Wellcare No Premium Open (PPO) H2775-106-000 2024 Plan Details and Costs

New York 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 New York 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	$450.00
Out-of-pocket maximum	$6,700.00
Initial drug coverage limit	$0.00
Catastrophic drug coverage limit	$8,000.00
Primary care doctor visit	Out-of-Network: Doctor Office Visit: Copayment for Medicare Covered Primary Care Office Visit $25.00
Specialty doctor visit	Out-of-Network: Doctor Specialty Visit: Copayment for Medicare Covered Physician Specialist Office Visit $60.00
Inpatient hospital care	Out-of-Network: $600.00 per day for days 1 to 12 $0.00 per day for days 13 to 90
Urgent care	Urgent Care: Copayment for Urgent Care $35.00 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	Out-of-Network: Ambulance Services: Copayment for Medicare Covered Ambulance Services - Ground $350.00 Copayment for Medicare Covered Ambulance Services - Air $350.00

Health Care Services and Medical Supplies

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

Coverage	Details
Chiropractic services	In-Network: Chiropractic Services: Copayment for Medicare-covered Chiropractic Services $15.00 Copayment for Routine Care $15.00 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 $0.00 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-rays	Out-of-Network: Outpatient Diag Procs/Tests/Lab Services: Coinsurance for Medicare Covered Diagnostic Procedures/Tests 30% Coinsurance for Medicare Covered Lab Services 30% Coinsurance for Medicare Covered Diagnostic Radiological Services 30% Coinsurance for Medicare Covered Therapeutic Radiological Services 30% Coinsurance for Medicare Covered Outpatient X-Ray Services 30%
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: $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	Out-of-Network: Outpatient Mental Health Services: Coinsurance for Medicare Covered Individual Sessions 30% Coinsurance for Medicare Covered Group Sessions 30%
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	In-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	In-Network: Over-The-Counter (OTC) Items: Copayment for Over-The-Counter (OTC) Items $0.00 Maximum Plan Benefit of $84.00 every three months Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit
Podiatry services	In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $40.00 Prior Authorization Required for Podiatry Services
Skilled Nursing Facility (SNF) care	Out-of-Network: $0.00 per day for days 1 to 20 $250.00 per day for days 21 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	Out-of-Network: Medicare Covered Dental Services: Copayment for Medicare Covered Comprehensive Dental $60.00 Non-Medicare Covered Dental Services: Coinsurance for Non-Medicare Covered Preventive Dental 50% Coinsurance for Non-Medicare Covered Comprehensive Dental 50%

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	Out-of-Network: Medicare Covered Vision Services: Copayment for Medicare Covered Eye Exams $0.00 to $60.00 Copayment for Medicare Covered Eyewear $60.00 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, though there may be provider network restrictions. See the plan Evidence of Coverage.

Coverage	Details
Hearing benefits	Out-of-Network: Medicare Covered Hearing Services: Copayment for Medicare Covered Hearing Exams $60.00 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, 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

Prescription Drug Costs and Coverage

The Wellcare No Premium Open (PPO) offers prescription drug coverage, with an annual drug deductible of $450.00 (excludes Tiers 1, 2 and 6)

Coverage	Cost
Coverage & Cost
Annual drug deductible	$450.00 (excludes Tiers 1, 2 and 6)
Tier 1	Preferred retail $0.00 Standard retail $5.00 Preferred mail order $0.00 Standard mail order $5.00
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	$450.00 (excludes Tiers 1, 2 and 6)
Tier 1	Preferred retail $0.00 Standard retail $10.00 Preferred mail order $0.00 Standard mail order $10.00
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	$450.00 (excludes Tiers 1, 2 and 6)
Tier 1	Preferred retail $0.00 Standard retail $15.00 Preferred mail order $0.00 Standard mail order $15.00
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 New York 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 New York 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	Summary of benefits Star ratings

Links to plan documents

New York Counties Served

Bergen Bronx Broome Cattaraugus Cayuga Chautauqua Chemung Chenango Clinton Columbia Cortland Delaware Dutchess Erie Fairfield Franklin Fulton Genesee Greene Hamilton Herkimer Jefferson Kings Lewis Madison Monroe Montgomery Nassau Niagara Oneida Onondaga Ontario Orange Oswego Otsego Passaic Putnam Queens Rensselaer Richmond Rockland Saint Lawrence Saratoga Schenectady Schoharie Schuyler Seneca Steuben Suffolk Sullivan Tioga Tompkins Ulster Warren Washington Wayne Westchester Wyoming Yates