Wellcare Ohana Patriot Open (PPO)
H6605 - 002 - 0
(2 / 5)
Wellcare Ohana Patriot Open (PPO) is a Medicare Advantage (Part C) Plan by Wellcare by �Ohana Health Plan.
This page features plan details for 2024 Wellcare Ohana Patriot Open (PPO) H6605 – 002 – 0 available in Select counties in HI.
IMPORTANT: This page has been updated with plan and premium data for 2024.
Locations
Wellcare Ohana Patriot Open (PPO) is offered in the following locations.
Plan Overview
Wellcare Ohana Patriot Open (PPO) offers the following coverage and cost-sharing.
| Insurer: | Wellcare by �Ohana Health Plan |
| Health Plan Deductible: | $0.00 |
| MOOP: | $13,300 In and Out-of-network $8,850 In-network |
| Drugs Covered: | No |
Ready to sign up for Wellcare Ohana Patriot Open (PPO) ?
Premium Breakdown
Wellcare Ohana Patriot Open (PPO) has a monthly premium of $0.00. This amount includes your Part C premium but does not include your Part B premium.| Part B | Part C | Part B Give Back | Total |
|---|---|---|---|
| $174.70 | $0.00 | $0.00 | $174.70 |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
Additional Benefits
Wellcare Ohana Patriot Open (PPO) also provides the following benefits.
| $0 |
| In-network | No |
| $13,300 In and Out-of-network $8,850 In-network |
| No |
| In-network | No |
| In-network | $0-400 copay per visit (Authorization is required.) (Referral is not required.) |
| out-of-network | 40% coinsurance per visit (Authorization is required.) (Referral is not required.) |
| In-network Primary | $5 copay per visit (Not applicable.) (Not applicable.) |
| out-of-network Primary | 40% coinsurance per visit (Not applicable.) (Not applicable.) |
| In-network Specialist | $50 copay per visit (Authorization is required.) (Referral is not required.) |
| out-of-network Specialist | 40% coinsurance per visit (Authorization is required.) (Referral is not required.) |
| 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 | $100 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Urgent care | $55 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| In-network Diagnostic tests and procedures | $0-40 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Diagnostic tests and procedures | 40% 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 services | 40% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network Diagnostic radiology services (e.g., MRI) | $0-400 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Diagnostic radiology services (e.g., MRI) | 40% 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-rays | 40% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network Hearing exam | $50 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Hearing exam | 40% 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/evaluation | 40% 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 aids | 40% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Oral exam | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Oral exam | 70% 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 Cleaning | 70% 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 treatment | 70% 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) | 70% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Non-routine services | 40% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Non-routine services | 70% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Diagnostic services | 40% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Diagnostic services | 70% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Restorative services | 40% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Restorative services | 70% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Endodontics | 40% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Endodontics | 70% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Periodontics | 40% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Periodontics | 70% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Extractions | 40% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Extractions | 70% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Prosthodontics, other oral/maxillofacial surgery, other services | 40% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Prosthodontics, other oral/maxillofacial surgery, other services | 70% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Routine eye exam | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| out-of-network Routine eye exam | 40% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Other | Not 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 lenses | 40% 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 frames | 40% 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 lenses | 40% 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 Upgrades | 40% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| In-network Occupational therapy visit | $40 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Occupational therapy visit | 40% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network Physical therapy and speech and language therapy visit | $40 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Physical therapy and speech and language therapy visit | 40% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network | $265 copay (Not applicable.) (Not applicable.) |
| out-of-network | $265 copay (Not applicable.) (Not applicable.) |
| Not covered (Not applicable.) (Not applicable.) |
| In-network Foot exams and treatment | $50 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Foot exams and treatment | 40% coinsurance (Authorization is required.) (Referral is not required.) |
| Routine foot care | Not covered (Not applicable.) (Not applicable.) |
| 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) | 20% 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) | 20% 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 supplies | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| Covered (Authorization is not required.) (Referral is not required.) |
| In-network Chemotherapy | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| out-of-network Chemotherapy | $35 copay or 0-40% coinsurance (Authorization is required.) (Not applicable.) |
| In-network Other Part B drugs | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| out-of-network Other Part B drugs | $35 copay or 0-40% 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 0-40% coinsurance (Authorization is required.) (Not applicable.) |
| In-network | $345 per day for days 1 through 5 $0 per day for days 6 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.) |
| In-network Inpatient hospital – psychiatric | $387 per day for days 1 through 5 $0 per day for days 6 through 90 (Authorization is required.) (Referral is not required.) |
| out-of-network Inpatient hospital – psychiatric | 35% per day for days 1 through 90 (Authorization is required.) (Referral is not required.) |
| In-network Outpatient group therapy visit with a psychiatrist | $25 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient group therapy visit with a psychiatrist | 40% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network Outpatient individual therapy visit with a psychiatrist | $25 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient individual therapy visit with a psychiatrist | 40% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network Outpatient group therapy visit | $25 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient group therapy visit | 40% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network Outpatient individual therapy visit | $25 copay (Authorization is required.) (Referral is not required.) |
| out-of-network Outpatient individual therapy visit | 40% coinsurance (Authorization is required.) (Referral is not required.) |
| In-network | $0 per day for days 1 through 20 $185 per day for days 21 through 70 $0 per day for days 71 through 100 (Authorization is required.) (Referral is not required.) |
| out-of-network | 30% per day for days 1 through 100 (Authorization is required.) (Referral is not required.) |
Ready to sign up for Wellcare Ohana Patriot Open (PPO) ?
Table of Contents
SMID: MULTIPLAN_HCIHNDOGMED01_M
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