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Wellcare 'Ohana Assist Open (PPO) - H6605-003-000

2 out of 5 stars* for plan year 2024

$11.60

Monthly Premium

Wellcare 'Ohana Assist Open (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by WellCare Health Plans, Inc.

Plan ID: H6605-003-000

* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.

$11.60

Monthly Premium

Hawaii Medicare beneficiaries may want to consider reviewing their Medicare Advantage (Medicare Part C) plan options. A Medicare Advantage plan combines your Original Medicare (Part A and Part B) benefits into a single plan.

Most Medicare Advantage plans cover prescription drugs, and many plans may offer other extra benefits Original Medicare doesn’t cover.

Learn more about Hawaii Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.

Enrollment may be limited to certain times of the year. See why you may be able to enroll.

Basic Costs and Coverage

CoverageDetails
Monthly plan premium$11.60
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible$545.00
Out-of-pocket maximum$8,850.00
Initial drug coverage limit$0.00
Catastrophic drug coverage limit$8,000.00
Primary care doctor visit
Out-of-Network:

Doctor Office Visit:
Coinsurance for Medicare Covered Primary Care Office Visit 40%
Specialty doctor visitIn-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $40.00
Prior Authorization Required for Doctor Specialty Visit
Inpatient hospital careIn-Network:

Acute Hospital Services:
$389.00 per day for days 1 to 4
$0.00 per day for days 5 to 90
Prior Authorization Required for Acute Hospital Services
Urgent care
Urgent Care:
Copayment for Urgent Care $55.00
Copayment for Medicare Covered Urgent Care waived if you are admitted to hospital within 24 hours

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $100.00
Maximum Plan Benefit of $50,000
Emergency room visit
Emergency Care:
Copayment for Emergency Care $100.00
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $100.00
Maximum Plan Benefit of $50,000
Ambulance transportationIn-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $300.00

Air Ambulance:
Copayment for Air Ambulance Services $300.00

Please see Evidence of Coverage for Prior Authorization rules

Health Care Services and Medical Supplies

Wellcare 'Ohana Assist Open (PPO) covers a range of additional benefits. Learn more about Wellcare 'Ohana Assist Open (PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).

CoverageDetails
Chiropractic services
Out-of-Network:

Chiropractic Services:
Coinsurance for Medicare Covered Chiropractic Services 40%
Chiropractic Services:
Coinsurance for Non-Medicare Covered Chiropractic Services 40%
Diabetes supplies, training, nutrition therapy and monitoring
Out-of-Network:

Diabetic Supplies and Services:
Coinsurance for Medicare Covered Diabetic Supplies and Services 40%
Durable medical equipment (DME)
Out-of-Network:

Durable Medical Equipment:
Coinsurance for Medicare Covered Durable Medical Equipment 40%
Diagnostic tests, lab and radiology services, and X-rays
Out-of-Network:

Outpatient Diag Procs/Tests/Lab Services:
Coinsurance for Medicare Covered Diagnostic Procedures/Tests 40%
Coinsurance for Medicare Covered Lab Services 40%
Coinsurance for Medicare Covered Diagnostic Radiological Services 40%
Coinsurance for Medicare Covered Therapeutic Radiological Services 40%
Coinsurance for Medicare Covered Outpatient X-Ray Services 40%
Home health care
Out-of-Network:

Home Health Services:
Coinsurance for Medicare Covered Home Health 40%
Mental health inpatient careIn-Network:

Psychiatric Hospital Services:
$484.00 per day for days 1 to 4
$0.00 per day for days 5 to 90
Prior Authorization Required for Psychiatric Hospital Services
Mental health outpatient care
Out-of-Network:

Outpatient Mental Health Services:
Coinsurance for Medicare Covered Individual Sessions 40%
Coinsurance for Medicare Covered Group Sessions 40%
Outpatient services/surgeryIn-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0.00 to $400.00
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $100.00 to $400.00

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $250.00
Prior Authorization Required for Ambulatory Surgical Center Services
Outpatient substance abuse careIn-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $25.00
Copayment for Medicare-covered Group Sessions $25.00
Prior Authorization Required for Outpatient Substance Abuse Services
Over-the-counter items
Out-of-Network:

Over-The-Counter (OTC) Items:
Copayment for Non-Medicare Covered Over-The-Counter (OTC) Items $0.00
Maximum Plan Benefit of $60.00
Podiatry services
Out-of-Network:

Podiatry Services:
Coinsurance for Medicare Covered Podiatry Services 40%
Skilled Nursing Facility (SNF) care
Out-of-Network:
30% per day for days 1 to 100

Dental Benefits

The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

CoverageDetails
Dental care
Out-of-Network:

Medicare Covered Dental Services:
Coinsurance for Medicare Covered Comprehensive Dental 40%
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, though there may be provider network restrictions. See the plan Evidence of Coverage

CoverageDetails
Vision careIn-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $0.00 to $40.00
Copayment for Routine Eye Exams $0.00
  • Maximum 1 Routine Eye Exam every year
Prior Authorization Required for Eye Exams

Eyewear:
Copayment for Medicare-Covered Benefits $0.00
Maximum Plan Allowance of $100.00 every year for all Non-Medicare covered eyewear for in and out of network services combined
Prior Authorization Required for Eyewear

Hearing Benefits

The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

CoverageDetails
Hearing careIn-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $40.00
Copayment for Routine Hearing Exams $0.00
  • Maximum 1 visit every year
Copayment for Fitting/Evaluation for Hearing Aid $0.00
  • Maximum 1 visit every year
Prior Authorization Required for Hearing Exams

Hearing Aids:
Copayment for Hearing Aids $0.00
  • Maximum 2 Hearing Aids every year
Maximum Plan Benefit of $350.00 every year per ear for in and out of network services combined
Prior Authorization Required for Hearing Aids

Preventive Services and Health/Wellness Education Programs

The following services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

CoverageDetails
Preventive services and health/wellness education programsIn-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:
  • COVID-19 shots
  • Flu shots
  • Hepatitis B shots
  • Pneumococcal shots
  • Tobacco use cessation
    Yearly "Wellness" visit

    Prescription Drug Costs and Coverage

    The Wellcare 'Ohana Assist Open (PPO) offers prescription drug coverage, with an annual drug deductible of $545.00 (excludes Tiers 1 and 6)

    Coverage & Cost
    Coverage
    Cost
    Annual drug deductible$545.00 (excludes Tiers 1 and 6)
    Tier 1
    • Preferred retail $0.00
    • Preferred retail $0.00
    • Standard retail $19.00
    • Standard retail $19.00
    • Preferred mail order $0.00
    • Preferred mail order $0.00
    • Standard mail order $19.00
    • Standard mail order $19.00
    Tier 6
    • Preferred retail $0.00
    • Preferred retail $0.00
    • Standard retail $0.00
    • Standard retail $0.00
    • Preferred mail order $0.00
    • Preferred mail order $0.00
    • Standard mail order $0.00
    • Standard mail order $0.00
    Annual drug deductible$545.00 (excludes Tiers 1 and 6)
    Tier 1
    • Preferred retail $0.00
    • Preferred retail $0.00
    • Standard retail $38.00
    • Standard retail $38.00
    • Preferred mail order $0.00
    • Preferred mail order $0.00
    • Standard mail order $38.00
    • Standard mail order $38.00
    Tier 6
    • Preferred retail $0.00
    • Preferred retail $0.00
    • Standard retail $0.00
    • Standard retail $0.00
    • Preferred mail order $0.00
    • Preferred mail order $0.00
    • Standard mail order $0.00
    • Standard mail order $0.00
    Annual drug deductible$545.00 (excludes Tiers 1 and 6)
    Tier 1
    • Preferred retail $0.00
    • Preferred retail $0.00
    • Standard retail $57.00
    • Standard retail $57.00
    • Preferred mail order $0.00
    • Preferred mail order $0.00
    • Standard mail order $57.00
    • Standard mail order $57.00
    Tier 6
    • Preferred retail $0.00
    • Preferred retail $0.00
    • Standard retail $0.00
    • Standard retail $0.00
    • Preferred mail order $0.00
    • Preferred mail order $0.00
    • Standard mail order $0.00
    • Standard mail order $0.00

    When reviewing Hawaii Medicare plans, be sure to find out if your doctors are part of the plan network. If a Medicare Advantage plan covers prescription drugs, make sure the plan formulary (list of drugs covered by the plan) includes your drugs.

    You may be able to find plans in your part of Hawaii that offer similar benefits at similar or lower prices than the plan above. Call 1-800-557-6059 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.

    Plan Documents

    Links to plan documents

    Hawaii Counties Served

    We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.

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