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Monthly Premium
Wellcare Giveback Open (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by WellCare Health Plans, Inc.
Plan ID: H2128-004-000
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
Monthly Premium
Pennsylvania 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 Pennsylvania 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 | $0.00 |
Vision coverage | |
Dental coverage | |
Hearing coverage | |
Prescription drugs | |
Medical deductible | $420.00 |
Out-of-pocket maximum | $7,550.00 |
Initial drug coverage limit | $0.00 |
Catastrophic drug coverage limit | $2,000.00 |
Primary care doctor visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0 |
Specialty doctor visit | Out-of-Network: Doctor Specialty Visit Services: Copayment for Medicare Covered Physician Specialist Office Visit $50 |
Inpatient hospital care | In-Network: Acute Hospital Services: $400 per day for days 1 to 5 $0 per day for days 6 to 90 Prior Authorization Required for Acute Hospital Services |
Urgent care | Urgent Care: Copayment for Urgent Care $40 Copayment for Medicare Covered Urgent Care waived if you are admitted to hospital within 24 hours Worldwide Coverage: Copayment for Worldwide Urgent Coverage $110 Maximum Plan Benefit of $50,000 |
Emergency room visit | Emergency Care: Copayment for Emergency Care $110 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital with in 24 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $110 Maximum Plan Benefit of $50,000 |
Ambulance transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $280 Air Ambulance: Copayment for Air Ambulance Services $280 Prior Authorization Required for Air Ambulance |
Wellcare Giveback Open (PPO) covers a range of additional benefits. Learn more about Wellcare Giveback 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 | In-Network: Chiropractic Services: Copayment for Medicare-covered Chiropractic Services $15 Prior Authorization Required for Chiropractic Services |
Diabetes supplies, training, nutrition therapy and monitoring | In-Network: Diabetic Supplies and Services: Copayment for Medicare-covered Diabetic Supplies $0 Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20% |
Durable medical equipment (DME) | Out-of-Network: Medicare Covered Durable Medical Equipment Services: Coinsurance for Medicare Covered Durable Medical Equipment 40% |
Diagnostic tests, lab and radiology services, and X-rays | Out-of-Network: Medicare Covered Diagnostic Procedures/Tests 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% Diagnostic Tests, Lab and Radiology Services, and X-Rays Outpatient Diagnostic Procedures/Tests: The minimum cost share is for spirometry testing and specified testing-related services. The maximum cost share is for all other services. The removal of abnormal tissue and/or polyps during a colonoscopy performed as a preventive screening for colorectal cancer will be covered at a $0 co-payment. |
Home health care | In-Network: Home Health Services: Copayment for Medicare-covered Home Health Services $0 Prior Authorization Required for Home Health Services |
Mental health inpatient care | Out-of-Network: Psychiatric Hospital Services: 40% per day for days 1 to 90 |
Mental health outpatient care | Out-of-Network: Medicare Covered Mental Health Services: Coinsurance for Medicare Covered Individual Sessions 40% Coinsurance for Medicare Covered Group Sessions 40% |
Outpatient services/surgery | Out-of-Network: Medicare Covered Outpatient Hospital Services: Coinsurance for Medicare Covered Outpatient Hospital Services 40% Coinsurance for Medicare Covered Ambulatory Surgical Center Services 40% Outpatient Hospital and ASC Services Outpatient Hospital Services: The $0 cost share is for diagnostic colonoscopy. The maximum cost share is for all other outpatient services. |
Outpatient substance abuse care | Out-of-Network: Medicare Covered Outpatient Substance Abuse Services: Coinsurance for Medicare Covered Individual Sessions 40% Coinsurance for Medicare Covered Group Sessions 40% |
Over-the-counter items | OTC allowance of $30 every quarter is loaded into the Wellcare Spendables card on a quarterly basis. Benefit is designed to allow members the flexibility to purchase OTC items at participating retailers, online, phone order, or catalog order. Benefit expires at end of quarter if unused. |
Podiatry services | Out-of-Network: Medicare Covered Podiatry Services: Coinsurance for Medicare Covered Podiatry Services 40% |
Skilled Nursing Facility (SNF) care | In-Network: Skilled Nursing Facility Services: $0 per day for days 1 to 20 $214 per day for days 21 to 60 $0 per day for days 61 to 100 Prior Authorization Required for Skilled Nursing Facility Services |
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: Medicare Covered Preventive Dental: Copayment for Office Visit $45 Prior Authorization Required for Medicare Covered Preventive Dental Non-Medicare Covered Preventive Dental: Copayment for Non-medicare preventive $0 Copayment for Oral exams $0
Non-Medicare Covered Comprehensive Dental: Copayment for Non-medicare comprehensive $0 Copayment for Adjunctive general services $0
|
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 to $45 Copayment for Routine Eye Exams $0
Eyewear: Copayment for Medicare-Covered Benefits $0 Maximum Plan Allowance of $100 every year |
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 Exams Services: Copayment for Medicare Covered Hearing Exams $50 |
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 | 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 |
The Wellcare Giveback Open (PPO) offers prescription drug coverage, with an annual drug deductible of $420.00 (excludes Tiers 1, 2, and 6)
Coverage & Cost | |
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Coverage | Cost |
Annual drug deductible | $420.00 (excludes Tiers 1, 2, and 6) |
Tier 1 |
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Tier 2 |
|
Tier 6 |
|
Annual drug deductible | $420.00 (excludes Tiers 1, 2, and 6) |
Tier 1 |
|
Tier 2 |
|
Tier 6 |
|
Annual drug deductible | $420.00 (excludes Tiers 1, 2, and 6) |
Tier 1 |
|
Tier 2 |
|
Tier 6 |
|
When reviewing Pennsylvania 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 Pennsylvania 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 60 seconds, we help someone enroll in a Medicare Advantage plan.1