Plan Basics
Contract Year 2020
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H0111-003-000
Plan Organization WellCare
Plan Type Local PPO
Plan Name WellCare Flex Complete (PPO)
Plan Organization Type Local CCP
Drugs Covered Yes
Doctors Choice Any Doctor
Benefit Type Enhanced Alternative
Special Needs Plan No
Overall Star Rating 3 Stars
Plan Cost Sharing
Premium $90.00
Total Premium (Includes Part B) $225.50
Monthly Part C Premium $68.70
Monthly Part D Basic Premium $21.30
Monthly Part D Supplemental Premium $0.00
Monthly Part D Total Premium $21.30
Monthly Part D Premium Full Assistance $0.00
Monthly Part D Premium 75% Assistance $5.30
Monthly Part D Premium 50% Assistance $10.60
Monthly Part D Premium 25% Assistance $16.00
Part D Drug Deductible $0.00
Part D Initial Coverage Limit $4020.00
Part D Catastrophic Coverage Threshold $6350.00
Maximum Out-of-Pocket Limit for Parts A & B (MOOP) $2500.00
Gap Coverage Yes
Formulary Website Formulary Link

Medicare Advantage Plan Health Benefits


Comprehensive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Endodontics Yes Out-of-Network Yes Yes 20-70%
Extractions Yes In-Network Yes Yes 20%
Prosthodontics, other oral/maxillofacial surgery, other services Yes Out-of-Network Yes Yes 20-70%
Restorative services Yes Out-of-Network Yes Yes 20-70%
Non-routine services No - - - Not covered
Periodontics Yes Out-of-Network Yes Yes 20-70%
Diagnostic services Yes In-Network Yes Yes $0
Diagnostic Procedures/lab Services/imaging
Service Cap Network Auth. Req. Ref. Req. Cost Share
Outpatient x-rays - Out-of-Network Yes Yes $0 copay
Diagnostic radiology services (e.g., MRI) - Out-of-Network Yes Yes $0-275
Diagnostic tests and procedures - In-Network Yes Yes $0-100
Lab services - Out-of-Network Yes Yes $0 copay
Emergency Care/Urgent Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
Urgent care - - - - $20 per visit (always covered)
Emergency - - - - $120 per visit (always covered)
Ground Ambulance
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network - - $0-275
Health Plan Deductible
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $0
Hearing
Service Cap Network Auth. Req. Ref. Req. Cost Share
Fitting/evaluation Yes Out-of-Network Yes Yes 50%
Hearing exam - Out-of-Network Yes Yes $0-275
Hearing aids Yes In-Network Yes Yes $0 copay
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes Yes $200 per day for days 1 through 5 $0 per day for days 6 through 90
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Outpatient group therapy visit with a psychiatrist - Out-of-Network Yes Yes $0-275
Outpatient individual therapy visit - In-Network Yes Yes $25
Inpatient hospital - psychiatric - Out-of-Network Yes Yes $2,200 per stay
Outpatient individual therapy visit with a psychiatrist - Out-of-Network Yes Yes $0-275
Outpatient group therapy visit - Out-of-Network Yes Yes $0-275
Preventive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Cleaning Yes In-Network Yes Yes $0 copay
Fluoride treatment Yes In-Network Yes Yes $0 copay
Dental x-ray(s) 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
Physical therapy and speech and language therapy visit - Out-of-Network Yes Yes $0-275
Occupational therapy visit - Out-of-Network Yes Yes $0-275
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
Eyeglass lenses Yes In-Network Yes Yes $0 copay
Eyeglasses (frames and lenses) Yes Out-of-Network Yes Yes 50%
Routine eye exam Yes In-Network Yes Yes $0 copay
Other No - - - Not covered
Upgrades - - - - Not covered
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Primary - Out-of-Network - - $0 copay
Specialist - In-Network Yes Yes $25 per visit
Medical Equipment/supplies
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diabetes supplies - Out-of-Network Yes - $0 or 20% per item
Durable medical equipment (e.g., wheelchairs, oxygen) - Out-of-Network Yes - 20-40% per item
Prosthetics (e.g., braces, artificial limbs) - Out-of-Network Yes - 20-40% per item
Medicare Part B Drugs
Service Cap Network Auth. Req. Ref. Req. Cost Share
Chemotherapy - In-Network Yes - 20%
Other Part B drugs - In-Network Yes - 20%
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
Foot Care (podiatry Services)
Service Cap Network Auth. Req. Ref. Req. Cost Share
Foot exams and treatment - Out-of-Network Yes Yes $0-275
Routine foot care - - - - Not covered
Maximum Out-of-pocket Enrollee Responsibility (does Not Include Prescription Drugs)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $5,100 In and Out-of-network $2,500 In-network
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 $0-275 per visit
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- In-Network Yes Yes $0 per day for days 1 through 20 $178 per day for days 21 through 100
Wellness Programs (e.g., Fitness, Nursing Hotline)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - No No Covered
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
Transportation
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - Not covered
Official Medicare Contact
Medicare Phone 1-800-MEDICARE (1-800-633-4227)
Medicare TTY User 1-877-486-2048

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