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Wellcare No Premium (HMO-POS)

3 out of 5 stars* for plan year 2024
$0.00 Monthly Premium

Wellcare No Premium (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by WellCare Health Plans, Inc.

Plan ID: H1416-077-000

$0.00 Monthly Premium

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

Basic Costs and Coverage

Coverage Details
Monthly plan premium$0.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible$150.00
Out-of-pocket maximum$5,500.00
Initial drug coverage limit$0.00
Catastrophic drug coverage limit$8,000.00
Primary care doctor visitIn-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0.00
Specialty doctor visitIn-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $25.00
Prior Authorization Required for Doctor Specialty Visit
Inpatient hospital care
Out-of-Network:
40% per day for days 1 to 90
Urgent care
Urgent Care:
Copayment for Urgent Care $40.00
Copayment for Medicare Covered Urgent Care waived if you are admitted to hospital within 24 hours

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $120.00
Maximum Plan Benefit of $50,000
Emergency room visit
Emergency Care:
Copayment for Emergency Care $120.00
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $120.00
Maximum Plan Benefit of $50,000
Ambulance transportation
POS (Out-of-Network):

Ambulance Services:
Coinsurance for Medicare Covered Ambulance Services - Ground 40%
Coinsurance for Medicare Covered Ambulance Services - Air 40%

Health Care Services and Medical Supplies

Wellcare No Premium (HMO-POS) covers a range of additional benefits. Learn more about Wellcare No Premium (HMO-POS) benefits, some of which may not be covered by Original Medicare (Part A and Part B).

Coverage Details
Chiropractic services
POS (Out-of-Network):

Chiropractic Services:
Coinsurance for Medicare Covered Chiropractic Services 40%
Diabetes supplies, training, nutrition therapy and monitoringIn-Network:

Diabetic Supplies and Services:
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)
Durable medical equipment (DME)In-Network:

Durable Medical Equipment:
Coinsurance for Medicare-covered Durable Medical Equipment 20%
Prior Authorization Required for Durable Medical Equipment
Diagnostic tests, lab and radiology services, and X-raysIn-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0.00 to $20.00
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 $325.00
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
Home health careIn-Network:

Home Health Services:
Copayment for Medicare-covered Home Health Services $0.00
Prior Authorization Required for Home Health Services
Mental health inpatient careIn-Network:

Psychiatric Hospital Services:
$300.00 per day for days 1 to 6
$0.00 per day for days 7 to 90
Prior Authorization Required for Psychiatric Hospital Services
Mental health outpatient care
POS (Out-of-Network):

Outpatient Mental Health Services:
Coinsurance for Medicare Covered Individual Sessions 40%
Coinsurance for Medicare Covered Group Sessions 40%
Outpatient services/surgery
POS (Out-of-Network):

Outpatient Hospital and ASC Services:
Coinsurance for Medicare Covered Outpatient Hospital Services 40%
Coinsurance for Medicare Covered Ambulatory Surgical Center Services 40%
Outpatient substance abuse careIn-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $40.00
Copayment for Medicare-covered Group Sessions $40.00
Prior Authorization Required for Outpatient Substance Abuse Services
Over-the-counter itemsIn-Network:

Over-The-Counter (OTC) Items:
Copayment for Over-The-Counter (OTC) Items $0.00
Maximum Plan Benefit of $59.00 every month
Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit
Podiatry servicesIn-Network:

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $25.00
Prior Authorization Required for Podiatry Services
Skilled Nursing Facility (SNF) care
Out-of-Network:
40% 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.

Coverage Details
Dental care
POS (Out-of-Network):

Medicare Covered Dental Services:
Coinsurance for Medicare Covered Comprehensive Dental 40%

Vision Benefits

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

Coverage Details
Vision benefits
POS (Out-of-Network):

Medicare Covered Vision Services:
Coinsurance for Medicare Covered Eye Exams 40%
Coinsurance for Medicare Covered Eyewear 40%

Hearing Benefits

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

Coverage Details
Hearing benefitsIn-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $25.00
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 $1000.00 every year per ear
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.

Coverage Details
Preventive services and health/wellness education programs
POS (Out-of-Network):

Medicare-covered Zero Dollar Preventive Services:
Coinsurance for Medicare Covered Medicare-covered Preventive Services 40%

Prescription Drug Costs and Coverage

The Wellcare No Premium (HMO-POS) offers prescription drug coverage, with an annual drug deductible of $150.00 (excludes Tiers 1, 2 and 6)

Coverage
Cost
Coverage & Cost
Annual drug deductible$150.00 (excludes Tiers 1, 2 and 6)
Tier 1
  • Preferred retail $0.00
  • Standard retail $0.00
  • Preferred mail order $0.00
  • Standard mail order $0.00
  • Tier 2
  • Preferred retail $7.00
  • Standard retail $12.00
  • Preferred mail order $7.00
  • Standard mail order $12.00
  • Tier 6
  • Preferred retail $0.00
  • Standard retail $0.00
  • Preferred mail order $0.00
  • Standard mail order $0.00
  • Annual drug deductible$150.00 (excludes Tiers 1, 2 and 6)
    Tier 1
  • Preferred retail $0.00
  • Standard retail $0.00
  • Preferred mail order $0.00
  • Standard mail order $0.00
  • Tier 2
  • Preferred retail $14.00
  • Standard retail $24.00
  • Preferred mail order $14.00
  • Standard mail order $24.00
  • Tier 6
  • Preferred retail $0.00
  • Standard retail $0.00
  • Preferred mail order $0.00
  • Standard mail order $0.00
  • Annual drug deductible$150.00 (excludes Tiers 1, 2 and 6)
    Tier 1
  • Preferred retail $0.00
  • Standard retail $0.00
  • Preferred mail order $0.00
  • Standard mail order $0.00
  • Tier 2
  • Preferred retail $21.00
  • Standard retail $36.00
  • Preferred mail order $0.00
  • Standard mail order $36.00
  • Tier 6
  • Preferred retail $0.00
  • Standard retail $0.00
  • Preferred mail order $0.00
  • Standard mail order $0.00
  • When reviewing Tennessee 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 Tennessee 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

    Tennessee 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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