Wellcare Patriot No Premium Open (PPO)
Wellcare Patriot No Premium Open (PPO) H5439-010 Plan Details
Wellcare Patriot No Premium Open (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Centene Corporation
Plan ID: H5439-010
HelpAdvisor Editorial Team analysis of data from the 2024 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
$0.00
Monthly Premium
Wellcare Patriot No Premium Open (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Centene Corporation
Plan ID: H5439-010
HelpAdvisor Editorial Team analysis of data from the 2024 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $-1 |
| Out of Pocket Max |
In-Network: $3500 Out-of-Network: N/A |
| Initial Coverage Limit | $5030 |
| Catastrophic Coverage Limit | $8,000 |
| Primary Care Doctor Visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $12.00 Out-of-Network: Doctor Office Visit: Coinsurance for Medicare Covered Primary Care Office Visit 20% |
| Specialty Doctor Visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $25.00 Prior Authorization Required for Doctor Specialty Visit Prior authorization required Out-of-Network: Doctor Specialty Visit: Coinsurance for Medicare Covered Physician Specialist Office Visit 20% |
| Inpatient Hospital Care | In-Network: Acute Hospital Services: $200.00 per day for days 1 to 8 $0.00 per day for days 9 to 90 Prior Authorization Required for Acute Hospital Services Prior authorization required Out-of-Network: 20% per day for days 1 to 90 |
| Urgent Care | Copayment for Urgent Care $65.00 Copayment for Medicare Covered Urgent Care waived if you are admitted to hospital within 24 hours Worldwide Coverage: Copayment for Worldwide Urgent Coverage $135.00 Maximum Plan Benefit of $50,000 |
| Emergency Room Visit | Copayment for Emergency Care $135.00 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $135.00 Maximum Plan Benefit of $50,000 |
| Ambulance Transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $175.00 Air Ambulance: Copayment for Air Ambulance Services $175.00 Please see Evidence of Coverage for Prior Authorization rules Prior authorization required Out-of-Network: Ambulance Services: Copayment for Medicare Covered Ambulance Services - Ground $175.00 Copayment for Medicare Covered Ambulance Services - Air $175.00 |
Health Care Services and Medical Supplies
Wellcare Patriot No Premium Open (PPO) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).
| Coverage | Cost |
|---|---|
| Chiropractic Services | In-Network: Copayment for Medicare-covered Chiropractic Services $0.00 Copayment for Routine Care $0.00
Prior authorization required Out-of-Network: Coinsurance for Medicare Covered Chiropractic Services 20% Coinsurance for Non-Medicare Covered Chiropractic Services 20% |
| Diabetes Supplies, Training, Nutrition Therapy and Monitoring | In-Network: Copayment for Medicare-covered Diabetic Supplies $0.00 Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20% Prior Authorization Required for Diabetic Supplies and Services Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage) Prior authorization required Out-of-Network: Coinsurance for Medicare Covered Diabetic Supplies and Services 20% |
| Durable Medical Eqipment (DME) | In-Network: Coinsurance for Medicare-covered Durable Medical Equipment 20% Prior Authorization Required for Durable Medical Equipment Prior authorization required Out-of-Network: Coinsurance for Medicare Covered Durable Medical Equipment 20% |
| Diagnostic Tests, Lab and Radiology Services, and X-Rays | In-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare-covered Diagnostic Procedures/Tests $0.00 Coinsurance for Medicare-covered Diagnostic Procedures/Tests 20% Copayment for Medicare-covered Lab Services $0.00 to $50.00 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $0.00 to $225.00 Coinsurance for Medicare-covered Therapeutic Radiological Services 20% Copayment for Medicare-covered X-Ray Services $0.00 Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services Prior authorization required Out-of-Network: Outpatient Diag Procs/Tests/Lab Services: Coinsurance for Medicare Covered Diagnostic Procedures/Tests 20% Coinsurance for Medicare Covered Lab Services 20% Coinsurance for Medicare Covered Diagnostic Radiological Services 20% Coinsurance for Medicare Covered Therapeutic Radiological Services 20% Coinsurance for Medicare Covered Outpatient X-Ray Services 20% |
| Home Health Care | In-Network: Copayment for Medicare-covered Home Health Services $0.00 Prior Authorization Required for Home Health Services Prior authorization required Out-of-Network: Coinsurance for Medicare Covered Home Health 20% |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: $200.00 per day for days 1 to 8 $0.00 per day for days 9 to 90 Prior Authorization Required for Psychiatric Hospital Services Prior authorization required Out-of-Network: 20% per day for days 1 to 90 |
| Mental Health Outpatient Care | In-Network: Copayment for Medicare-covered Individual Sessions $25.00 Copayment for Medicare-covered Group Sessions $25.00 Prior Authorization Required for Outpatient Mental Health Services Prior authorization required Out-of-Network: Coinsurance for Medicare Covered Individual Sessions 20% Coinsurance for Medicare Covered Group Sessions 20% |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0.00 to $225.00 Prior Authorization Required for Outpatient Hospital Services Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $135.00 to $225.00 Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $150.00 Prior Authorization Required for Ambulatory Surgical Center Services Prior authorization required Out-of-Network: Outpatient Hospital and ASC Services: Coinsurance for Medicare Covered Outpatient Hospital Services 20% Coinsurance for Medicare Covered Ambulatory Surgical Center Services 20% |
| Outpatient Substance Abuse Care | In-Network: Copayment for Medicare-covered Individual Sessions $25.00 Copayment for Medicare-covered Group Sessions $25.00 Prior Authorization Required for Outpatient Substance Abuse Services Prior authorization required Out-of-Network: Coinsurance for Medicare Covered Individual or Group Sessions 20% |
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $25.00 Prior Authorization Required for Podiatry Services Prior authorization required Out-of-Network: Coinsurance for Medicare Covered Podiatry Services 20% |
| Skilled Nursing Facility Care | In-Network: Skilled Nursing Facility Services: $0.00 per day for days 1 to 20 $203.00 per day for days 21 to 40 $0.00 per day for days 41 to 100 Prior Authorization Required for Skilled Nursing Facility Services Prior authorization required Out-of-Network: 20% per day for days 1 to 100 |
Dental Benefits
The following dental services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Dental Care | In-Network: Preventive Dental: Copayment for Oral Exams $0.00
Comprehensive Dental: Copayment for Medicare-covered Benefits $25.00 Coinsurance for Non-routine Services 40%
Prior Authorization Required for Comprehensive Dental Prior authorization required Out-of-Network: Medicare Covered Dental Services: Coinsurance for Medicare Covered Comprehensive Dental 20% Non-Medicare Covered Dental Services: Coinsurance for Non-Medicare Covered Preventive Dental 70% Coinsurance for Non-Medicare Covered Comprehensive Dental 70% |
Vision Benefits
The following vision services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Vision Benefits | In-Network: Eye Exams: Copayment for Medicare Covered Benefits $0.00 to $25.00 Copayment for Routine Eye Exams $0.00
Eyewear: Copayment for Medicare-Covered Benefits $0.00 Maximum Plan Allowance of $200.00 every year for all Non-Medicare covered eyewear for in and out of network services combined Prior Authorization Required for Eyewear Prior authorization required Out-of-Network: Medicare Covered Vision Services: Copayment for Medicare Covered Eye Exams $0.00 Coinsurance for Medicare Covered Eye Exams 20% Coinsurance for Medicare Covered Eyewear 20% Non-Medicare Covered Vision Services: Coinsurance for Non-Medicare Covered Eye Exams 40% Coinsurance for Non-Medicare Covered Eyewear 40% |
Hearing Benefits
The following hearing services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Hearing Benefits | In-Network: Hearing Exams: Copayment for Medicare Covered Benefits $25.00 Copayment for Routine Hearing Exams $0.00
Hearing Aids: Copayment for Hearing Aids $0.00
Prior Authorization Required for Hearing Aids Prior authorization required Out-of-Network: Medicare Covered Hearing Services: Coinsurance for Medicare Covered Hearing Exams 20% Non-Medicare Covered Hearing Services: Coinsurance for Non-Medicare Covered Hearing Exams 40% Coinsurance for Non-Medicare Covered Hearing Aids 40% |
Preventive Services and Health/Wellness Education Programs
The following services are covered from in-network providers.
| Coverage | Cost |
|---|---|
| Preventive Services and Health/Wellness Education Programs | In-Network: $0.00 copay for Medicare Covered Preventive Services: Abdominal aortic aneurysm screening Alcohol misuse screenings & counseling Bone mass measurements (bone density) Cardiovascular disease screenings Cardiovascular disease (behavioral therapy) Cervical & vaginal cancer screening Colorectal cancer screenings Depression screenings Diabetes screenings Diabetes self-management training Glaucoma tests Hepatitis B (HBV) infection screening Hepatitis C screening test HIV screening Lung cancer screening Mammograms (screening) Nutrition therapy services Obesity screenings & counseling One-time Welcome to Medicare preventive visit Prostate cancer screenings(PSA) Sexually transmitted infections screening & counseling Shots:
Yearly "Wellness" visit Out-of-Network: Medicare-covered Zero Dollar Preventive Services: Copayment for Medicare Covered Medicare-covered Preventive Services $0.00 |
