Wellcare Premium Ultra (HMO)
H0562 - 084 - 0
(3 / 5)
Wellcare Premium Ultra (HMO) is a Medicare Advantage (Part C) Plan by Wellcare by Health Net.
This page features plan details for 2023 Wellcare Premium Ultra (HMO) H0562 – 084 – 0 available in Select counties in CA.
IMPORTANT: This page features the 2023 version of this plan. See the 2024 version using the link below:
No 2024 version found. You can use the location links below to find 2024 plans in your area.
Locations
Wellcare Premium Ultra (HMO) is offered in the following locations.
Plan Overview
Wellcare Premium Ultra (HMO) offers the following coverage and cost-sharing.
| Insurer: | Wellcare by Health Net |
| Health Plan Deductible: | $0.00 |
| MOOP: | $5,000 In-network |
| Drugs Covered: | Yes |
Ready to sign up for Wellcare Premium Ultra (HMO) ?
Premium Breakdown
Wellcare Premium Ultra (HMO) has a monthly premium of $163.00. 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 | $140.60 | $22.40 | $0.00 | $327.90 |
- 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 Premium Ultra (HMO) 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 |
|---|---|---|---|---|
| $22.40 | $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) | $3.00 copay | $10.00 copay | $3.00 copay | $10.00 copay |
| 2 (Generic) | $11.00 copay | $20.00 copay | $11.00 copay | $20.00 copay |
| 3 (Preferred Brand) | $37.00 copay | $47.00 copay | $37.00 copay | $47.00 copay |
| 4 (Non-Preferred Drug) | $90.00 copay | $100.00 copay | $90.00 copay | $100.00 copay |
| 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) | $9.00 copay | $30.00 copay | $0.00 copay | $30.00 copay |
| 2 (Generic) | $33.00 copay | $60.00 copay | $0.00 copay | $60.00 copay |
| 3 (Preferred Brand) | $111.00 copay | $141.00 copay | $74.00 copay | $141.00 copay |
| 4 (Non-Preferred Drug) | $270.00 copay | $300.00 copay | $180.00 copay | $300.00 copay |
| 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 Premium Ultra (HMO) 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: | $0-15 copay (no limits) (authorization required) (referral not required) |
| Endodontics: | $5-275 copay (no limits) (authorization required) (referral not required) |
| Extractions: | $15-150 copay (no limits) (authorization required) (referral not required) |
| Non-routine services: | $0 copay (no limits) (authorization required) (referral not required) |
| Periodontics: | $0-375 copay (limits may apply) (authorization required) (referral not required) |
| Prosthodontics, other oral/maxillofacial surgery, other services: | $0-2,250 copay (no limits) (authorization required) (referral not required) |
| Restorative services: | $0-300 copay (no limits) (authorization required) (referral not required) |
Dental (preventive)
| Cleaning: | $0 copay (limits may apply) (authorization required) (referral not required) |
| Dental x-ray(s): | $0 copay (limits may apply) (authorization required) (referral not required) |
| Fluoride treatment: | $0 copay (limits may apply) (authorization required) (referral not required) |
| Oral exam: | $0 copay (limits may apply) (authorization required) (referral not required) |
Diagnostic procedures/lab services/imaging
| Diagnostic radiology services (e.g., MRI): | $0-275 copay (authorization required) (referral required) |
| Diagnostic tests and procedures: | $0 copay (authorization required) (referral not required) |
| Lab services: | $0 copay (authorization required) (referral not required) |
| Outpatient x-rays: | $0 copay (authorization required) (referral required) |
Doctor visits
| Primary: | $15 copay per visit |
| Specialist: | $20 copay per visit (authorization required) (referral required) |
Emergency care/Urgent care
| Emergency: | $110 copay per visit (always covered) |
| Urgent care: | $20 copay per visit (always covered) |
Foot care (podiatry services)
| Foot exams and treatment: | $20 copay (authorization required) (referral required) |
| Routine foot care: | Not covered |
Ground ambulance
| $220 copay |
Health plan deductible
| $0.00 |
Health plan deductibles (other)
| In-Network: No |
Hearing
| Fitting/evaluation: | $0 copay (limits may apply) (authorization required) (referral required) |
| 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: | $20 copay (authorization required) (referral required) |
Hospital coverage (inpatient)
| $250 per day for days 1 through 5 $0 per day for days 6 through 90 $0 per day for days 91 through 180 (authorization required) (referral required) |
Hospital coverage (outpatient)
| $275 copay per visit (authorization required) (referral required) |
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
| $5,000 In-network |
Medical equipment/supplies
| Diabetes supplies: | $0 copay per item (authorization required) |
| Durable medical equipment (e.g., wheelchairs, oxygen): | 20% coinsurance per item (authorization required) |
| Prosthetics (e.g., braces, artificial limbs): | 20% coinsurance per item (authorization required) |
Medicare Part B drugs
| Chemotherapy: | 20% coinsurance (authorization required) |
| Other Part B drugs: | 20% coinsurance (authorization required) |
Mental health services
| Inpatient hospital – psychiatric: | $900 per stay (authorization required) (referral not required) |
| Outpatient group therapy visit: | $25 copay (authorization required) (referral not required) |
| Outpatient group therapy visit with a psychiatrist: | $25 copay (authorization required) (referral not required) |
| Outpatient individual therapy visit: | $25 copay (authorization required) (referral not required) |
| Outpatient individual therapy visit with a psychiatrist: | $25 copay (authorization required) (referral not required) |
Optional supplemental benefits
| Yes |
Preventive care
| $0 copay (authorization not required) (referral not required) |
Rehabilitation services
| Occupational therapy visit: | $20 copay (authorization required) (referral required) |
| Physical therapy and speech and language therapy visit: | $20 copay (authorization required) (referral required) |
Skilled Nursing Facility
| $0 per day for days 1 through 20 $150 per day for days 21 through 60 $0 per day for days 61 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: | $0 copay (limits may apply) (authorization required) (referral required) |
| Upgrades: | Not covered |
Wellness programs (e.g., fitness, nursing hotline)
| Covered (authorization not required) (referral not required) |
Optional Benefits
Package #1
| Chiropractic care: | Monthly Premium: | $16.00 |
| Chiropractic care: | Deductible: | N/A |
| Acupuncture: | Monthly Premium: | $16.00 |
| Acupuncture: | Deductible: | N/A |
| Wellness programs (e.g., fitness, nursing hotline): | Monthly Premium: | $16.00 |
| Wellness programs (e.g., fitness, nursing hotline): | Deductible: | N/A |
| Eyewear: | Monthly Premium: | $16.00 |
| Eyewear: | Deductible: | N/A |
Ready to sign up for Wellcare Premium Ultra (HMO) ?