2022 Wellcare Low Premium Open (PPO)

Wellcare Low Premium Open (PPO) H5439-018 is a 2022 Medicare Advantage Plan or Part-C by Wellcare by Health Net available to residents in Oregon and Washington. This plan includes additional prescription drug (Part-D) coverage. The Wellcare Low Premium Open (PPO) has a monthly premium of $30.00 and has an in-network maximum out-of-pocket limit of $6,900 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $6,900 out-of-pocket. This can be a extremely nice safety net.

Wellcare Low Premium Open (PPO) is a Local PPO. A preferred provider organization (PPO) is a Medicare plan that has created contracts with a network of "preferred" providers for you to choose from at reduced rates. You do not need to select a primary care physician and you do not need referrals to see other providers in the network. Offering you a little more flexibility overall. You can get medical attention from a provider outside of the network but you will have to pay the difference between the out-of-network bill and the PPOs discounted rate.

Wellcare by Health Net works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Wellcare Low Premium Open (PPO) you still retain Original Medicare. But you will get additional Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Wellcare by Health Net and not Original Medicare. With Medicare Advantage you are always covered for urgently needed and emergency care. Plus you receive all the benefits of Original Medicare from Wellcare by Health Net except hospice care. Original Medicare still provides you with hospice care even if you sign up for Medicare Advantage.

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2022 Wellcare by Health Net Medicare Advantage Plan Costs

Wellcare Low Premium Open (PPO) Part-C Premium

Wellcare by Health Net charges a $2.70 Part-C premium. The Part C premium covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.

H5439-018 Part-D Deductible and Premium

Wellcare Low Premium Open (PPO) has a monthly drug premium of $27.30 and a $150.00 drug deductible. This Wellcare by Health Net plan offers a $27.30 Part-D Basic Premium that is not below the regional benchmark. This covers the basic prescription benefit only and does not cover enhanced drug benefits such as medical benefits or hospital benefits. The Part D Supplemental Premium is $0.00 this Premium covers any enhanced plan benefits offered by Wellcare by Health Net above and beyond the standard PDP benefits. This can include additional coverage in the gap, lower co-payments and coverage of non-Part D drugs. The Part D Total Premium is $27.30 . The Part D Total Premium is the addition of the supplemental and basic premiums for some plans this amount can be lowered due to negative basic or supplemental premiums.

Wellcare by Health Net Gap Coverage

In 2022 once you and your plan provider have spent $4430 on covered drugs. (combined amount plus your deductible) You will be in the coverage gap. (AKA "donut hole") You will be required to pay 25% for prescription drugs unless your plan offers additional coverage. This Wellcare by Health Net plan does offer additional coverage through the gap.

Premium Assistance

The Low Income Subsidy (LIS) helps people with Medicare pay for prescription drugs, and lowers the costs of Medicare prescription drug coverage. Depending on your income level you may be eligible for full 75%, 50%, 25% premium assistance. The Wellcare Low Premium Open (PPO) medicare insurance offers a $0.00 premium obligation if you receive a full low-income subsidy (LIS) assistance. And the payment is $6.80 for 75% low income subsidy $13.60 for 50% and $20.50 for 25%.

H5439-018 Formulary or Drug Coverage

Wellcare Low Premium Open (PPO) formulary is divided into Tiers or levels of coverage based on usage and according to the medication costs. Each tier will have a defined copay that you must pay to receive the drug. Drugs in lower tiers will usually cost less than those in higher tiers. By reviewing different Medicare Drug formularies, you can pick a Medicare Advantage plan that covers your medications. Additionally, you can choose a plan that has your drugs listed at a lower price. You can see complete 2022 Wellcare Low Premium Open (PPO) H5439-018 Formulary here.

Drug Tier	Copay Preferred Pharmacy	Copay Nonpreferred Pharmacy
Tier 1	$0	$2
Tier 2	$15	$20
Tier 3	$37	$47
Tier 4	$90	$100
Tier 5	30%	30%
Tier 6	$0	$0

*Initial Coverage Phase and 30 day supply

2021 Wellcare Low Premium Open (PPO) Summary of Benefits

*This will be updated with 2022 data when available.

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Additional Benefits

No

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Comprehensive Dental

Diagnostic services	$0 copay
Diagnostic services	0-50% coinsurance (Out-of-Network)
Endodontics	Not covered
Extractions	Not covered
Non-routine services	0-50% coinsurance (Out-of-Network)
Non-routine services	$0 copay
Periodontics	Not covered
Prosthodontics, other oral/maxillofacial surgery, other services	Not covered
Restorative services	50% coinsurance
Restorative services	0-50% coinsurance (Out-of-Network)

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Deductible

$195 annual deductible

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Diagnostic Tests and Procedures

Diagnostic radiology services (e.g., MRI)	20% coinsurance (Out-of-Network)
Diagnostic radiology services (e.g., MRI)	18% coinsurance
Diagnostic tests and procedures	0-18% coinsurance
Diagnostic tests and procedures	0-20% coinsurance (Out-of-Network)
Lab services	$0-15 copay
Lab services	$20 copay (Out-of-Network)
Outpatient x-rays	$18 copay
Outpatient x-rays	$20 copay (Out-of-Network)

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Doctor Visits

Primary	$15 copay per visit
Primary	$30 copay per visit (Out-of-Network)
Specialist	$50 copay per visit (Out-of-Network)
Specialist	$30 copay per visit

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Emergency care/Urgent Care

Emergency	$90 copay per visit (always covered)
Urgent care	$35 copay per visit (always covered)

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Foot Care (podiatry services)

Foot exams and treatment	$50 copay (Out-of-Network)
Foot exams and treatment	$30 copay
Routine foot care	Not covered

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Ground Ambulance

$380 copay
$380 copay (Out-of-Network)

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Hearing

Fitting/evaluation	$0 copay
Fitting/evaluation	$0 copay (Out-of-Network)
Hearing aids	$0-1,580 copay
Hearing aids	$0-1,580 copay (Out-of-Network)
Hearing exam	$25 copay
Hearing exam	$50 copay (Out-of-Network)

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Inpatient Hospital Coverage

$375 per day for days 1 through 4 $0 per day for days 5 through 90
$500 per day for days 1 through 10 $0 per day for days 11 and beyond (Out-of-Network)

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Medical Equipment/Supplies

Diabetes supplies	$0 copay or 20% coinsurance per item (Out-of-Network)
Diabetes supplies	$0 copay
Durable medical equipment (e.g., wheelchairs, oxygen)	18% coinsurance per item
Durable medical equipment (e.g., wheelchairs, oxygen)	20% coinsurance per item (Out-of-Network)
Prosthetics (e.g., braces, artificial limbs)	20% coinsurance per item (Out-of-Network)
Prosthetics (e.g., braces, artificial limbs)	18% coinsurance per item

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Medicare Part B Drugs

Chemotherapy	18% coinsurance
Chemotherapy	20% coinsurance (Out-of-Network)
Other Part B drugs	20% coinsurance (Out-of-Network)
Other Part B drugs	18% coinsurance

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Mental Health Services

Inpatient hospital - psychiatric	$500 per day for days 1 through 10 $0 per day for days 11 through 190 (Out-of-Network)
Inpatient hospital - psychiatric	$375 per day for days 1 through 4 $0 per day for days 5 through 90
Outpatient group therapy visit	$50 copay (Out-of-Network)
Outpatient group therapy visit	$30 copay
Outpatient group therapy visit with a psychiatrist	$30 copay
Outpatient group therapy visit with a psychiatrist	$50 copay (Out-of-Network)
Outpatient individual therapy visit	$30 copay
Outpatient individual therapy visit	$50 copay (Out-of-Network)
Outpatient individual therapy visit with a psychiatrist	$50 copay (Out-of-Network)
Outpatient individual therapy visit with a psychiatrist	$30 copay

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MOOP

$6,900 In and Out-of-network $6,900 In-network

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Option

No

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Optional supplemental benefits

No

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Outpatient Hospital Coverage

20% coinsurance per visit
$450 copay per visit (Out-of-Network)

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Preventive Care

$0 copay
$0 copay (Out-of-Network)

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Preventive Dental

Cleaning	$0 copay (Out-of-Network)
Cleaning	$0 copay
Dental x-ray(s)	$0 copay
Dental x-ray(s)	$0 copay (Out-of-Network)
Fluoride treatment	$0 copay (Out-of-Network)
Fluoride treatment	$0 copay
Oral exam	$0 copay (Out-of-Network)
Oral exam	$0 copay

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Rehabilitation Services

Occupational therapy visit	$50 copay (Out-of-Network)
Occupational therapy visit	$30 copay
Physical therapy and speech and language therapy visit	$30 copay
Physical therapy and speech and language therapy visit	$50 copay (Out-of-Network)

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Skilled Nursing Facility

$0 per day for days 1 through 20 $220 per day for days 21 through 100 (Out-of-Network)
$0 per day for days 1 through 20 $184 per day for days 21 through 100

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Transportation

Not covered

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Vision

Contact lenses	$0 copay
Contact lenses	20% coinsurance (Out-of-Network)
Eyeglass frames	Not covered
Eyeglass lenses	Not covered
Eyeglasses (frames and lenses)	20% coinsurance (Out-of-Network)
Eyeglasses (frames and lenses)	$0 copay
Other	Not covered
Routine eye exam	$10 copay
Routine eye exam	$10 copay (Out-of-Network)
Upgrades	Not covered

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Wellness Programs (e.g. fitness nursing hotline)

Covered

CMS Star Ratings for Wellcare Low Premium Open (PPO) H5439

Staying Healthy, Screening, Testing, & Vaccines

Managing Chronic And Long Term Care for Older Adults

Member Experience with Health Plan

Member Complaints and Changes in Wellcare Low Premium Open (PPO) Plans Performance

Health Plan Customer Service Rating for Wellcare Low Premium Open (PPO)

Wellcare Low Premium Open (PPO) Drug Plan Customer Service Ratings

Ratings For Member Complaints and Changes in the Drug Plans Performance

Member Experience with the Drug Plan

Drug Safety and Accuracy of Drug Pricing

Ready to Enroll?

Click Here

Or Call
1-855-778-4180
Mon-Fri 8am-8pm EST
Sat 8am-8pm EST

Coverage Area for Wellcare Low Premium Open (PPO)

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Source: CMS.
Data as of September 1, 2021.
Notes: Data are subject to change as contracts are finalized. For 2022, enhanced alternative may offer additional cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part-D benefit. Includes 2022 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.