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 |
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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