Plan Basics
Contract Year 2020
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H1112-034-000
Plan Organization WellCare
Plan Type Local HMO *
Plan Name WellCare Advance (HMO-POS)
Drugs Covered No
Doctors Choice Plan Doctors Only (some exceptions)
Overall Star Rating 3.5 Stars
Plan Cost Sharing
Premium $0.00
Total Premium (Includes Part B) $135.50
Maximum Out-of-Pocket Limit for Parts A & B (MOOP) $4500.00
Formulary Website Formulary Link

Medicare Advantage Plan Health Benefits


Comprehensive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Extractions Yes In-Network Yes Yes $0 copay
Periodontics Yes In-Network Yes Yes $0 copay
Diagnostic services Yes In-Network Yes Yes $0 copay
Non-routine services No - - - Not covered
Prosthodontics, other oral/maxillofacial surgery, other services Yes In-Network Yes Yes $0 copay
Endodontics Yes In-Network Yes Yes $0 copay
Restorative services Yes In-Network Yes Yes $0 copay
Diagnostic Procedures/lab Services/imaging
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diagnostic radiology services (e.g., MRI) - In-Network Yes Yes $0-100
Lab services - Out-of-Network Yes Yes 20%
Diagnostic tests and procedures - Out-of-Network Yes Yes 20%
Outpatient x-rays - Out-of-Network Yes Yes 20%
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Primary - Out-of-Network - - 20% per visit
Specialist - Out-of-Network Yes Yes 20% per visit
Foot Care (podiatry Services)
Service Cap Network Auth. Req. Ref. Req. Cost Share
Foot exams and treatment - Out-of-Network Yes Yes 20%
Routine foot care - - - - Not covered
Hearing
Service Cap Network Auth. Req. Ref. Req. Cost Share
Hearing aids Yes In-Network Yes Yes $0 copay
Hearing exam - Out-of-Network Yes Yes 20%
Fitting/evaluation Yes In-Network Yes Yes $0 copay
Maximum Out-of-pocket Enrollee Responsibility (does Not Include Prescription Drugs)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $4,500 In and Out-of-network $4,500 In-network $4,500 Out-of-network
Medical Equipment/supplies
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diabetes supplies - In-Network Yes - $0 per item
Durable medical equipment (e.g., wheelchairs, oxygen) - In-Network Yes - 20% per item
Prosthetics (e.g., braces, artificial limbs) - Out-of-Network Yes - 20% per item
Medicare Part B Drugs
Service Cap Network Auth. Req. Ref. Req. Cost Share
Chemotherapy - Out-of-Network No - 20%
Other Part B drugs - Out-of-Network No - 20%
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Outpatient group therapy visit - In-Network Yes Yes $40
Outpatient group therapy visit with a psychiatrist - Out-of-Network Yes Yes 20%
Outpatient individual therapy visit - In-Network Yes Yes $40
Inpatient hospital - psychiatric - Out-of-Network Yes Yes 20% per stay
Outpatient individual therapy visit with a psychiatrist - Out-of-Network Yes Yes 20%
Optional Supplemental Benefits
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - No
Outpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes Yes 20% per visit
Preventive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Dental x-ray(s) Yes In-Network Yes Yes $0 copay
Cleaning Yes In-Network Yes Yes $0 copay
Fluoride treatment Yes In-Network Yes Yes $0 copay
Oral exam Yes In-Network Yes Yes $0 copay
Rehabilitation Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Occupational therapy visit - Out-of-Network Yes Yes 20%
Physical therapy and speech and language therapy visit - In-Network Yes Yes $35
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network Yes Yes $0 per day for days 1 through 20 $164.50 per day for days 21 through 100
Emergency Care/Urgent Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
Emergency - - - - $90 per visit (always covered)
Urgent care - - - - $35 per visit (always covered)
Ground Ambulance
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - $200
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network Yes Yes $325 per day for days 1 through 5 $0 per day for days 6 through 90
Vision
Service Cap Network Auth. Req. Ref. Req. Cost Share
Contact lenses Yes In-Network Yes Yes $0 copay
Eyeglass frames Yes In-Network Yes Yes $0 copay
Eyeglasses (frames and lenses) Yes In-Network Yes Yes $0 copay
Other No - - - Not covered
Routine eye exam Yes In-Network Yes Yes $0 copay
Upgrades - - - - Not covered
Eyeglass lenses Yes In-Network Yes Yes $0 copay
Additional Benefits And/or Reduced Cost-sharing For Enrollees With Certain Health Conditions?
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - No
Health Plan Deductible
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $0
Other Health Plan Deductibles?
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network - - No
Preventive Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network No No $0 copay
Transportation
Service Cap Network Auth. Req. Ref. Req. Cost Share
Yes In-Network Yes Yes $0 copay
Wellness Programs (e.g., Fitness, Nursing Hotline)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - Yes Yes Covered
Official Medicare Contact
Medicare Phone 1-800-MEDICARE (1-800-633-4227)
Medicare TTY User 1-877-486-2048

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