Wellcare No Premium Open (PPO)

Not enough data available* for plan year 2023
$0.00 Monthly Premium

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

Plan ID: H4699-001-000

$0.00 Monthly Premium

Rhode Island 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 Rhode Island 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$0.00
Out-of-pocket maximum$5,500.00
Initial drug coverage limit$0.00
Catastrophic drug coverage limit$7,400.00
Primary care doctor visit
Out-of-Network:

Doctor Office Visit:
Copayment for Medicare Covered Primary Care Office Visit $0.00
Specialty doctor visit
Out-of-Network:

Doctor Specialty Visit:
Copayment for Medicare Covered Physician Specialist Office Visit $35.00
Inpatient hospital careIn-Network:

Acute Hospital Services:
$325.00 per day for days 1 to 6
$0.00 per day for days 7 to 90
Prior Authorization Required for Acute Hospital Services
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 $110.00
Maximum Plan Benefit of $50,000
Emergency room visit
Emergency Care:
Copayment for Emergency Care $110.00
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $110.00
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 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 servicesIn-Network:

Chiropractic Services:
Copayment for Medicare-covered Chiropractic Services $20.00
Prior Authorization Required for Chiropractic Services
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)
Out-of-Network:

Durable Medical Equipment:
Coinsurance for Medicare Covered Durable Medical Equipment 20%
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
Out-of-Network:

Home Health Services:
Coinsurance for Medicare Covered Home Health 30%
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
Out-of-Network:

Outpatient Mental Health Services:
Coinsurance for Medicare Covered Individual Sessions 30%
Coinsurance for Medicare Covered Group Sessions 30%
Outpatient services/surgeryIn-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $275.00
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $110.00 to $275.00
Prior Authorization Required for Outpatient Observation Services

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $200.00
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 30%
Over-the-counter itemsIn-Network:

Over-The-Counter (OTC) Items:
Copayment for Over-The-Counter (OTC) Items $0.00
Maximum Plan Benefit of $61.00 every three months
Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit
Podiatry servicesIn-Network:

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $30.00
Prior Authorization Required for Podiatry Services
Skilled Nursing Facility (SNF) careIn-Network:

Skilled Nursing Facility Services:
$0.00 per day for days 1 to 20
$196.00 per day for days 21 to 50
$0.00 per day for days 51 to 100
Prior Authorization Required for Skilled Nursing Facility Services

Dental Benefits

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

Coverage Details
Dental careIn-Network:

Preventive Dental:
Copayment for Oral Exams $0.00
  • Maximum 2 visits every year
Copayment for Prophylaxis (Cleaning) $0.00
  • Maximum 2 visits every year
Copayment for Fluoride Treatment $0.00
  • Maximum 1 visit every year
Copayment for Dental X-Rays $0.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Referral Required for Preventive Dental

Comprehensive Dental:
Copayment for Medicare-covered Benefits $30.00
Copayment for Non-routine Services $0.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Diagnostic Services $0.00
  • Maximum 1 visit every year
Copayment for Restorative Services $0.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Endodontics $0.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Periodontics $0.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Extractions $0.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services $0.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Maximum Plan Benefit of $1500.00 every year for in and out of network services combined for Non-Medicare Covered Comprehensive
Prior Authorization Required for Comprehensive Dental

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 $35.00
Copayment for Medicare Covered Eyewear $35.00
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 benefitsIn-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $30.00
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 $500.00 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.

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

When reviewing Rhode Island 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 Rhode Island 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

Rhode Island Counties Served

Bristol Kent Newport Providence Washington
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