Wellcare Patriot No Premium Open (PPO) is a Medicare Advantage (Part C) Plan by Wellcare.
This page features plan details for 2023 Wellcare Patriot No Premium Open (PPO) H7175 – 005 – 0 available in Select counties in NC.
Wellcare Patriot No Premium Open (PPO) is offered in the following locations.
Wellcare Patriot No Premium Open (PPO) offers the following coverage and cost-sharing.
Insurer: | Wellcare |
Health Plan Deductible: | $0.00 |
MOOP: | $10,000 In and Out-of-network $6,500 In-network |
Drugs Covered: | No |
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Part B | Part C | Part B Give Back | Total |
---|---|---|---|
$164.90 | $0.00 | $0.00 | $164.90 |
Wellcare Patriot No Premium Open (PPO) also provides the following benefits.
In-Network: No |
Diagnostic services: | In-Network: 40% coinsurance (limits may apply) (authorization required) (referral not required) |
Diagnostic services: | Out-of-Network: 70% coinsurance (limits may apply) (authorization required) (referral not required) |
Endodontics: | In-Network: 40% coinsurance (limits may apply) (authorization required) (referral not required) |
Endodontics: | Out-of-Network: 70% coinsurance (limits may apply) (authorization required) (referral not required) |
Extractions: | In-Network: 40% coinsurance (limits may apply) (authorization required) (referral not required) |
Extractions: | Out-of-Network: 70% coinsurance (limits may apply) (authorization required) (referral not required) |
Non-routine services: | In-Network: 40% coinsurance (limits may apply) (authorization required) (referral not required) |
Non-routine services: | Out-of-Network: 70% coinsurance (limits may apply) (authorization required) (referral not required) |
Periodontics: | In-Network: 40% coinsurance (limits may apply) (authorization required) (referral not required) |
Periodontics: | Out-of-Network: 70% coinsurance (limits may apply) (authorization required) (referral not required) |
Prosthodontics, other oral/maxillofacial surgery, other services: | In-Network: 40% coinsurance (limits may apply) (authorization required) (referral not required) |
Prosthodontics, other oral/maxillofacial surgery, other services: | Out-of-Network: 70% coinsurance (limits may apply) (authorization required) (referral not required) |
Restorative services: | In-Network: 40% coinsurance (limits may apply) (authorization required) (referral not required) |
Restorative services: | Out-of-Network: 70% coinsurance (limits may apply) (authorization required) (referral not required) |
Cleaning: | In-Network: $0 copay (limits may apply) (authorization required) (referral not required) |
Cleaning: | Out-of-Network: 70% 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: 70% 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: 70% 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: 70% coinsurance (limits may apply) (authorization required) (referral not required) |
Diagnostic radiology services (e.g., MRI): | In-Network: $0-200 copay (authorization required) (referral not required) |
Diagnostic radiology services (e.g., MRI): | Out-of-Network: $0-350 copay (authorization required) (referral not required) |
Diagnostic tests and procedures: | In-Network: $0-75 copay (authorization required) (referral not required) |
Diagnostic tests and procedures: | Out-of-Network: $0-350 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) |
Primary: | In-Network: $0 copay |
Primary: | Out-of-Network: $0 copay |
Specialist: | In-Network: $40 copay per visit (authorization required) (referral not required) |
Specialist: | Out-of-Network: $40 copay per visit (authorization required) (referral not required) |
Emergency: | $95 copay per visit (always covered) |
Urgent care: | $30 copay per visit (always covered) |
Foot exams and treatment: | In-Network: $40 copay (authorization required) (referral not required) |
Foot exams and treatment: | Out-of-Network: $40 copay (authorization required) (referral not required) |
Routine foot care: | Not covered |
In-Network: $250 copay | |
Out-of-Network: $250 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: $40 copay (authorization required) (referral not required) |
Hearing exam: | Out-of-Network: $40 copay (authorization required) (referral not required) |
In-Network: $325 per day for days 1 through 5 $0 per day for days 6 through 90 (authorization required) (referral not required) | |
Out-of-Network: 35% per day for days 1 through 90 (authorization required) (referral not required) |
In-Network: $200-350 copay per visit (authorization required) (referral not required) | |
Out-of-Network: $0-350 copay per visit (authorization required) (referral not required) |
$10,000 In and Out-of-network $6,500 In-network |
Diabetes supplies: | In-Network: $0 copay per item (authorization required) |
Diabetes supplies: | Out-of-Network: 20-35% 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: 20-35% 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: 20-35% coinsurance per item (authorization required) |
Chemotherapy: | In-Network: 20% coinsurance (authorization required) |
Chemotherapy: | Out-of-Network: 20-35% coinsurance (authorization required) |
Other Part B drugs: | In-Network: 20% coinsurance (authorization required) |
Other Part B drugs: | Out-of-Network: 20-35% coinsurance (authorization required) |
Inpatient hospital – psychiatric: | In-Network: $370 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: 35% per day for days 1 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: $25 copay (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: $25 copay (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: $25 copay (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: $25 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: $40 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: $40 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: 35% per day for days 1 through 100 (authorization required) (referral not required) |
Not covered |
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) |
Covered (authorization not required) (referral not required) |
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SMID: MULTIPLAN_HCIHNDOGMED01_M
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