Wellcare Giveback Open (PPO) is a Medicare Advantage Plan by Wellcare by Allwell.
This page features plan details for 2023 Wellcare Giveback Open (PPO) H9976 – 004 – 0.
IMPORTANT: This page features the 2023 version of this plan. See the 2025 version using the link below:
Wellcare Giveback Open (PPO) is offered in the following locations.
Wellcare Giveback Open (PPO) offers the following coverage and cost-sharing.
| Insurer: | Wellcare by Allwell |
| Health Plan Deductible: | $0.00 |
| MOOP: | $10,000 In and Out-of-network $6,700 In-network |
| Drugs Covered: | Yes |
Ready to sign up for Wellcare Giveback Open (PPO) ?
Get help from a licensed insurance agent.
Call 1-877-354-4611 / TTY 711.
M-F: 8:00 am – 10:00 pm EST
Sat-Sun: 8:00 am – 9:00 pm EST
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 $40.00.
| Premium Reduction: | $40.00 |
| Part B | Part C | Part D | Part B Give Back | Total |
|---|---|---|---|---|
| $164.90 | $0.00 | $0.00 | $40.00 | $ |
Wellcare Giveback Open (PPO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
| Drug Deductible: | $200.00 |
| Initial Coverage Limit: | $4,660.00 |
| Catastrophic Coverage Limit: | $7,400.00 |
| Drug Benefit Type: | Enhanced |
| Gap Coverage: | Yes |
| Formulary Link: | Formulary Link |
| Part D | LIS 25% | LIS 50% | LIS 75% | LIS Full |
|---|---|---|---|---|
| $0.00 | $43.40 | $34.80 | $26.30 | $17.70 |
After you pay your $200.00 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 $4,660.00. Once you reach that amount, you will enter the next coverage phase.
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $5.00 copay | $0.00 copay | $5.00 copay |
| 2 (Generic) | $5.00 copay | $20.00 copay | $5.00 copay | $20.00 copay |
| 3 (Preferred Brand) | $37.00 copay | $47.00 copay | $37.00 copay | $47.00 copay |
| 4 (Non-Preferred Drug) | $90.00 copay | $100.00 copay | $90.00 copay | $100.00 copay |
| 5 (Specialty Tier) | 29% | 29% | 29% | 29% |
| 6 (Select Care Drugs) | $0.00 copay | $0.00 copay | $0.00 copay | $0.00 copay |
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | ||||
| 2 (Generic) | ||||
| 3 (Preferred Brand) | ||||
| 4 (Non-Preferred Drug) | ||||
| 5 (Specialty Tier) | ||||
| 6 (Select Care Drugs) |
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $15.00 copay | $0.00 copay | $15.00 copay |
| 2 (Generic) | $15.00 copay | $60.00 copay | $0.00 copay | $60.00 copay |
| 3 (Preferred Brand) | $111.00 copay | $141.00 copay | $74.00 copay | $141.00 copay |
| 4 (Non-Preferred Drug) | $270.00 copay | $300.00 copay | $180.00 copay | $300.00 copay |
| 5 (Specialty Tier) | ||||
| 6 (Select Care Drugs) | $0.00 copay | $0.00 copay | $0.00 copay | $0.00 copay |
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 6 (Select Care Drugs) * | $0.00 copay | $0.00 copay | $0.00 copay | $0.00 copay |
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 6 (Select Care Drugs) * | $0.00 copay | $0.00 copay | $0.00 copay | $0.00 copay |
| Tier | Cost |
|---|---|
| All other tiers (Generic) | 25% |
| All other tiers (Brand-name) | 25% |
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $7,400.00, 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 | $4.15 copay or 5% (whichever costs more) |
| Brand-name drugs | $10.35 copay or 5% (whichever costs more) |
Wellcare Giveback Open (PPO) also provides the following benefits.
| In-Network: No |
| Diagnostic services: | Not covered (no limits) |
| Endodontics: | Not covered (no limits) |
| Extractions: | Not covered (no limits) |
| Non-routine services: | Not covered (no limits) |
| Periodontics: | Not covered (no limits) |
| Prosthodontics, other oral/maxillofacial surgery, other services: | Not covered (no limits) |
| Restorative services: | Not covered (no limits) |
| Cleaning: | Not covered (no limits) |
| Dental x-ray(s): | Not covered (no limits) |
| Fluoride treatment: | Not covered (no limits) |
| Oral exam: | Not covered (no limits) |
| Diagnostic radiology services (e.g., MRI): | In-Network: $0-350 copay (authorization required) (referral not required) |
| Diagnostic radiology services (e.g., MRI): | Out-of-Network: 40% coinsurance (authorization required) (referral not required) |
| Diagnostic tests and procedures: | In-Network: $0-40 copay (authorization required) (referral not required) |
| Diagnostic tests and procedures: | Out-of-Network: 40% coinsurance (authorization required) (referral not required) |
| Lab services: | In-Network: $0 copay (authorization required) (referral not required) |
| Lab services: | Out-of-Network: 40% coinsurance (authorization required) (referral not required) |
| Outpatient x-rays: | In-Network: $0 copay (authorization required) (referral not required) |
| Outpatient x-rays: | Out-of-Network: 40% coinsurance (authorization required) (referral not required) |
| Primary: | In-Network: $5 copay per visit |
| Primary: | Out-of-Network: $50 copay per visit |
| Specialist: | In-Network: $45 copay per visit (authorization required) (referral not required) |
| Specialist: | Out-of-Network: $50 copay per visit (authorization required) (referral not required) |
| Emergency: | $95 copay per visit (always covered) |
| Urgent care: | $40 copay per visit (always covered) |
| Foot exams and treatment: | In-Network: $45 copay (authorization required) (referral not required) |
| Foot exams and treatment: | Out-of-Network: $50 copay (authorization required) (referral not required) |
| Routine foot care: | In-Network: $45 copay (limits may apply) (authorization required) (referral not required) |
| Routine foot care: | Out-of-Network: $50 copay (limits may apply) (authorization required) (referral not required) |
| In-Network: $245 copay | |
| Out-of-Network: $245 copay |
| $0.00 |
| In-Network: No |
| Fitting/evaluation: | In-Network: $0 copay (limits may apply) (authorization required) (referral not required) |
| Fitting/evaluation: | Out-of-Network: 40% coinsurance (limits may apply) (authorization required) (referral not required) |
| Hearing aids: | In-Network: $0 copay (limits may apply) (authorization required) (referral not required) |
| Hearing aids: | Out-of-Network: 40% coinsurance (limits may apply) (authorization required) (referral not required) |
| Hearing exam: | In-Network: $45 copay (authorization required) (referral not required) |
| Hearing exam: | Out-of-Network: $50 copay (authorization required) (referral not required) |
| In-Network: $330 per day for days 1 through 5 $0 per day for days 6 through 90 (authorization required) (referral not required) | |
| Out-of-Network: 40% per day for days 1 through 90 (authorization required) (referral not required) |
| In-Network: $350 copay per visit (authorization required) (referral not required) | |
| Out-of-Network: 40% coinsurance per visit (authorization required) (referral not required) |
| $10,000 In and Out-of-network $6,700 In-network |
| Diabetes supplies: | In-Network: $0 copay per item (authorization required) |
| Diabetes supplies: | Out-of-Network: 20% 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: 20% 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: 20% coinsurance per item (authorization required) |
| Chemotherapy: | In-Network: 20% coinsurance (authorization required) |
| Chemotherapy: | Out-of-Network: 20% coinsurance (authorization required) |
| Other Part B drugs: | In-Network: 20% coinsurance (authorization required) |
| Other Part B drugs: | Out-of-Network: 20% coinsurance (authorization required) |
| Inpatient hospital – psychiatric: | In-Network: $350 per day for days 1 through 5 $0 per day for days 6 through 90 (authorization required) (referral not required) |
| Inpatient hospital – psychiatric: | Out-of-Network: 40% per day for days 1 through 90 (authorization required) (referral not required) |
| Outpatient group therapy visit: | In-Network: $40 copay (authorization required) (referral not required) |
| Outpatient group therapy visit: | Out-of-Network: $50 copay (authorization required) (referral not required) |
| Outpatient group therapy visit with a psychiatrist: | In-Network: $40 copay (authorization required) (referral not required) |
| Outpatient group therapy visit with a psychiatrist: | Out-of-Network: $50 copay (authorization required) (referral not required) |
| Outpatient individual therapy visit: | In-Network: $40 copay (authorization required) (referral not required) |
| Outpatient individual therapy visit: | Out-of-Network: $50 copay (authorization required) (referral not required) |
| Outpatient individual therapy visit with a psychiatrist: | In-Network: $40 copay (authorization required) (referral not required) |
| Outpatient individual therapy visit with a psychiatrist: | Out-of-Network: $50 copay (authorization required) (referral not required) |
| No |
| In-Network: $0 copay (authorization not required) (referral not required) | |
| Out-of-Network: $0 copay (authorization not required) (referral not required) |
| Occupational therapy visit: | In-Network: $40 copay (authorization required) (referral not required) |
| Occupational therapy visit: | Out-of-Network: $50 copay (authorization required) (referral not required) |
| Physical therapy and speech and language therapy visit: | In-Network: $40 copay (authorization required) (referral not required) |
| Physical therapy and speech and language therapy visit: | Out-of-Network: $50 copay (authorization required) (referral not required) |
| In-Network: $0 per day for days 1 through 20 $196 per day for days 21 through 60 $0 per day for days 61 through 100 (authorization required) (referral not required) | |
| Out-of-Network: 20% per day for days 1 through 100 (authorization required) (referral not required) |
| Not covered |
| Contact lenses: | Not covered (no limits) |
| Eyeglass frames: | Not covered (no limits) |
| Eyeglass lenses: | Not covered (no limits) |
| Eyeglasses (frames and lenses): | Not covered (no limits) |
| Other: | Not covered (no limits) |
| Routine eye exam: | Not covered (no limits) |
| Upgrades: | Not covered |
| Covered (authorization not required) (referral not required) |
Ready to sign up for Wellcare Giveback Open (PPO) ?
Get help from a licensed insurance agent.
Call 1-877-354-4611 / TTY 711.
M-F: 8:00 am – 10:00 pm EST
Sat-Sun: 8:00 am – 9:00 pm EST