Plan Basics
Contract Year 2021
Medicare Type Medicare Advantage Plan (Part C)
CMS Plan ID H1112-034-000
Plan Organization WellCare
Plan Type Local HMO *
Plan Name WellCare Patriot (HMO-POS)
Drugs Covered No
Doctors Choice Plan Doctors Only (some exceptions)
Overall Star Rating 3.5
Plan Cost Sharing
Premium $0.00
Total Premium (Includes Part B) $135.50
Monthly Part C Premium $0.00
Maximum Out-of-Pocket Limit for Parts A & B (MOOP) $3400.00

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 In-Network Yes Yes $0 copay
Endodontics Yes In-Network Yes Yes $0 copay
Extractions Yes In-Network Yes Yes $0 copay
Non-routine services Yes In-Network Yes Yes $0 copay
Periodontics Yes In-Network Yes Yes $0 copay
Prosthodontics, other oral/maxillofacial surgery, other services Yes In-Network Yes Yes $0 copay
Restorative services Yes In-Network Yes Yes $0 copay
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 - - - - $120 copay per visit (always covered)
Urgent care - - - - $35 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 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 In-Network Yes Yes $0 copay
Hearing aids Yes In-Network Yes Yes $0 copay
Hearing exam - Out-of-Network Yes Yes 20% coinsurance
Inpatient Hospital Coverage
Service Cap Network Auth. Req. Ref. Req. Cost Share
- Out-of-Network Yes No 20% per stay
Maximum Out-of-pocket Enrollee Responsibility (does Not Include Prescription Drugs)
Service Cap Network Auth. Req. Ref. Req. Cost Share
- - - - $3,400 In and Out-of-network$3,400 In-network$3,400 Out-of-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 20% 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 20% coinsurance
Preventive Dental
Service Cap Network Auth. Req. Ref. Req. Cost Share
Cleaning Yes In-Network Yes Yes $0 copay
Dental x-ray(s) Yes In-Network Yes Yes $0 copay
Fluoride treatment 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
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 20% per stay
Transportation
Service Cap Network Auth. Req. Ref. Req. Cost Share
Yes In-Network Yes No $0 copay
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 In-Network Yes Yes $0 copay
Other No - - - Not covered
Routine eye exam Yes In-Network Yes Yes $0 copay
Upgrades Yes In-Network Yes Yes $0 copay
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, 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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