Wellcare Premium Enhanced (PFFS) H2816-019 is a 2023 Medicare Advantage Plan or Part-C by Wellcare available to residents in New York. This plan includes extra prescription drug (Part-D) coverage. Wellcare Wellcare Premium Enhanced (PFFS) has a monthly premium of $53.00 and has an in-network maximum out-of-pocket limit of $- (MOOP). This means that if you get sick or need a high-cost procedure the co-pays are capped once you pay $- 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 Premium Enhanced (PFFS) 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 New York.

2023 Wellcare Medicare Advantage Plan Overview

What type of plan is Wellcare Premium Enhanced (PFFS)

Wellcare Premium Enhanced (PFFS) is a PFFS. A Private Fee-For-Service (PFFS) plan is a Medicare Advantage (MA) health plan offered by a contract with the Centers for Medicare & Medicaid Services (CMS) to provide you with benefits. Wellcare (instead of Medicare) will decide on how much it will cover and how much you will pay for the services you get. You may go to any Medicare approved doctor or hospital or any other health care provider that accepts both Medicare and your plans payment. A PFFS plan has no provider network, and you dont need a referral or a primary care physician for any health care or services. PFFS plans are the most flexible but a doctor will make a visit-by-visit decisions on whether to accept your provider.

How much does Wellcare Premium Enhanced (PFFS) cost?

Monthly Premium

A monthly premium is the fee you pay to the plan in exchange for coverage. Wellcare charges a $53.00 consolidated premium. The Part C premium is $53.00 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 Premium Enhanced (PFFS) has a monthly drug premium of $(1.10) and a $0 drug deductible. This Wellcare plan offers a $(1.10) 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 $1.10. 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 not offer extra coverage through the gap.

Formulary and Drug Coverage

Wellcare Premium Enhanced (PFFS) 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	$6
Tier 2	$7	$12
Tier 3	$37	$47
Tier 4	48%	50%
Tier 5	33%	33%
Tier 6	$0	$0

The complete Wellcare Premium Enhanced (PFFS) Formulary.
*Initial Coverage Phase and 30 day supply

2023 Summary of Benefits

The benefit information provided is a summary of what Wellcare Premium Enhanced (PFFS) 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

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Contact lenses

Vision	Not covered

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Eyeglass frames

Vision	Not covered

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Eyeglass lenses

Vision	Not covered

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Eyeglasses (frames and lenses)

Vision	Not covered

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Other

Vision	Not covered

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Routine eye exam

Out-of-Network Vision	40% coinsurance
In-Network Vision	$0 copay

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Upgrades

Vision	Not covered

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Transportation	Not covered
In-Network Skilled Nursing Facility	$0 per day for days 1 through 20 $175 per day for days 21 through 40 $0 per day for days 41 through 100
Out-of-Network Skilled Nursing Facility	$0 per day for days 1 through 20 $250 per day for days 21 through 100

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Occupational therapy visit

In-Network Rehabilitation services	$35 copay
Out-of-Network Rehabilitation services	30% coinsurance

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Physical therapy and speech and language therapy visit

In-Network Rehabilitation services	$35 copay
Out-of-Network Rehabilitation services	30% coinsurance

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Cleaning

Preventive dental	Not covered

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Dental x-ray(s)

Preventive dental	Not covered

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Fluoride treatment

Preventive dental	Not covered

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Oral exam

Preventive dental	Not covered

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In-Network Preventive care	$0 copay
Out-of-Network Preventive care	$0 copay
In-Network Outpatient hospital coverage	$300 copay per visit
Out-of-Network Outpatient hospital coverage	30% coinsurance per visit
In-Network Other health plan deductibles?	No
Optional supplemental benefits	No

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Inpatient hospital - psychiatric

In-Network Mental health services	$295 per day for days 1 through 5 $0 per day for days 6 through 90
Out-of-Network Mental health services	$300 per day for days 1 through 7 $0 per day for days 8 through 90

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Outpatient group therapy visit

In-Network Mental health services	$25 copay
Out-of-Network Mental health services	30% coinsurance

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Outpatient group therapy visit with a psychiatrist

In-Network Mental health services	$25 copay
Out-of-Network Mental health services	30% coinsurance

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Outpatient individual therapy visit

Out-of-Network Mental health services	30% coinsurance
In-Network Mental health services	$25 copay

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Outpatient individual therapy visit with a psychiatrist

In-Network Mental health services	$25 copay
Out-of-Network Mental health services	30% coinsurance

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Chemotherapy

In-Network Medicare Part B drugs	20% coinsurance
Out-of-Network Medicare Part B drugs	30% coinsurance

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Other Part B drugs

In-Network Medicare Part B drugs	20% coinsurance
Out-of-Network Medicare Part B drugs	30% coinsurance

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Diabetes supplies

Out-of-Network Medical equipment/supplies	30% coinsurance per item
In-Network Medical equipment/supplies	$0 copay per item

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

In-Network Medical equipment/supplies	20% coinsurance per item
Out-of-Network Medical equipment/supplies	30% coinsurance per item

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

In-Network Medical equipment/supplies	20% coinsurance per item
Out-of-Network Medical equipment/supplies	30% coinsurance per item

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Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)	$3,400 In and Out-of-network
In-Network Inpatient hospital coverage	$295 per day for days 1 through 5 $0 per day for days 6 through 90 $0 per day for days 91 through 150
Out-of-Network Inpatient hospital coverage	$300 per day for days 1 through 7 $0 per day for days 8 through 150

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Fitting/evaluation

Out-of-Network Hearing	40% coinsurance
In-Network Hearing	$0 copay

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Hearing aids - inner ear

Hearing	Not covered

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Hearing aids - outer ear

Hearing	Not covered

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Hearing aids - over the ear

Hearing	Not covered

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Hearing exam

Out-of-Network Hearing	$60 copay
In-Network Hearing	$35 copay

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Health plan deductible	$0
Out-of-Network Ground ambulance	$350 copay
In-Network Ground ambulance	$350 copay

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Foot exams and treatment

Out-of-Network Foot care (podiatry services)	$60 copay
In-Network Foot care (podiatry services)	$35 copay

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Routine foot care

Foot care (podiatry services)	Not covered

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Emergency

Emergency care/Urgent care	$125 copay per visit (always covered)

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Urgent care

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

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Primary

In-Network Doctor visits	$10 copay per visit
Out-of-Network Doctor visits	$25 copay per visit

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Specialist

Out-of-Network Doctor visits	$60 copay per visit
In-Network Doctor visits	$35 copay per visit

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Diagnostic radiology services (e.g., MRI)

In-Network Diagnostic procedures/lab services/imaging	$0-300 copay
Out-of-Network Diagnostic procedures/lab services/imaging	30% coinsurance

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Diagnostic tests and procedures

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

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Lab services

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

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Outpatient x-rays

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

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Diagnostic services

Comprehensive dental	Not covered

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Endodontics

Comprehensive dental	Not covered

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Extractions

Comprehensive dental	Not covered

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Non-routine services

Comprehensive dental	Not covered

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Periodontics

Comprehensive dental	Not covered

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Prosthodontics, other oral/maxillofacial surgery, other services

Comprehensive dental	Not covered

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Restorative services

Comprehensive dental	Not covered

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

Wellcare Premium Enhanced (PFFS) Reviews

Is Wellcare Premium Enhanced (PFFS) a good plan? Wellcare Premium Enhanced (PFFS) received a 3 overall star rating from the CMS. The CMS uses a Star Rating System to measure how well Medicare Advantage and Part D plans perform. Plans are rated on a one-to-five scale, with one star representing poor performance and five stars representing excellent performance. Medicare Advantage with prescription drug (Part D) coverage (MA-PD) contracts are rated on up to 38 unique quality and performance measures. You can use the CMS star rating to compare Wellcare Premium Enhanced Reviews among several different plans.

Staying Healthy, Screening, Testing, & Vaccines

Managing Chronic And Long Term Care for Older Adults

Member Experience with H2816-019 Health Plan

Member Complaints and Changes in Plans Performance

Health Plan Customer Service Rating for Wellcare

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

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 Premium Enhanced (PFFS) requires you to live in that plan’s service area. The service area is listed below:

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

Last updated on December 03, 2022

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.