Plan Basics
Contract Year |
2021 |
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 |
Plan Cost Sharing
Premium |
$90.00 |
Total Premium (Includes Part B) |
$225.50 |
Monthly Part C Premium |
$56.50 |
Monthly Part D Basic Premium |
$33.50 |
Monthly Part D Supplemental Premium |
$0.00 |
Monthly Part D Total Premium |
$33.50 |
Monthly Part D Premium Full Assistance |
$3.70 |
Monthly Part D Premium 75% Assistance |
$11.10 |
Monthly Part D Premium 50% Assistance |
$18.60 |
Monthly Part D Premium 25% Assistance |
$26.00 |
Part D Drug Deductible |
$0.00 |
Part D Initial Coverage Limit |
$4130.00 |
Part D Catastrophic Coverage Threshold |
$6550.00 |
Maximum Out-of-Pocket Limit for Parts A & B (MOOP) |
$2500.00 |
Gap Coverage |
Yes |
Medicare Advantage Plan Health Benefits
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 |
Comprehensive Dental
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
Diagnostic services |
Yes |
Out-of-Network |
Yes |
No |
50% coinsurance |
Endodontics |
Yes |
Out-of-Network |
Yes |
No |
50% coinsurance |
Extractions |
Yes |
Out-of-Network |
Yes |
No |
50% coinsurance |
Non-routine services |
Yes |
Out-of-Network |
Yes |
No |
50% coinsurance |
Periodontics |
Yes |
Out-of-Network |
Yes |
No |
50% coinsurance |
Prosthodontics, other oral/maxillofacial surgery, other services |
Yes |
Out-of-Network |
Yes |
No |
50% coinsurance |
Restorative services |
Yes |
Out-of-Network |
Yes |
No |
50% coinsurance |
Diagnostic Procedures/lab Services/imaging
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
Diagnostic radiology services (e.g., MRI) |
- |
Out-of-Network |
Yes |
No |
$0-230 copay |
Diagnostic tests and procedures |
- |
Out-of-Network |
Yes |
No |
$0-230 copay |
Lab services |
- |
Out-of-Network |
Yes |
No |
$0 copay |
Outpatient x-rays |
- |
Out-of-Network |
Yes |
No |
$0 copay |
Doctor Visits
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
Primary |
- |
Out-of-Network |
- |
- |
$0 copay |
Specialist |
- |
Out-of-Network |
Yes |
No |
$0-230 copay per visit |
Emergency Care/Urgent Care
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
Emergency |
- |
- |
- |
- |
$120 copay per visit (always covered) |
Urgent care |
- |
- |
- |
- |
$15 copay per visit (always covered) |
Foot Care (podiatry Services)
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
Foot exams and treatment |
- |
Out-of-Network |
Yes |
No |
$0-230 copay |
Routine foot care |
- |
- |
- |
- |
Not covered |
Ground Ambulance
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
|
- |
Out-of-Network |
- |
- |
$0-230 copay |
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 |
No |
40% coinsurance |
Hearing aids |
Yes |
Out-of-Network |
Yes |
No |
40% coinsurance |
Hearing exam |
- |
Out-of-Network |
Yes |
No |
$0-230 copay |
Inpatient Hospital Coverage
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
|
- |
Out-of-Network |
Yes |
No |
$200 per day for days 1 through 5$0 per day for days 6 and beyond |
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 |
Medical Equipment/supplies
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
Diabetes supplies |
- |
Out-of-Network |
Yes |
- |
$0 copay or 20% coinsurance per item |
Durable medical equipment (e.g., wheelchairs, oxygen) |
- |
Out-of-Network |
Yes |
- |
20-40% coinsurance per item |
Prosthetics (e.g., braces, artificial limbs) |
- |
Out-of-Network |
Yes |
- |
20-40% coinsurance per item |
Medicare Part B Drugs
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
Chemotherapy |
- |
Out-of-Network |
Yes |
- |
20-40% coinsurance |
Other Part B drugs |
- |
Out-of-Network |
Yes |
- |
20-40% coinsurance |
Mental Health Services
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
Inpatient hospital - psychiatric |
- |
Out-of-Network |
Yes |
No |
$2,200 per stay |
Outpatient group therapy visit |
- |
Out-of-Network |
Yes |
No |
$0-230 copay |
Outpatient group therapy visit with a psychiatrist |
- |
Out-of-Network |
Yes |
No |
$0-230 copay |
Outpatient individual therapy visit |
- |
Out-of-Network |
Yes |
No |
$0-230 copay |
Outpatient individual therapy visit with a psychiatrist |
- |
Out-of-Network |
Yes |
No |
$0-230 copay |
Optional Supplemental Benefits
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
|
- |
- |
- |
- |
No |
Other Health Plan Deductibles?
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
|
- |
In-Network |
- |
- |
No |
Outpatient Hospital Coverage
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
|
- |
Out-of-Network |
Yes |
No |
$0-230 copay per visit |
Preventive Care
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
|
- |
Out-of-Network |
No |
No |
$0 copay |
Preventive Dental
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
Cleaning |
Yes |
Out-of-Network |
Yes |
No |
50% coinsurance |
Dental x-ray(s) |
Yes |
Out-of-Network |
Yes |
No |
50% coinsurance |
Fluoride treatment |
Yes |
Out-of-Network |
Yes |
No |
50% coinsurance |
Oral exam |
Yes |
Out-of-Network |
Yes |
No |
50% coinsurance |
Rehabilitation Services
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
Occupational therapy visit |
- |
Out-of-Network |
Yes |
No |
$0-230 copay |
Physical therapy and speech and language therapy visit |
- |
Out-of-Network |
Yes |
No |
$0-230 copay |
Skilled Nursing Facility
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
|
- |
Out-of-Network |
Yes |
No |
$0 per day for days 1 through 20$178 per day for days 21 through 100 |
Transportation
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
|
- |
- |
- |
- |
Not covered |
Vision
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
Contact lenses |
Yes |
Out-of-Network |
Yes |
No |
40% coinsurance |
Eyeglass frames |
Yes |
Out-of-Network |
Yes |
No |
40% coinsurance |
Eyeglass lenses |
Yes |
Out-of-Network |
Yes |
No |
40% coinsurance |
Eyeglasses (frames and lenses) |
Yes |
Out-of-Network |
Yes |
No |
40% coinsurance |
Other |
No |
- |
- |
- |
Not covered |
Routine eye exam |
Yes |
Out-of-Network |
Yes |
No |
40% coinsurance |
Upgrades |
Yes |
Out-of-Network |
Yes |
No |
40% coinsurance |
Wellness Programs (e.g., Fitness, Nursing Hotline)
Service |
Cap |
Network |
Auth. Req. |
Ref. Req. |
Cost Share |
|
- |
- |
No |
No |
Covered |
Official Medicare Contact
Medicare Phone |
1-800-MEDICARE (1-800-633-4227) |
Medicare TTY User |
1-877-486-2048 |
Plan Available in these Counties
Baldwin County, Georgia,
Barrow County, Georgia,
Bartow County, Georgia,
Bibb County, Georgia,
Bleckley County, Georgia,
Brantley County, Georgia,
Bryan County, Georgia,
Burke County, Georgia,
Butts County, Georgia,
Camden County, Georgia,
Carroll County, Georgia,
Chatham County, Georgia,
Chattahoochee County, Georgia,
Cherokee County, Georgia,
Clarke County, Georgia,
Clayton County, Georgia,
Cobb County, Georgia,
Columbia County, Georgia,
Coweta County, Georgia,
Crawford County, Georgia,
Dekalb County, Georgia,
Dodge County, Georgia,
Dooly County, Georgia,
Douglas County, Georgia,
Effingham County, Georgia,
Emanuel County, Georgia,
Fayette County, Georgia,
Forsyth County, Georgia,
Fulton County, Georgia,
Glascock County, Georgia,
Glynn County, Georgia,
Greene County, Georgia,
Gwinnett County, Georgia,
Haralson County, Georgia,
Harris County, Georgia,
Heard County, Georgia,
Henry County, Georgia,
Houston County, Georgia,
Jasper County, Georgia,
Jefferson County, Georgia,
Jenkins County, Georgia,
Johnson County, Georgia,
Jones County, Georgia,
Lamar County, Georgia,
Liberty County, Georgia,
Lincoln County, Georgia,
Long County, Georgia,
Macon County, Georgia,
Marion County, Georgia,
Mcduffie County, Georgia,
Mcintosh County, Georgia,
Meriwether County, Georgia,
Monroe County, Georgia,
Morgan County, Georgia,
Muscogee County, Georgia,
Newton County, Georgia,
Oconee County, Georgia,
Paulding County, Georgia,
Peach County, Georgia,
Pickens County, Georgia,
Pike County, Georgia,
Polk County, Georgia,
Pulaski County, Georgia,
Putnam County, Georgia,
Richmond County, Georgia,
Rockdale County, Georgia,
Screven County, Georgia,
Spalding County, Georgia,
Stewart County, Georgia,
Talbot County, Georgia,
Treutlen County, Georgia,
Troup County, Georgia,
Twiggs County, Georgia,
Upson County, Georgia,
Walton County, Georgia,
Warren County, Georgia,
Washington County, Georgia,
Wayne County, Georgia,
Wheeler County, Georgia,
Wilkes County, Georgia,
Wilkinson County, Georgia
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