2022 Wellcare No Premium Open (PPO)

Wellcare No Premium Open (PPO) H3975-001 is a 2022 Medicare Advantage Plan or Part-C by Wellcare available to residents in Kentucky. This plan includes additional prescription drug (Part-D) coverage. The Wellcare No Premium Open (PPO) has a monthly premium of $0 and has an in-network maximum out-of-pocket limit of $6,000 (MOOP). This means that if you get sick or need a high cost procedure the co-pays are capped once you pay $6,000 out-of-pocket. This can be a extremely nice safety net.

Wellcare No 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 works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Wellcare No 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 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 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 Medicare Advantage Plan Costs

Wellcare No Premium Open (PPO) Part-C Premium

Wellcare charges a $0.00 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.

H3975-001 Part-D Deductible and Premium

Wellcare No Premium Open (PPO) has a monthly drug premium of $0.00 and a $100.00 drug deductible. This Wellcare plan offers a $0.00 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 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 $0.00 . 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 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 plan does offer additional coverage through the gap.

H3975-001 Formulary or Drug Coverage

Wellcare No 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 No Premium Open (PPO) H3975-001 Formulary here.

Drug Tier	Copay Preferred Pharmacy	Copay Nonpreferred Pharmacy
Tier 1	$0	$0
Tier 2	$3	$8
Tier 3	$37	$47
Tier 4	43%	45%
Tier 5	31%	31%
Tier 6	$0	$0

*Initial Coverage Phase and 30 day supply

2021 Wellcare No 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	50% coinsurance (Out-of-Network)
Endodontics	$0 copay
Endodontics	50% coinsurance (Out-of-Network)
Extractions	$0 copay
Extractions	50% coinsurance (Out-of-Network)
Non-routine services	$0 copay
Non-routine services	50% coinsurance (Out-of-Network)
Periodontics	$0 copay
Periodontics	50% coinsurance (Out-of-Network)
Prosthodontics, other oral/maxillofacial surgery, other services	$0 copay
Prosthodontics, other oral/maxillofacial surgery, other services	50% coinsurance (Out-of-Network)
Restorative services	$0 copay
Restorative services	50% coinsurance (Out-of-Network)

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Deductible

$0

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Diagnostic Tests and Procedures

Diagnostic radiology services (e.g., MRI)	$0-250 copay
Diagnostic radiology services (e.g., MRI)	35% coinsurance (Out-of-Network)
Diagnostic tests and procedures	$0-35 copay
Diagnostic tests and procedures	35% coinsurance (Out-of-Network)
Lab services	$0 copay
Lab services	35% coinsurance (Out-of-Network)
Outpatient x-rays	$0 copay
Outpatient x-rays	35% coinsurance (Out-of-Network)

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Doctor Visits

Primary	$0 copay
Primary	$25 copay per visit (Out-of-Network)
Specialist	$35 copay per visit
Specialist	$50 copay per visit (Out-of-Network)

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Emergency care/Urgent Care

Emergency	$90 copay per visit (always covered)
Urgent care	$30 copay per visit (always covered)

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Foot Care (podiatry services)

Foot exams and treatment	$35 copay
Foot exams and treatment	$50 copay (Out-of-Network)
Routine foot care	Not covered

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Ground Ambulance

$300 copay
$300 copay (Out-of-Network)

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Hearing

Fitting/evaluation	$0 copay
Fitting/evaluation	40% coinsurance (Out-of-Network)
Hearing aids	$0 copay
Hearing aids	40% coinsurance (Out-of-Network)
Hearing exam	$35 copay
Hearing exam	$50 copay (Out-of-Network)

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Inpatient Hospital Coverage

$325 per day for days 1 through 6 $0 per day for days 7 through 90
35% per day for days 1 through 90 (Out-of-Network)

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Medical Equipment/Supplies

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

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Medicare Part B Drugs

Chemotherapy	20% coinsurance
Chemotherapy	35% coinsurance (Out-of-Network)
Other Part B drugs	20% coinsurance
Other Part B drugs	35% coinsurance (Out-of-Network)

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Mental Health Services

Inpatient hospital - psychiatric	$350 per day for days 1 through 5 $0 per day for days 6 through 90
Inpatient hospital - psychiatric	35% per day for days 1 through 90 (Out-of-Network)
Outpatient group therapy visit	$40 copay
Outpatient group therapy visit	35% coinsurance (Out-of-Network)
Outpatient group therapy visit with a psychiatrist	$40 copay
Outpatient group therapy visit with a psychiatrist	35% coinsurance (Out-of-Network)
Outpatient individual therapy visit	$40 copay
Outpatient individual therapy visit	35% coinsurance (Out-of-Network)
Outpatient individual therapy visit with a psychiatrist	$40 copay
Outpatient individual therapy visit with a psychiatrist	35% coinsurance (Out-of-Network)

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MOOP

$10,000 In and Out-of-network $5,500 In-network

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Option

No

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Optional supplemental benefits

No

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Outpatient Hospital Coverage

$250-300 copay per visit
35% coinsurance 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
Cleaning	50% coinsurance (Out-of-Network)
Dental x-ray(s)	$0 copay
Dental x-ray(s)	50% coinsurance (Out-of-Network)
Fluoride treatment	$0 copay
Fluoride treatment	50% coinsurance (Out-of-Network)
Oral exam	$0 copay
Oral exam	50% coinsurance (Out-of-Network)

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Rehabilitation Services

Occupational therapy visit	$40 copay
Occupational therapy visit	35% coinsurance (Out-of-Network)
Physical therapy and speech and language therapy visit	$40 copay
Physical therapy and speech and language therapy visit	35% coinsurance (Out-of-Network)

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Skilled Nursing Facility

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

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Transportation

$0 copay
75% coinsurance (Out-of-Network)

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Vision

Contact lenses	$0 copay
Contact lenses	40% coinsurance (Out-of-Network)
Eyeglass frames	$0 copay
Eyeglass frames	40% coinsurance (Out-of-Network)
Eyeglass lenses	$0 copay
Eyeglass lenses	40% coinsurance (Out-of-Network)
Eyeglasses (frames and lenses)	$0 copay
Eyeglasses (frames and lenses)	40% coinsurance (Out-of-Network)
Other	Not covered
Routine eye exam	$0 copay
Routine eye exam	40% coinsurance (Out-of-Network)
Upgrades	$0 copay
Upgrades	40% coinsurance (Out-of-Network)

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Wellness Programs (e.g. fitness nursing hotline)

Covered

Ready to Enroll?

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

Coverage Area for Wellcare No 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.