Wellcare Patriot Giveback Open (PPO)

Plan too new to be measured* for plan year 2023
$0.00 Monthly Premium

Wellcare Patriot Giveback Open (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by WellCare Health Plans, Inc.

Plan ID: H2117-003-000

$0.00 Monthly Premium

Michigan 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 Michigan 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($1.00)
Out-of-pocket maximum$5,000.00
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:
Copayment for Medicare Covered Physician Specialist Office Visit $20.00 to $30.00
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 $50.00
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 transportation
Out-of-Network:

Ambulance Services:
Copayment for Medicare Covered Ambulance Services - Ground $250.00
Copayment for Medicare Covered Ambulance Services - Air $250.00

Health Care Services and Medical Supplies

Wellcare Patriot Giveback Open (PPO) covers a range of additional benefits. Learn more about Wellcare Patriot Giveback Open (PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).

Coverage Details
Chiropractic services
Out-of-Network:

Chiropractic Services:
Copayment for Medicare Covered Chiropractic Services $20.00 to $30.00
Diabetes supplies, training, nutrition therapy and monitoring
Out-of-Network:

Diabetic Supplies and Services:
Copayment for Medicare Covered Diabetic Supplies and Services $0.00
Coinsurance for Medicare Covered Diabetic Supplies and Services 20%
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 $100.00
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 $275.00
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
Out-of-Network:

Outpatient Mental Health Services:
Copayment for Medicare Covered Individual Sessions $40.00
Copayment for Medicare Covered Group Sessions $40.00
Outpatient services/surgery
Out-of-Network:

Outpatient Hospital and ASC Services:
Copayment for Medicare Covered Outpatient Hospital Services $275.00
Copayment for Medicare Covered Ambulatory Surgical Center Services $175.00
Outpatient substance abuse care
Out-of-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare Covered Individual or Group Sessions $40.00
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 $75.00
Podiatry servicesIn-Network:

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $30.00
Prior Authorization Required for Podiatry Services
Skilled Nursing Facility (SNF) care
Out-of-Network:
$0.00 per day for days 1 to 20
$196.00 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 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 $2000.00 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 $275.00
Copayment for Medicare Covered Eyewear $20.00 to $30.00
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 $1000.00 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 Michigan 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 Michigan 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

Michigan Counties Served

Allegan Arenac Barry Bay Branch Calhoun Cass Crawford Eaton Genesee Gladwin Gratiot Hillsdale Huron Ingham Iosco Jackson Kalamazoo Kalkaska Kent Lake Lapeer Livingston Macomb Mecosta Missaukee Monroe Montcalm Muskegon Newaygo Oakland Oceana Ogemaw Osceola Oscoda Otsego Ottawa Roscommon Saginaw Saint Clair Saint Joseph Sanilac Shiawassee Tuscola Van Buren Washtenaw Wayne Wexford
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