Wellcare No Premium Open (PPO)
H2775 - 109 - 0
(2.5 / 5)
Wellcare No Premium Open (PPO) is a Medicare Advantage (Part C) Plan by Wellcare.
This page features plan details for 2023 Wellcare No Premium Open (PPO) H2775 – 109 – 0 available in All counties in ME.
IMPORTANT: This page has been updated with plan and premium data for 2023.
Locations
Wellcare No Premium Open (PPO) is offered in the following locations.
Plan Overview
Wellcare No Premium Open (PPO) offers the following coverage and cost-sharing.
| Insurer: | Wellcare |
| Health Plan Deductible: | $0.00 |
| MOOP: | $8,950 In and Out-of-network $5,000 In-network |
| Drugs Covered: | Yes |
Ready to sign up for Wellcare No Premium Open (PPO) ?
Get help from a licensed insurance agent.
Click to Call 1-877-354-4611 TTY 711.
Mon-Fri 8am-9pm EST | Sat 8am-8pm EST.
Premium Breakdown
Wellcare No Premium Open (PPO) has a monthly premium of $0.00. 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 |
|---|---|---|---|---|
| $164.90 | $0.00 | $0.00 | $0.00 | $164.90 |
- 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 No Premium Open (PPO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
| Drug Deductible: | $0.00 |
| Initial Coverage Limit: | $4,660.00 |
| Catastrophic Coverage Limit: | $7,400.00 |
| 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 | $43.40 | $34.80 | $26.30 | $17.70 |
Initial Coverage Phase
After you pay your $0.00 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.
30 Day
60 Day
90 Day
30 Day
| 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) | $4.00 copay | $10.00 copay | $4.00 copay | $10.00 copay |
| 3 (Preferred Brand) | $37.00 copay | $47.00 copay | $37.00 copay | $47.00 copay |
| 4 (Non-Preferred Drug) | 45% | 47% | 45% | 47% |
| 5 (Specialty Tier) | 33% | 33% | 33% | 33% |
| 6 (Select Care Drugs) | $0.00 copay | $0.00 copay | $0.00 copay | $0.00 copay |
60 Day
| 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) |
90 Day
| 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) | $12.00 copay | $30.00 copay | $0.00 copay | $30.00 copay |
| 3 (Preferred Brand) | $111.00 copay | $141.00 copay | $74.00 copay | $141.00 copay |
| 4 (Non-Preferred Drug) | 45% | 47% | 45% | 47% |
| 5 (Specialty Tier) | ||||
| 6 (Select Care Drugs) | $0.00 copay | $0.00 copay | $0.00 copay | $0.00 copay |
Gap Coverage Phase
After your total drug costs (including what this plan has paid and what you have paid) reach $4,660.00, you will pay no more than the amounts below for any drug tier until you reach $7,400.00.
30 Day
90 Day
30 Day
90 Day
| Tier | Cost |
|---|---|
| All other tiers (Generic) | 25% |
| All other tiers (Brand-name) | 25% |
Catastrophic Coverage Phase
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $7,400.00, 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) |
Additional Benefits
Wellcare No Premium 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) (referral not required) |
| Diagnostic services: | Out-of-Network: 50% coinsurance (limits may apply) (authorization required) (referral not required) |
| Endodontics: | In-Network: $0 copay (limits may apply) (authorization required) (referral not required) |
| Endodontics: | Out-of-Network: 50% coinsurance (limits may apply) (authorization required) (referral not required) |
| Extractions: | In-Network: $0 copay (limits may apply) (authorization required) (referral not required) |
| Extractions: | Out-of-Network: 50% coinsurance (limits may apply) (authorization required) (referral not required) |
| Non-routine services: | In-Network: $0 copay (limits may apply) (authorization required) (referral not required) |
| Non-routine services: | Out-of-Network: 50% coinsurance (limits may apply) (authorization required) (referral not required) |
| Periodontics: | In-Network: $0 copay (limits may apply) (authorization required) (referral not required) |
| Periodontics: | Out-of-Network: 50% coinsurance (limits may apply) (authorization required) (referral not required) |
| Prosthodontics, other oral/maxillofacial surgery, other services: | In-Network: $0 copay (limits may apply) (authorization required) (referral not required) |
| Prosthodontics, other oral/maxillofacial surgery, other services: | Out-of-Network: 50% coinsurance (limits may apply) (authorization required) (referral not required) |
| Restorative services: | In-Network: $0 copay (limits may apply) (authorization required) (referral not required) |
| Restorative services: | Out-of-Network: 50% coinsurance (limits may apply) (authorization required) (referral not required) |
Dental (preventive)
| Cleaning: | In-Network: $0 copay (limits may apply) (authorization required) (referral not required) |
| Cleaning: | Out-of-Network: 50% coinsurance (limits may apply) (authorization required) (referral not required) |
| Dental x-ray(s): | In-Network: $0 copay (limits may apply) (authorization required) (referral not required) |
| Dental x-ray(s): | Out-of-Network: 50% coinsurance (limits may apply) (authorization required) (referral not required) |
| Fluoride treatment: | In-Network: $0 copay (limits may apply) (authorization required) (referral not required) |
| Fluoride treatment: | Out-of-Network: 50% coinsurance (limits may apply) (authorization required) (referral not required) |
| Oral exam: | In-Network: $0 copay (limits may apply) (authorization required) (referral not required) |
| Oral exam: | Out-of-Network: 50% coinsurance (limits may apply) (authorization required) (referral not required) |
Diagnostic procedures/lab services/imaging
| Diagnostic radiology services (e.g., MRI): | In-Network: $0-300 copay (authorization required) (referral not required) |
| Diagnostic radiology services (e.g., MRI): | Out-of-Network: 30% coinsurance (authorization required) (referral not required) |
| Diagnostic tests and procedures: | In-Network: $0-20 copay (authorization required) (referral not required) |
| Diagnostic tests and procedures: | Out-of-Network: 30% coinsurance (authorization required) (referral not required) |
| Lab services: | In-Network: $0 copay (authorization required) (referral not required) |
| Lab services: | Out-of-Network: 30% coinsurance (authorization required) (referral not required) |
| Outpatient x-rays: | In-Network: $0 copay (authorization required) (referral not required) |
| Outpatient x-rays: | Out-of-Network: 30% coinsurance (authorization required) (referral not required) |
Doctor visits
| Primary: | In-Network: $0 copay |
| Primary: | Out-of-Network: $25 copay per visit |
| Specialist: | In-Network: $30 copay per visit (authorization required) (referral not required) |
| Specialist: | Out-of-Network: $50 copay per visit (authorization required) (referral not required) |
Emergency care/Urgent care
| Emergency: | $110 copay per visit (always covered) |
| Urgent care: | $35 copay per visit (always covered) |
Foot care (podiatry services)
| Foot exams and treatment: | In-Network: $30 copay (authorization required) (referral not required) |
| Foot exams and treatment: | Out-of-Network: $50 copay (authorization required) (referral not required) |
| Routine foot care: | Not covered |
Ground ambulance
| In-Network: $300 copay | |
| Out-of-Network: $300 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) (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: $30 copay (authorization required) (referral not required) |
| Hearing exam: | Out-of-Network: $50 copay (authorization required) (referral not required) |
Hospital coverage (inpatient)
| In-Network: $275 per day for days 1 through 6 $0 per day for days 7 through 90 (authorization required) (referral not required) | |
| Out-of-Network: $300 per day for days 1 through 7 $0 per day for days 8 through 90 (authorization required) (referral not required) |
Hospital coverage (outpatient)
| In-Network: $300 copay per visit (authorization required) (referral not required) | |
| Out-of-Network: 30% coinsurance per visit (authorization required) (referral not required) |
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
| $8,950 In and Out-of-network $5,000 In-network |
Medical equipment/supplies
| 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) |
Medicare Part B drugs
| Chemotherapy: | In-Network: 20% coinsurance (authorization required) |
| Chemotherapy: | Out-of-Network: 30% coinsurance (authorization required) |
| Other Part B drugs: | In-Network: 20% coinsurance (authorization required) |
| Other Part B drugs: | Out-of-Network: 30% coinsurance (authorization required) |
Mental health services
| Inpatient hospital – psychiatric: | In-Network: $300 per day for days 1 through 6 $0 per day for days 7 through 90 (authorization required) (referral not required) |
| Inpatient hospital – psychiatric: | Out-of-Network: $300 per day for days 1 through 7 $0 per day for days 8 through 90 (authorization required) (referral not required) |
| Outpatient group therapy visit: | In-Network: $25 copay (authorization required) (referral not required) |
| Outpatient group therapy visit: | Out-of-Network: 30% coinsurance (authorization required) (referral not required) |
| Outpatient group therapy visit with a psychiatrist: | In-Network: $25 copay (authorization required) (referral not required) |
| Outpatient group therapy visit with a psychiatrist: | Out-of-Network: 30% coinsurance (authorization required) (referral not required) |
| Outpatient individual therapy visit: | In-Network: $25 copay (authorization required) (referral not required) |
| Outpatient individual therapy visit: | Out-of-Network: 30% coinsurance (authorization required) (referral not required) |
| Outpatient individual therapy visit with a psychiatrist: | In-Network: $25 copay (authorization required) (referral not required) |
| Outpatient individual therapy visit with a psychiatrist: | Out-of-Network: 30% coinsurance (authorization required) (referral not required) |
Optional supplemental benefits
| No |
Preventive care
| In-Network: $0 copay (authorization not required) (referral not required) | |
| Out-of-Network: $0 copay (authorization not required) (referral not required) |
Rehabilitation services
| Occupational therapy visit: | In-Network: $30 copay (authorization required) (referral not required) |
| Occupational therapy visit: | Out-of-Network: 30% coinsurance (authorization required) (referral not required) |
| Physical therapy and speech and language therapy visit: | In-Network: $30 copay (authorization required) (referral not required) |
| Physical therapy and speech and language therapy visit: | Out-of-Network: 30% coinsurance (authorization required) (referral not required) |
Skilled Nursing Facility
| In-Network: $0 per day for days 1 through 20 $196 per day for days 21 through 50 $0 per day for days 51 through 100 (authorization required) (referral not required) | |
| Out-of-Network: $0 per day for days 1 through 20 $196 per day for days 21 through 100 (authorization required) (referral not required) |
Transportation
| In-Network: $0 copay (limits may apply) (authorization required) (referral not required) | |
| Out-of-Network: 75% coinsurance (limits may apply) (authorization required) (referral not required) |
Vision
| Contact lenses: | In-Network: $0 copay (limits may apply) (authorization required) (referral not required) |
| Contact lenses: | Out-of-Network: 40% coinsurance (limits may apply) (authorization required) (referral not required) |
| Eyeglass frames: | In-Network: $0 copay (limits may apply) (authorization required) (referral not required) |
| Eyeglass frames: | Out-of-Network: 40% coinsurance (limits may apply) (authorization required) (referral not required) |
| Eyeglass lenses: | In-Network: $0 copay (limits may apply) (authorization required) (referral not required) |
| Eyeglass lenses: | Out-of-Network: 40% coinsurance (limits may apply) (authorization required) (referral not required) |
| Eyeglasses (frames and lenses): | In-Network: $0 copay (limits may apply) (authorization required) (referral not required) |
| Eyeglasses (frames and lenses): | Out-of-Network: 40% coinsurance (limits may apply) (authorization required) (referral not required) |
| Other: | Not covered (no limits) |
| Routine eye exam: | In-Network: $0 copay (limits may apply) (authorization required) (referral not required) |
| Routine eye exam: | Out-of-Network: 40% coinsurance (limits may apply) (authorization required) (referral not required) |
| Upgrades: | In-Network: $0 copay (limits may apply) (authorization required) (referral not required) |
| Upgrades: | Out-of-Network: 40% coinsurance (limits may apply) (authorization required) (referral not required) |
Wellness programs (e.g., fitness, nursing hotline)
| Covered (authorization not required) (referral not required) |
Ready to sign up for Wellcare No Premium Open (PPO) ?
Get help from a licensed insurance agent.
Click to Call 1-877-354-4611 TTY 711.
Mon-Fri 8am-9pm EST | Sat 8am-8pm EST.