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2023 Wellcare Giveback Open (PPO)

Wellcare Giveback Open (PPO) H4699-002 is a 2023 Medicare Advantage Plan or Part-C by Wellcare available to residents in Rhode Island. This plan includes extra prescription drug (Part-D) coverage. Wellcare Wellcare Giveback Open (PPO) has a monthly premium of $0 and has an in-network maximum out-of-pocket limit of $7,550 (MOOP). This means that if you get sick or need a high-cost procedure the co-pays are capped once you pay $7,550 out-of-pocket. This can be an extremely nice safety net.

Wellcare works with Medicare to provide significant coverage beyond Part A and Part B benefits. If you decide to sign up for Wellcare Giveback Open (PPO) you still retain Original Medicare. But you will get extra Part A (Hospital Insurance) and Part B (Medical Insurance) coverage from Wellcare and not Original Medicare. With 2023 Medicare Advantage Plan 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 if you sign up for Medicare Advantage in Rhode Island.



2023 Wellcare Medicare Advantage Plan Overview

Name:Wellcare Giveback Open (PPO)
Plan ID:H4699 002 0
Provider:Wellcare
Year:2023
Type:Local PPO
Combined Premium (C+D):$0/mo
Part C Premium:$0/mo
MOOP:$7,550/yr
Part D (Drug) Premium:$0/mo
Part D Supplemental Premium$0/mo
Total Part D Premium:$0/mo
Drug Deductible:$200.00/yr
Tiers with No Deductible:1
Gap Coverage:Yes
Benchmark:Not below the regional benchmark
Type of Medicare Health:Enhanced Alternative
Drug Benefit Type:Enhanced
Similar Plan: H4699-004




What type of plan is Wellcare Giveback Open (PPO)

Wellcare Giveback 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.



How much does Wellcare Giveback Open (PPO) cost?


Monthly Premium

A monthly premium is the fee you pay to the plan in exchange for coverage. Wellcare charges a $0 consolidated premium. The Part C premium is $0 this charge covers Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.


Part-D Deductible and Premium

An annual deductible is the amount you pay out-of-pocket for your prescription drugs before your plan begins to pay. Wellcare Giveback Open (PPO) has a monthly drug premium of $0 and a $200.00 drug deductible. This Wellcare plan offers a $0 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. This Premium covers any enhanced plan benefits offered by Wellcare above and beyond the standard PDP benefits. This can include extra coverage in the gap, lower co-payments, and coverage of non-Part D drugs. The Part D Total Premium is $0. The Part D Total Premium is the addition of supplemental and basic premiums for some plans this amount can be lowered due to negative basic or supplemental premiums.


Wellcare Gap Coverage

In 2023 once you and your plan provider have spent $4660 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 extra coverage. This Wellcare plan does offer extra coverage through the gap.


MOOP

The maximum out-of-pocket (MOOP) is a yearly limit on your out-of-pocket costs. Wellcare Giveback Open (PPO) by Wellcare MOOP is $7,550. Once you spend $7,550 you will pay nothing for Part A or Part B covered services. Copayments and coinsurance for Medicare approved services apply toward your out-of-pocket limit. Remember Original Medicare (Parts A and B) doesn’t have a MOOP.



Formulary and Drug Coverage

Wellcare Giveback 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.

Drug Tier Copay
Preferred
Pharmacy		 Copay
Nonpreferred
Pharmacy
Tier 1 $0 $5
Tier 2 $5 $10
Tier 3 $37 $47
Tier 4 48% 50%
Tier 5 29% 29%
Tier 6 $0 $0

The complete Wellcare Giveback Open (PPO) Formulary.
*Initial Coverage Phase and 30 day supply





2023 Summary of Benefits


The benefit information provided is a summary of what Wellcare Giveback Open (PPO) covers and what you pay (such as copayments and coinsurance amounts) for certain common medical events. The Summary of Benefits from Wellcare helps get an idea of how much financial protection the plan is generally expected to provide for common health conditions. This section also contains information on coverage for in-network and out-of-network providers.

Wellness programs (e.g., fitness, nursing hotline)Covered


Contact lenses


In-Network Vision$0 copay
Out-of-Network Vision40% coinsurance


Eyeglass frames


In-Network Vision$0 copay
Out-of-Network Vision40% coinsurance


Eyeglass lenses


In-Network Vision$0 copay
Out-of-Network Vision40% coinsurance


Eyeglasses (frames and lenses)


In-Network Vision$0 copay
Out-of-Network Vision40% coinsurance


Other


VisionNot covered


Routine eye exam


In-Network Vision$0 copay
Out-of-Network Vision40% coinsurance


Upgrades


In-Network Vision$0 copay
Out-of-Network Vision40% coinsurance



TransportationNot covered
In-Network Skilled Nursing Facility$0 per day for days 1 through 20
$196 per day for days 21 through 60
$0 per day for days 61 through 100
Out-of-Network Skilled Nursing Facility$0 per day for days 1 through 20
$196 per day for days 21 through 100


Occupational therapy visit


In-Network Rehabilitation services$40 copay
Out-of-Network Rehabilitation services30% coinsurance


Physical therapy and speech and language therapy visit


In-Network Rehabilitation services$40 copay
Out-of-Network Rehabilitation services30% coinsurance


Cleaning


In-Network Preventive dental$0 copay
Out-of-Network Preventive dental50% coinsurance


Dental x-ray(s)


Out-of-Network Preventive dental50% coinsurance
In-Network Preventive dental$0 copay


Fluoride treatment


In-Network Preventive dental$0 copay
Out-of-Network Preventive dental50% coinsurance


Oral exam


In-Network Preventive dental$0 copay
Out-of-Network Preventive dental50% coinsurance



Out-of-Network Preventive care$0 copay
In-Network Preventive care$0 copay
In-Network Outpatient hospital coverage$275 copay per visit
Out-of-Network Outpatient hospital coverage30% coinsurance per visit
In-Network Other health plan deductibles?No
Optional supplemental benefitsNo


Inpatient hospital - psychiatric


Out-of-Network Mental health services40% per day for days 1 through 90
In-Network Mental health services$450 per day for days 1 through 4
$0 per day for days 5 through 90


Outpatient group therapy visit


In-Network Mental health services$25 copay
Out-of-Network Mental health services30% coinsurance


Outpatient group therapy visit with a psychiatrist


In-Network Mental health services$25 copay
Out-of-Network Mental health services30% coinsurance


Outpatient individual therapy visit


Out-of-Network Mental health services30% coinsurance
In-Network Mental health services$25 copay


Outpatient individual therapy visit with a psychiatrist


Out-of-Network Mental health services30% coinsurance
In-Network Mental health services$25 copay


Chemotherapy


In-Network Medicare Part B drugs20% coinsurance
Out-of-Network Medicare Part B drugs30% coinsurance


Other Part B drugs


In-Network Medicare Part B drugs20% coinsurance
Out-of-Network Medicare Part B drugs30% coinsurance


Diabetes supplies


Out-of-Network Medical equipment/supplies20% coinsurance per item
In-Network Medical equipment/supplies$0 copay per item


Durable medical equipment (e.g., wheelchairs, oxygen)


Out-of-Network Medical equipment/supplies20% coinsurance per item
In-Network Medical equipment/supplies20% coinsurance per item


Prosthetics (e.g., braces, artificial limbs)


In-Network Medical equipment/supplies20% coinsurance per item
Out-of-Network Medical equipment/supplies20% coinsurance per item



Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)$10,000 In and Out-of-network
$7,550 In-network
Out-of-Network Inpatient hospital coverage20% per day for days 1 through 90
In-Network Inpatient hospital coverage$465 per day for days 1 through 4
$0 per day for days 5 through 90


Fitting/evaluation


Out-of-Network Hearing40% coinsurance
In-Network Hearing$0 copay


Hearing aids


Out-of-Network Hearing40% coinsurance
In-Network Hearing$0 copay


Hearing exam


In-Network Hearing$40 copay
Out-of-Network Hearing30% coinsurance



Health plan deductible$0
In-Network Ground ambulance$285 copay
Out-of-Network Ground ambulance$285 copay


Foot exams and treatment


In-Network Foot care (podiatry services)$40 copay
Out-of-Network Foot care (podiatry services)30% coinsurance


Routine foot care


Foot care (podiatry services)Not covered


Emergency


Emergency care/Urgent care$95 copay per visit (always covered)


Urgent care


Emergency care/Urgent care$40 copay per visit (always covered)


Primary


In-Network Doctor visits$0 copay
Out-of-Network Doctor visits$20 copay per visit


Specialist


In-Network Doctor visits$40 copay per visit
Out-of-Network Doctor visits30% coinsurance per visit


Diagnostic radiology services (e.g., MRI)


In-Network Diagnostic procedures/lab services/imaging$0-275 copay
Out-of-Network Diagnostic procedures/lab services/imaging30% coinsurance


Diagnostic tests and procedures


Out-of-Network Diagnostic procedures/lab services/imaging30% coinsurance
In-Network Diagnostic procedures/lab services/imaging$0-30 copay


Lab services


In-Network Diagnostic procedures/lab services/imaging$0 copay
Out-of-Network Diagnostic procedures/lab services/imaging30% coinsurance


Outpatient x-rays


In-Network Diagnostic procedures/lab services/imaging$0 copay
Out-of-Network Diagnostic procedures/lab services/imaging30% coinsurance


Diagnostic services


In-Network Comprehensive dental$0 copay
Out-of-Network Comprehensive dental50% coinsurance


Endodontics


Comprehensive dentalNot covered


Extractions


Comprehensive dentalNot covered


Non-routine services


Out-of-Network Comprehensive dental50% coinsurance
In-Network Comprehensive dental$0 copay


Periodontics


Comprehensive dentalNot covered


Prosthodontics, other oral/maxillofacial surgery, other services


Comprehensive dentalNot covered


Restorative services


Comprehensive dentalNot covered



In-Network Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?No




Coverage Area

(Click county or state to compare all available Advantage plans)

The availability of Medicare Advantage Plans will vary according to your region. This is why the Coverage Area matters in terms of Medicare eligibility. You will always be eligible for Original Medicare, but eligibility for Wellcare Giveback Open (PPO) requires you to live in that plan’s service area. The service area is listed below:

State: Rhode Island Medicare
County:Bristol County MA Plans

Kent County MA Plans

Newport County MA Plans

Providence County MA Plans

Washington County MA Plans



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How much does Wellcare Giveback Open (PPO) cost?

Wellcare charges a $0 consolidated monthly premium. A monthly premium is the fee you pay to the plan in exchange for coverage of Medicare medical, hospital benefits and supplemental benefits if offered. You generally are also responsible for paying the Part B premium.

How much is Wellcare Giveback Open (PPO) MOOP?

The maximum out-of-pocket (MOOP) is a yearly limit on your out-of-pocket costs. Wellcare Giveback Open (PPO) by Wellcare MOOP is $7,550. Once you spend $7,550 you will pay nothing for Part A or Part B covered services.

What type of plan is Wellcare Giveback Open (PPO)?

Wellcare Giveback Open (PPO) is a Local PPO. A (PPO) is a Medicare plan that has contracts with a network of preferred providers. You do not need to select a primary care physician and you do not need referrals to see other providers in the network.



Source:CMS. Data as of Oct 1, 2022.

Last updated on

Notes: Data are subject to change as contracts are finalized. For 2023, enhanced alternative may offer extra cost sharing reductions in the gap on a sub-set of the formulary drugs, beyond the standard Part-D benefit. Includes 2023 approved contracts. Employer sponsored 800 series and plans under sanction are excluded.

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Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options. Enrollment depends on the plan’s contract renewal.

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