WellCare Imperial (PPO D-SNP) - 2021

WellCare Imperial (PPO D-SNP) - WellCare - Local PPO

Plan Basics
Contract Year 2021
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H0111-004-000
Plan Organization WellCare
Plan Type Local PPO
Plan Name WellCare Imperial (PPO D-SNP)
Plan Organization Type Local CCP
Drugs Covered Yes
Doctors Choice Any Doctor
Benefit Type Enhanced Alternative
Special Needs Plan Yes
Special Needs Plan Type Dual-Eligible
Overall Star Rating 3
Plan Cost Sharing
Premium $0.00
Total Premium (Includes Part B) $135.50
Monthly Part C Premium $0.00
Monthly Part D Basic Premium $29.80
Monthly Part D Supplemental Premium $0.00
Monthly Part D Total Premium $29.80
Monthly Part D Premium Full Assistance $0.00
Monthly Part D Premium 75% Assistance $7.40
Monthly Part D Premium 50% Assistance $14.90
Monthly Part D Premium 25% Assistance $22.30
Part D Drug Deductible $445.00
Annual Drug Deductible $445.00
Tiers Excluded From Deductible 1
Part D Initial Coverage Limit $4130.00
Part D Catastrophic Coverage Threshold $6550.00

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 20% coinsurance
Diagnostic tests and procedures - Out-of-Network Yes No 20% coinsurance
Lab services - Out-of-Network Yes No 20% coinsurance
Outpatient x-rays - Out-of-Network Yes No 20% coinsurance
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Primary - Out-of-Network - - 20% coinsurance per visit
Specialist - Out-of-Network Yes No 20% coinsurance per visit
Emergency Care/Urgent Care
Service Cap Network Auth. Req. Ref. Req. Cost Share
Emergency - - - - $0 copay
Urgent care - - - - $0 copay
Foot Care (podiatry Services)
Service Cap Network Auth. Req. Ref. Req. Cost Share
Foot exams and treatment - Out-of-Network Yes No 20% coinsurance
Routine foot care - - - - Not covered
Ground Ambulance
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network - - 20% coinsurance
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 20% coinsurance
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No $1,900 per stay
Maximum Out-of-pocket Enrollee Responsibility (does Not Include Prescription Drugs)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $5,150 In and Out-of-network$3,000 In-network
Medical Equipment/supplies
Service Cap Network Auth. Req. Ref. Req. Cost Share
Diabetes supplies - Out-of-Network Yes - 20% coinsurance per item
Durable medical equipment (e.g., wheelchairs, oxygen) - Out-of-Network Yes - 20% coinsurance per item
Prosthetics (e.g., braces, artificial limbs) - Out-of-Network Yes - 20% coinsurance per item
Medicare Part B Drugs
Service Cap Network Auth. Req. Ref. Req. Cost Share
Chemotherapy - Out-of-Network Yes - 20% coinsurance
Other Part B drugs - Out-of-Network Yes - 20% coinsurance
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Inpatient hospital - psychiatric - Out-of-Network Yes No $2,339 per stay
Outpatient group therapy visit - Out-of-Network Yes No 20% coinsurance
Outpatient group therapy visit with a psychiatrist - Out-of-Network Yes No 20% coinsurance
Outpatient individual therapy visit - Out-of-Network Yes No 20% coinsurance
Outpatient individual therapy visit with a psychiatrist - Out-of-Network Yes No 20% coinsurance
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 20% coinsurance 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 20% coinsurance
Physical therapy and speech and language therapy visit - Out-of-Network Yes No 20% coinsurance
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$184 per day for days 21 through 100
Transportation
Service Cap Network Auth. Req. Ref. Req. Cost Share
Yes Out-of-Network Yes No 75% coinsurance
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
- - Yes No Covered
Plan Drug Info
Formulary Link Drug Formulary Directory
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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