Wellcare Mutual of Omaha No Premium Open (PPO)

Washington Medicare Advantage Plan (2024 Plan)


Monthly Premium

Your Cost
$0
by Wellcare

Additional Coverage

HearingVisionDental

Overall Government Star Rating

No Rating (new plan)

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Plan Name
Wellcare Mutual of Omaha No Premium Open (PPO)
Insurance Carrier
Wellcare
Plan Type
Medicare Advantage Plan With Part D Prescription Drug Coverage
Network Type
PPO

Wellcare Mutual of Omaha No Premium Open (PPO) is a Medicare Advantage Plan With Part D Prescription Drug Coverage, which is available in Washington and offered by the health insurance company Wellcare. This plan’s network type is PPO which determines in-network doctors who accept the health plan and whether a referral is needed.

Monthly Premium
$0
Annual Deductible
$0
Max Out-of-Pocket
$6,700
Primary doctor visit
$0 copay
Specialist visit
$25 copay per visit
ER visit
$100 copay per visit (always covered)
Ambulance
$300 copay

Wellcare Mutual of Omaha No Premium Open (PPO) has a monthly premium cost of $0 per month, with an annual deductible of $0 and a maximum out of pocket cost sharing of $10,000 In and Out-of-network $6,700 In-network. The most common benefit costs which people evaluate when choosing a plan are costs for a primary doctor visit, specialist doctor visit, emergency room visit, and ambulance. These costs are listed in this summary section and a full list of benefit costs for Wellcare Mutual of Omaha No Premium Open (PPO) are defined below.

Yes
Part D Prescription Drug Coverage
Yes
Dental
Yes
Vision
Yes
Hearing

Wellcare Mutual of Omaha No Premium Open (PPO) is a Medicare Advantage plan which does include Medicare Part D Prescription Drug coverage. Other common benefits included with Medicare Advantage plans are coverage for dental, vision, and hearing. Wellcare Mutual of Omaha No Premium Open (PPO) includes coverage for hearing, vision, dental.

Medicare Advantage health plans can offer even more additional benefits. Wellcare Mutual of Omaha No Premium Open (PPO) includes coverage for the following additional benefits:

Other benefits

Fitness benefit
Limited coverage
Over the counter drug benefits
Limited coverage
In-home support services
Not covered
Home and bathroom safety devices
Not covered
Meals for short duration
Limited coverage
Annual physical exams
Limited coverage
Telehealth
Limited coverage

Monthly Premium
$0
Health Portion of Premium
$0
Drug Portion of Premium
$0
Health Plan Deductible
$0
Health Plan Max Out-of-Pocket
$10,000 In and Out-of-network
$6,700 In-network
Nationwide Coverage included
No
Hearing Coverage included
Yes
Vision Coverage included
Yes
Dental Coverage included
Yes

Doctor Services

Primary doctor visit
In-network: $0 copay
Out-of-network: $35 copay per visit
Specialist visit
In-network: $25 copay per visit
Out-of-network: $65 copay per visit

Tests, labs, & imaging

Diagnostic tests & procedures
In-network: $0-50 copay
Out-of-network: 40% coinsurance
Lab services
In-network: $0-50 copay
Out-of-network: 40% coinsurance
Diagnostic radiology services (like MRI)
In-network: $0-300 copay
Out-of-network: 40% coinsurance
Outpatient x-rays
In-network: $0 copay
Out-of-network: 40% coinsurance
Emergency care
$100 copay per visit (always covered)
Urgent care
$55 copay per visit (always covered)

Hospital Services

Inpatient hospital coverage
In-network: $400 per day for days 1 through 5
$0 per day for days 6 through 90
Out-of-network: 30% per day for days 1 through 90
Outpatient hospital coverage
In-network: $0-300 copay per visit
Out-of-network: 40% coinsurance per visit

Skilled nursing facility

Skilled nursing facility
In-network: $0 per day for days 1 through 20
$203 per day for days 21 through 60
$0 per day for days 61 through 100
Out-of-network: 30% per day for days 1 through 100

Preventive services

Preventive services
In-network: $0 copay
Out-of-network: $0 copay

Ambulance

Ground ambulance
In-network: $300 copay
Out-of-network: $300 copay

Therapy services

Occupational therapy visit
In-network: $25 copay
Out-of-network: 40% coinsurance
Physical therapy & speech & language therapy visit
In-network: $25 copay
Out-of-network: 40% coinsurance

Mental health services

Outpatient group therapy with a psychiatrist
In-network: $40 copay
Out-of-network: 40% coinsurance
Outpatient individual therapy with a psychiatrist
In-network: $40 copay
Out-of-network: 40% coinsurance
Outpatient group therapy visit
In-network: $40 copay
Out-of-network: 40% coinsurance
Outpatient individual therapy visit
In-network: $40 copay
Out-of-network: 40% coinsurance

Opioid treatment services

Opioid treatment services
Covered

Other services

Durable medical equipment (like wheelchairs & oxygen)
In-network: 20% coinsurance per item
Out-of-network: 20% coinsurance per item
Prosthetics (like braces, artificial limbs)
In-network: 20% coinsurance per item
Out-of-network: 20% coinsurance per item
Diabetes supplies
In-network: $0 copay per item
Out-of-network: 20-40% coinsurance per item

Tier drug costs for: Standard retail pharmacy drug cost for 1-month

TiersInitial coverage phaseGap coverage phaseCatastrophic coverage phase
Preferred Generic$0.00 copay


Generic drugs :
25%

Brand-name drugs :
25%


Generic drugs :
$0 copay

Brand-name drugs :
$0 copay

Generic$10.00 copay
Preferred Brand$47.00 copay
Non-Preferred Drug50%
Specialty Tier31%

Part B Drugs

Chemotherapy drugs
In-network: 0-20% coinsurance
Out-of-network: $35 copay or 0-20% coinsurance
Other Part B drugs
In-network: 0-20% coinsurance
Out-of-network: $35 copay or 0-20% coinsurance

Hearing

Hearing exam
In-network: $25 copay
Out-of-network: $65 copay
Fitting/evaluation
In-network: $0 copay
Out-of-network: 40% coinsurance
Hearing aids - All types
In-network: $0 copay
Out-of-network: 40% coinsurance

Preventive Dental

Oral exam
In-network: $0 copay
Out-of-network: 50% coinsurance
Cleaning
In-network: $0 copay
Out-of-network: 50% coinsurance
Fluoride treatment
In-network: $0 copay
Out-of-network: 50% coinsurance
Dental x-rays
In-network: $0 copay
Out-of-network: 50% coinsurance

Comprehensive dental

Non-routine services
In-network: $0 copay
Out-of-network: 50% coinsurance
Diagnostic services
In-network: $0 copay
Out-of-network: 50% coinsurance
Restorative services
In-network: $0 copay
Out-of-network: 50% coinsurance
Endodontics
In-network: $0 copay
Out-of-network: 50% coinsurance
Periodontics
In-network: $0 copay
Out-of-network: 50% coinsurance
Extractions
In-network: $0 copay
Out-of-network: 50% coinsurance
Prosthodontics, other oral/maxillofacial surgery, other services
In-network: $0 copay
Out-of-network: 50% coinsurance

Vision

Routine eye exam
In-network: $0 copay
Out-of-network: 40% coinsurance
Contact lenses
In-network: $0 copay
Out-of-network: 40% coinsurance
Eyeglasses (frames & lenses)
In-network: $0 copay
Out-of-network: 40% coinsurance
Eyeglass frames (only)
In-network: $0 copay
Out-of-network: 40% coinsurance
Eyeglass lenses (only)
In-network: $0 copay
Out-of-network: 40% coinsurance
Upgrades
In-network: $0 copay
Out-of-network: 40% coinsurance

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