WellCare Imperial (PPO D-SNP) H0270-002-000 is a 2021 Medicare Advantage Dual-Eligible Special Needs Plan provided by WellCare.

A Special Needs Plan (SNP) is a type of Medicare Advantage Plan designed for Medicare beneficiaries with specific conditions or characteristics.

Dual Eligible Special Needs Plans are for beneficiaries enrolled in Medicare and Medicaid. This includes all categories of Medicaid. Please only choose this plan if you are eligible for both Medicare and Medicaid.

Special Needs plans provide both health coverage and drug coverage, and each coverage type has different costs to consider.

This plan has a monthly premium of $0.00, which covers both the health and drug portions of the plan.

When it comes to out-of-pocket costs for drugs, this plan has a Part D drug Deductible of $445.00 and an Initial Coverage Limit of $4130. Each drug tier may be subject to different cost-sharing in each coverage phase, so keep that in mind when considering out-of-pocket costs. Check out the drug formulary below for more information, or reach out to a licensed Medicare agent for help using the call number on this page. Alternatively, if you know what plan you want, you can enroll online yourself using our site as well.


Plan Basics
Contract Year 2021
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H0270-002-000
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 Plan too new to be measured
Plan Cost Sharing
Premium $0.00
Total Premium (Includes Part B) $135.50
Monthly Part C Premium $0.00
Monthly Part D Basic Premium $26.80
Monthly Part D Supplemental Premium $0.00
Monthly Part D Total Premium $26.80
Monthly Part D Premium Full Assistance $0.00
Monthly Part D Premium 75% Assistance $6.70
Monthly Part D Premium 50% Assistance $13.40
Monthly Part D Premium 25% Assistance $20.10
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 40% coinsurance
Diagnostic tests and procedures - Out-of-Network Yes No 40% coinsurance
Lab services - Out-of-Network Yes No 40% coinsurance
Outpatient x-rays - Out-of-Network Yes No 40% coinsurance
Doctor Visits
Service Cap Network Auth. Req. Ref. Req. Cost Share
Primary - Out-of-Network - - 40% coinsurance per visit
Specialist - Out-of-Network Yes No 40% 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 40% 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 40% coinsurance
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No $2,150 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$3,450 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 - 40% coinsurance
Other Part B drugs - Out-of-Network Yes - 40% coinsurance
Mental Health Services
Service Cap Network Auth. Req. Ref. Req. Cost Share
Inpatient hospital - psychiatric - Out-of-Network Yes No $1,660 per stay
Outpatient group therapy visit - Out-of-Network Yes No 40% coinsurance
Outpatient group therapy visit with a psychiatrist - Out-of-Network Yes No 40% coinsurance
Outpatient individual therapy visit - Out-of-Network Yes No 40% coinsurance
Outpatient individual therapy visit with a psychiatrist - Out-of-Network Yes No 40% 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 40% 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 40% coinsurance
Physical therapy and speech and language therapy visit - Out-of-Network Yes No 40% coinsurance
Skilled Nursing Facility
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No 40% per day for days 1 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
- - No 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

NOTE: Information on MedicarePolicyHelper.com is for educational purposes only. We are not affiliated with Medicare, or CMS. Medicare has not reviewed or endorsed the information on our site. All plan data on our site comes directly from medicare.gov and is subject to change.