Wellcare Patriot Giveback Open (PPO)
H7169 - 004 - 0
Plan Not Rated
Wellcare Patriot Giveback Open (PPO) is a Medicare Advantage Plan by Wellcare.
This page features plan details for 2023 Wellcare Patriot Giveback Open (PPO) H7169 – 004 – 0.
IMPORTANT: This page features the 2023 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 Patriot Giveback Open (PPO) is offered in the following locations.
Plan Overview
Wellcare Patriot Giveback Open (PPO) offers the following coverage and cost-sharing.
| Insurer: | Wellcare |
| Health Plan Deductible: | $0.00 |
| MOOP: | $10,000 In and Out-of-network $6,700 In-network |
| Drugs Covered: | No |
Ready to sign up for Wellcare Patriot 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
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 Patriot Giveback Open (PPO) qualifies for a monthly Medicare Give Back Benefit of $65.00.
| Premium Reduction: | $65.00 |
Premium Breakdown
Wellcare Patriot Giveback 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 |
|---|---|---|---|
| $164.90 | $0.00 | $65.00 | $ |
- Your Part B premium may differ based on factors including late enrollment, income, and disability status.
Additional Benefits
Wellcare Patriot 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) (referral not required) |
| Diagnostic services: | Out-of-Network: 50% coinsurance (limits may apply) (authorization required) (referral not required) |
| Endodontics: | Not covered (no limits) |
| Extractions: | Not covered (no limits) |
| 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: | Not covered (no limits) |
| Prosthodontics, other oral/maxillofacial surgery, other services: | Not covered (no limits) |
| Restorative services: | Not covered (no limits) |
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: $0-275 copay (authorization required) (referral not required) |
| Diagnostic radiology services (e.g., MRI): | Out-of-Network: $0-275 copay (authorization required) (referral not required) |
| Diagnostic tests and procedures: | In-Network: $0-100 copay (authorization required) (referral not required) |
| Diagnostic tests and procedures: | Out-of-Network: $0-275 copay (authorization required) (referral not required) |
| Lab services: | In-Network: $0 copay (authorization required) (referral not required) |
| Lab services: | Out-of-Network: $0 copay (authorization required) (referral not required) |
| Outpatient x-rays: | In-Network: $0 copay (authorization required) (referral not required) |
| Outpatient x-rays: | Out-of-Network: $0 copay (authorization required) (referral not required) |
Doctor visits
| Primary: | In-Network: $0 copay |
| Primary: | Out-of-Network: $0 copay |
| Specialist: | In-Network: $30 copay per visit (authorization required) (referral not required) |
| Specialist: | Out-of-Network: $30 copay per visit (authorization required) (referral not required) |
Emergency care/Urgent care
| Emergency: | $95 copay per visit (always covered) |
| Urgent care: | $50 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: $30 copay (authorization required) (referral not required) |
| Routine foot care: | Not covered |
Ground ambulance
| In-Network: $250 copay | |
| Out-of-Network: $250 copay |
Health plan deductible
| $0.00 |
Health plan deductibles (other)
| In-Network: No |
Hearing
| Fitting/evaluation: | Not covered (no limits) |
| Hearing aids – inner ear: | Not covered (no limits) |
| Hearing aids – outer ear: | Not covered (no limits) |
| Hearing aids – over the ear: | Not covered (no limits) |
| Hearing exam: | In-Network: $30 copay (authorization required) (referral not required) |
| Hearing exam: | Out-of-Network: $30 copay (authorization required) (referral not required) |
Hospital coverage (inpatient)
| In-Network: $325 per day for days 1 through 6 $0 per day for days 7 through 90 (authorization required) (referral not required) | |
| Out-of-Network: $325 per day for days 1 through 6 $0 per day for days 7 through 90 (authorization required) (referral not required) |
Hospital coverage (outpatient)
| In-Network: $275 copay per visit (authorization required) (referral not required) | |
| Out-of-Network: $275 copay per visit (authorization required) (referral not required) |
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
| $10,000 In and Out-of-network $6,700 In-network |
Medical equipment/supplies
| Diabetes supplies: | In-Network: $0 copay per item (authorization required) |
| Diabetes supplies: | Out-of-Network: $0 copay or 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: 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) |
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 6 $0 per day for days 7 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: $40 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: $40 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: $40 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: $40 copay (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 copay (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 copay (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 60 $0 per day for days 61 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
| Not covered |
Vision
| 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 |
Wellness programs (e.g., fitness, nursing hotline)
| Covered (authorization not required) (referral not required) |
Ready to sign up for Wellcare Patriot 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