Wellcare No Premium Rx Plus Open (PPO)

2.5 out of 5 stars* for plan year 2023
$0.00 Monthly Premium

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

Plan ID: H7323-006-000

$0.00 Monthly Premium

Texas 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 Texas 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$300.00
Out-of-pocket maximum$6,000.00
Initial drug coverage limit$0.00
Catastrophic drug coverage limit$7,400.00
Primary care doctor visitIn-Network:

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

Doctor Specialty Visit:
Coinsurance for Medicare Covered Physician Specialist Office Visit 20%
Inpatient hospital care
Out-of-Network:
20% 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 $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 $285.00

Air Ambulance:
Copayment for Air Ambulance Services $285.00

Please see Evidence of Coverage for Prior Authorization rules

Health Care Services and Medical Supplies

Wellcare No Premium Rx Plus Open (PPO) covers a range of additional benefits. Learn more about Wellcare No Premium Rx Plus 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-raysIn-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0.00 to $40.00
Copayment for Medicare-covered Lab Services $0.00
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 $300.00
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 careIn-Network:

Outpatient Mental Health Services:
Copayment for Medicare-covered Individual Sessions $25.00
Copayment for Medicare-covered Group Sessions $25.00
Prior Authorization Required for Outpatient Mental Health Services
Outpatient services/surgery
Out-of-Network:

Outpatient Hospital and ASC Services:
Coinsurance for Medicare Covered Outpatient Hospital Services 20%
Coinsurance for Medicare Covered Ambulatory Surgical Center Services 20%
Outpatient substance abuse care
Out-of-Network:

Outpatient Substance Abuse Services:
Coinsurance for Medicare Covered Individual or Group Sessions 20%
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 $68.00
Podiatry services
Out-of-Network:

Podiatry Services:
Coinsurance for Medicare Covered Podiatry Services 20%
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 60
$0.00 per day for days 61 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 $40.00
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
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
Coinsurance for Medicare Covered Eye Exams 20%
Coinsurance for Medicare Covered Eyewear 20%
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:
Coinsurance for Medicare Covered Hearing Exams 20%
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 Rx Plus Open (PPO) offers prescription drug coverage, with an annual drug deductible of $300.00 (excludes Tiers 1, 2 and 6)

Coverage
Cost
Coverage & Cost
Annual drug deductible$300.00 (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 $0.00
  • Standard retail $10.00
  • Preferred mail order $0.00
  • Standard mail order $10.00
  • Tier 6
  • Preferred retail $0.00
  • Standard retail $0.00
  • Preferred mail order $0.00
  • Standard mail order $0.00
  • Annual drug deductible$300.00 (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 $0.00
  • Standard retail $20.00
  • Preferred mail order $0.00
  • Standard mail order $20.00
  • Tier 6
  • Preferred retail $0.00
  • Standard retail $0.00
  • Preferred mail order $0.00
  • Standard mail order $0.00
  • Annual drug deductible$300.00 (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 $0.00
  • Standard retail $30.00
  • Preferred mail order $0.00
  • Standard mail order $30.00
  • Tier 6
  • Preferred retail $0.00
  • Standard retail $0.00
  • Preferred mail order $0.00
  • Standard mail order $0.00
  • When reviewing Texas 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 Texas 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

    Texas Counties Served

    Austin Bastrop Bexar Blanco Brazoria Burnet Caldwell Chambers Collin Comal Cooke Dallas Denton Dona Ana El Paso Fort Bend Galveston Guadalupe Hardin Harris Hays Hidalgo Jefferson Johnson Lee Liberty Medina Milam Montgomery Orange Polk Rockwall San Jacinto Starr Tarrant Travis Walker Waller Williamson
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