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Monthly Premium
Wellcare 'Ohana Low Premium Open (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by WellCare Health Plans, Inc.
Plan ID: H6605-004-000
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
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.
Coverage | Details |
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Monthly plan premium | $33.00 |
Vision coverage | |
Dental coverage | |
Hearing coverage | |
Prescription drugs | |
Medical deductible | $300.00 |
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 visit | Out-of-Network: Doctor Specialty Visit: Coinsurance for Medicare Covered Physician Specialist Office Visit 40% |
Inpatient hospital care | In-Network: Acute Hospital Services: $349.00 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 transportation | In-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 |
Wellcare 'Ohana Low Premium Open (PPO) covers a range of additional benefits. Learn more about Wellcare 'Ohana Low Premium Open (PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).
Coverage | Details |
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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 | In-Network: Home Health Services: Copayment for Medicare-covered Home Health Services $0.00 Prior Authorization Required for Home Health Services |
Mental health inpatient care | In-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/surgery | In-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 care | Out-of-Network: Outpatient Substance Abuse Services: Coinsurance for Medicare Covered Individual or Group Sessions 40% |
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 $40.00 |
Podiatry services | In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $45.00 Prior Authorization Required for Podiatry Services |
Skilled Nursing Facility (SNF) care | Out-of-Network: 30% per day for days 1 to 100 |
The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
Coverage | Details |
---|---|
Dental care | In-Network: Preventive Dental: Copayment for Oral Exams $0.00
Comprehensive Dental: Copayment for Medicare-covered Benefits $45.00 Coinsurance for Non-routine Services 40%
Prior Authorization Required for Comprehensive Dental |
The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage
Coverage | Details |
---|---|
Vision care | In-Network: Eye Exams: Copayment for Medicare Covered Benefits $0.00 to $45.00 Copayment for Routine Eye Exams $0.00
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 |
The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
Coverage | Details |
---|---|
Hearing care | Out-of-Network: Medicare Covered Hearing Services: Coinsurance for Medicare Covered Hearing Exams 40% Non-Medicare Covered Hearing Services: Coinsurance for Non-Medicare Covered Hearing Exams 40% Coinsurance for Non-Medicare Covered Hearing Aids 40% |
The following services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
Coverage | Details |
---|---|
Preventive services and health/wellness education programs | Out-of-Network: Medicare-covered Zero Dollar Preventive Services: Copayment for Medicare Covered Medicare-covered Preventive Services $0.00 |
The Wellcare 'Ohana Low Premium Open (PPO) offers prescription drug coverage, with an annual drug deductible of $300.00 (excludes Tiers 1, 2, and 6)
Coverage & Cost | |
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Coverage | Cost |
Annual drug deductible | $300.00 (excludes Tiers 1, 2, and 6) |
Tier 1 |
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Tier 2 |
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Tier 6 |
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Annual drug deductible | $300.00 (excludes Tiers 1, 2, and 6) |
Tier 1 |
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Tier 2 |
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Tier 6 |
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Annual drug deductible | $300.00 (excludes Tiers 1, 2, and 6) |
Tier 1 |
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Tier 2 |
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Tier 6 |
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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.
Links to plan documents |
We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.
Every minute we help someone compare their Medicare Advantage plan options.2