Wellcare Premium Ultra Open (PPO)

3 out of 5 stars* for plan year 2023
$119.00 Monthly Premium

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

Plan ID: H5439-011-000

$119.00 Monthly Premium

Oregon and Washington 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 Oregon and Washington 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$119.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible$95.00
Out-of-pocket maximum$4,000.00
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 $12.00
Specialty doctor visit
Out-of-Network:

Doctor Specialty Visit:
Copayment for Medicare Covered Physician Specialist Office Visit $40.00
Inpatient hospital care
Out-of-Network:
$500.00 per day for days 1 to 15
$0.00 per day for days 16 to 999
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 $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 $350.00

Air Ambulance:
Copayment for Air Ambulance Services $350.00

Please see Evidence of Coverage for Prior Authorization rules

Health Care Services and Medical Supplies

Wellcare Premium Ultra Open (PPO) covers a range of additional benefits. Learn more about Wellcare Premium Ultra 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 $0.00
Chiropractic Services:
Copayment for Non-Medicare Covered Chiropractic Services $0.00
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:
Copayment for Medicare Covered Diagnostic Procedures/Tests
$0.00
Coinsurance for Medicare Covered Diagnostic Procedures/Tests
20%
Copayment for Medicare Covered Lab Services
$20.00
Coinsurance for Medicare Covered Diagnostic Radiological Services 30%
Coinsurance for Medicare Covered Therapeutic Radiological Services 30%
Copayment for Medicare Covered Outpatient X-Ray Services $20.00
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 care
Out-of-Network:
$325.00 per day for days 1 to 7
$0.00 per day for days 8 to 90
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/surgeryIn-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $225.00
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $110.00 to $225.00
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 careIn-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
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:
$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 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 $25.00
Coinsurance for Non-routine Services 40%
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Coinsurance for Diagnostic Services 40%
  • Maximum 1 visit every year
Coinsurance for Restorative Services 40%
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Coinsurance for Endodontics 40%
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Coinsurance for Periodontics 40%
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Coinsurance for Extractions 40%
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Coinsurance for Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services 40%
  • 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 benefitsIn-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $0.00 to $25.00
Copayment for Routine Eye Exams $0.00
  • Maximum 1 Routine Eye Exam every year
Prior Authorization Required for Eye Exams

Eyewear:
Copayment for Medicare-Covered Benefits $0.00
Maximum Plan Allowance of $200.00 every year for all Non-Medicare covered eyewear for in and out of network services combined
Prior Authorization Required for Eyewear

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 $40.00
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 Premium Ultra Open (PPO) offers prescription drug coverage, with an annual drug deductible of $95.00 (excludes Tiers 1, 2 and 6)

Coverage
Cost
Coverage & Cost
Annual drug deductible$95.00 (excludes Tiers 1, 2 and 6)
Tier 1
  • Preferred retail $5.00
  • Standard retail $15.00
  • Preferred mail order $5.00
  • Standard mail order $15.00
  • Tier 2
  • Preferred retail $10.00
  • Standard retail $20.00
  • Preferred mail order $10.00
  • 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$95.00 (excludes Tiers 1, 2 and 6)
    Tier 1
  • Preferred retail $10.00
  • Standard retail $30.00
  • Preferred mail order $10.00
  • Standard mail order $30.00
  • Tier 2
  • Preferred retail $20.00
  • Standard retail $40.00
  • Preferred mail order $20.00
  • Standard mail order $40.00
  • Tier 6
  • Preferred retail $0.00
  • Standard retail $0.00
  • Preferred mail order $0.00
  • Standard mail order $0.00
  • Annual drug deductible$95.00 (excludes Tiers 1, 2 and 6)
    Tier 1
  • Preferred retail $15.00
  • Standard retail $45.00
  • Preferred mail order $0.00
  • Standard mail order $45.00
  • Tier 2
  • Preferred retail $30.00
  • Standard retail $60.00
  • Preferred mail order $0.00
  • Standard mail order $60.00
  • Tier 6
  • Preferred retail $0.00
  • Standard retail $0.00
  • Preferred mail order $0.00
  • Standard mail order $0.00
  • When reviewing Oregon and Washington 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 Oregon and Washington 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

    Oregon Counties Served

    Benton Clackamas Douglas Jackson Josephine Lane Linn Marion Multnomah Polk Washington Yamhill

    Washington Counties Served

    Clark
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