Wellcare No Premium Open (PPO)

H9428 - 001 - 0
2.5 out of 5 stars (2.5 / 5)

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Wellcare No Premium Open (PPO) is a Medicare Advantage Plan by Wellcare.

This page features plan details for 2024 Wellcare No Premium Open (PPO) H9428 – 001 – 0 available in Select counties in TN.

IMPORTANT: This page features the 2024 version of this plan. See the 2025 version using the link below:

No 2025 version found. You can use the location links below to find 2025 plans in your area.

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:$5,500.00
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 No Premium 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

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
$174.70 $0.00 $0.00 $0.00 $
Please Note:
  • 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:$300.00
Initial Coverage Limit:$5,030.00
Catastrophic Coverage Limit:$8,000.00
Drug Benefit Type:Enhanced Alternative
Additional Gap Coverage:Yes
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 DLIS Full
$0.00$

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 $5,030.00. Once you reach that amount, you will enter the next coverage phase.

Gap Coverage Phase

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 $8,000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. Please note, that this plan has a Enhanced Alternative benefit type.

Additional Benefits

Wellcare No Premium Open (PPO) also provides the following benefits.

Health plan deductible

$0

Other health plan deductibles?

In-network No

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

$8,950 In and Out-of-network
$5,500 In-network

Optional supplemental benefits

No

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

In-network No

Outpatient hospital coverage

In-network $0-325 copay per visit (Authorization is required.) (Referral is not required.)
out-of-network 35% coinsurance per visit (Authorization is required.) (Referral is not required.)

Doctor visits

In-network Primary$0 copay (Not applicable.) (Not applicable.)
out-of-network Primary35% coinsurance per visit (Not applicable.) (Not applicable.)
In-network Specialist$25 copay per visit (Authorization is required.) (Referral is not required.)
out-of-network Specialist35% coinsurance per visit (Authorization is required.) (Referral is not required.)

Preventive care

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 care/Urgent care

Emergency$120 copay per visit (always covered) (Not applicable.) (Not applicable.)
Urgent care$40 copay per visit (always covered) (Not applicable.) (Not applicable.)

Diagnostic procedures/lab services/imaging

In-network Diagnostic tests and procedures$0-40 copay (Authorization is required.) (Referral is not required.)
out-of-network Diagnostic tests and procedures35% coinsurance (Authorization is required.) (Referral is not required.)
In-network Lab services$0-50 copay (Authorization is required.) (Referral is not required.)
out-of-network Lab services35% coinsurance (Authorization is required.) (Referral is not required.)
In-network Diagnostic radiology services (e.g., MRI)$0-325 copay (Authorization is required.) (Referral is not required.)
out-of-network Diagnostic radiology services (e.g., MRI)35% coinsurance (Authorization is required.) (Referral is not required.)
In-network Outpatient x-rays$0 copay (Authorization is required.) (Referral is not required.)
out-of-network Outpatient x-rays35% coinsurance (Authorization is required.) (Referral is not required.)

Hearing

In-network Hearing exam$25 copay (Authorization is required.) (Referral is not required.)
out-of-network Hearing exam35% coinsurance (Authorization is required.) (Referral is not required.)
In-network Fitting/evaluation$0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.)
out-of-network Fitting/evaluation40% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.)
In-network Hearing aids$0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.)
out-of-network Hearing aids40% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.)

Preventive dental

In-network Oral exam$0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.)
out-of-network Oral exam50% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.)
In-network Cleaning$0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.)
out-of-network Cleaning50% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.)
In-network Fluoride treatment$0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.)
out-of-network Fluoride treatment50% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.)
In-network Dental x-ray(s)$0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.)
out-of-network Dental x-ray(s)50% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.)

Comprehensive dental

In-network Non-routine services20% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.)
out-of-network Non-routine services50% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.)
In-network Diagnostic services20% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.)
out-of-network Diagnostic services50% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.)
In-network Restorative services20% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.)
out-of-network Restorative services50% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.)
In-network Endodontics20% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.)
out-of-network Endodontics50% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.)
In-network Periodontics20% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.)
out-of-network Periodontics50% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.)
In-network Extractions20% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.)
out-of-network Extractions50% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.)
In-network Prosthodontics, other oral/maxillofacial surgery, other services20% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.)
out-of-network Prosthodontics, other oral/maxillofacial surgery, other services50% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.)

Vision

In-network Routine eye exam$0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.)
out-of-network Routine eye exam40% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.)
OtherNot covered (There are no limits.) (Not applicable.) (Not applicable.)
In-network Contact lenses$0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.)
out-of-network Contact lenses40% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.)
In-network Eyeglasses (frames and lenses)$0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.)
out-of-network Eyeglasses (frames and lenses)40% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.)
In-network Eyeglass frames$0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.)
out-of-network Eyeglass frames40% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.)
In-network Eyeglass lenses$0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.)
out-of-network Eyeglass lenses40% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.)
In-network Upgrades$0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.)
out-of-network Upgrades40% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.)

Rehabilitation services

In-network Occupational therapy visit$25 copay (Authorization is required.) (Referral is not required.)
out-of-network Occupational therapy visit35% coinsurance (Authorization is required.) (Referral is not required.)
In-network Physical therapy and speech and language therapy visit$25 copay (Authorization is required.) (Referral is not required.)
out-of-network Physical therapy and speech and language therapy visit35% coinsurance (Authorization is required.) (Referral is not required.)

Ground ambulance

In-network $300 copay (Not applicable.) (Not applicable.)
out-of-network $300 copay (Not applicable.) (Not applicable.)

Transportation

Not covered (Not applicable.) (Not applicable.)

Foot care (podiatry services)

In-network Foot exams and treatment$25 copay (Authorization is required.) (Referral is not required.)
out-of-network Foot exams and treatment35% coinsurance (Authorization is required.) (Referral is not required.)
Routine foot careNot covered (Not applicable.) (Not applicable.)

Medical equipment/supplies

In-network Durable medical equipment (e.g., wheelchairs, oxygen)20% coinsurance per item (Authorization is required.) (Not applicable.)
out-of-network Durable medical equipment (e.g., wheelchairs, oxygen)35% coinsurance per item (Authorization is required.) (Not applicable.)
In-network Prosthetics (e.g., braces, artificial limbs)20% coinsurance per item (Authorization is required.) (Not applicable.)
out-of-network Prosthetics (e.g., braces, artificial limbs)35% coinsurance per item (Authorization is required.) (Not applicable.)
In-network Diabetes supplies$0 copay per item (Authorization is required.) (Not applicable.)
out-of-network Diabetes supplies35% coinsurance per item (Authorization is required.) (Not applicable.)

Wellness programs (e.g., fitness, nursing hotline)

Covered (Authorization is not required.) (Referral is not required.)

Medicare Part B drugs

In-network Chemotherapy0-20% coinsurance (Authorization is required.) (Not applicable.)
out-of-network Chemotherapy$35 copay or 0-20% coinsurance (Authorization is required.) (Not applicable.)
In-network Other Part B drugs0-20% coinsurance (Authorization is required.) (Not applicable.)
out-of-network Other Part B drugs$35 copay or 0-20% coinsurance (Authorization is required.) (Not applicable.)
In-network Part B Insulin drugs$35 copay (Authorization is required.) (Not applicable.)
out-of-network Part B Insulin drugs$35 copay or 0-20% coinsurance (Authorization is required.) (Not applicable.)

Inpatient hospital coverage

In-network $300 per day for days 1 through 6
$0 per day for days 7 through 90 (Authorization is required.) (Referral is not required.)
out-of-network 35% per day for days 1 through 90 (Authorization is required.) (Referral is not required.)

Mental health services

In-network Inpatient hospital – psychiatric$300 per day for days 1 through 6
$0 per day for days 7 through 90 (Authorization is required.) (Referral is not required.)
out-of-network Inpatient hospital – psychiatric35% per day for days 1 through 90 (Authorization is required.) (Referral is not required.)
In-network Outpatient group therapy visit with a psychiatrist$40 copay (Authorization is required.) (Referral is not required.)
out-of-network Outpatient group therapy visit with a psychiatrist35% coinsurance (Authorization is required.) (Referral is not required.)
In-network Outpatient individual therapy visit with a psychiatrist$40 copay (Authorization is required.) (Referral is not required.)
out-of-network Outpatient individual therapy visit with a psychiatrist35% coinsurance (Authorization is required.) (Referral is not required.)
In-network Outpatient group therapy visit$40 copay (Authorization is required.) (Referral is not required.)
out-of-network Outpatient group therapy visit35% coinsurance (Authorization is required.) (Referral is not required.)
In-network Outpatient individual therapy visit$40 copay (Authorization is required.) (Referral is not required.)
out-of-network Outpatient individual therapy visit35% coinsurance (Authorization is required.) (Referral is not required.)

Skilled Nursing Facility

In-network $0 per day for days 1 through 20
$203 per day for days 21 through 50
$0 per day for days 51 through 100 (Authorization is required.) (Referral is not required.)
out-of-network 35% per day for days 1 through 100 (Authorization is required.) (Referral is not required.)

Ready to sign up for Wellcare No Premium 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

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