therapy visit: | Out-of-Network: 50% coinsurance (authorization required) |
Optional supplemental benefits
| No |
Preventive care
| In-Network: $0 copay | |
| Out-of-Network: $0 copay |
Rehabilitation services
| Occupational therapy visit: | In-Network: $40 copay (authorization required) |
| Occupational therapy visit: | Out-of-Network: 50% coinsurance (authorization required) |
| Physical therapy and speech and language therapy visit: | In-Network: $40 copay (authorization required) |
| Physical therapy and speech and language therapy visit: | Out-of-Network: 50% coinsurance (authorization required) |
Skilled Nursing Facility
| In-Network: $0 per day for days 1 through 20 $184 per day for days 21 through 100 (authorization required) | |
| Out-of-Network: 20% per day for days 1 through 100 (authorization required) |
Transportation
| Not covered |
Vision
| Contact lenses: | In-Network: $0 copay (limits may apply) (authorization required) |
| Contact lenses: | Out-of-Network: 40% coinsurance (limits may apply) (authorization required) |
| Eyeglass frames: | In-Network: $0 copay (limits may apply) (authorization required) |
| Eyeglass frames: | Out-of-Network: 40% coinsurance (limits may apply) (authorization required) |
| Eyeglass lenses: | In-Network: $0 copay (limits may apply) (authorization required) |
| Eyeglass lenses: | Out-of-Network: 40% coinsurance (limits may apply) (authorization required) |
| Eyeglasses (frames and lenses): | In-Network: $0 copay (limits may apply) (authorization required) |
| Eyeglasses (frames and lenses): | Out-of-Network: 40% coinsurance (limits may apply) (authorization required) |
| Other: | Not covered |
| Routine eye exam: | In-Network: $0 copay (limits may apply) (authorization required) |
| Routine eye exam: | Out-of-Network: 40% coinsurance (limits may apply) (authorization required) |
| Upgrades: | In-Network: $0 copay (limits may apply) (authorization required) |
| Upgrades: | Out-of-Network: 40% coinsurance (limits may apply) (authorization required) |
Wellness programs (e.g., fitness, nursing hotline)
| Covered |
Ready to sign up for Wellcare Giveback Open (PPO) ?