2018 WellCare Premier (PPO) H0088-1-0 in NY from Universal American | HealthPocket

WellCare Premier (PPO)

Medicare Advantage Plan for New York

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PARTCRX

Plan Summary

Insurance TypeMedicare Advantage Plan (Part C w/ RX)
Insurance ProviderUniversal American
Plan IDH0088-1-0
CMS RatingNot Rated1
Plan TypePPO
Annual Deductible$0.00

What To Know About This Plan

  • This plan has health and drug coverage

Why We Like This Plan

  • has both Health and Drug Coverage
  • has no additional premium costs outside of your Medicare Part B premium

Plan Details

Costs and Other Important Information

Plan Year:
2018
Optional Supplemental Benefits
No
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
$10,000 In and Out-of-network $6,700 In-network
Other health plan deductibles?
No
Health Plan Deductible
$0
Monthly Drug Plan Premium
$0.00
Monthly Health Plan Premium
$0.00

Benefits

Service
Cost
Inpatient hospital coverage
In-Network:
Tier 1
$300 for days 1 through 5
$0 for days 6 through 90
Tier 2
$360 for days 1 through 5
$0 for days 6 through 90
Out-of-Network:
35% for days 1 through 210
Outpatient hospital coverage
In-Network:
$75-300 per visit
Out-of-Network:
35% per visit
Doctor visits
Primary:
In-Network:
$0-25 per visit
Out-of-Network:
35% per visit
Specialist:
In-Network:
$35-50 per visit
Out-of-Network:
35% per visit
Preventive care
In-Network:
$0 copay
Out-of-Network:
$0 copay
Emergency care/Urgent care
Emergency:
$80 per visit (always covered)
Urgent care:
$30 per visit (always covered)
Diagnostic procedures/lab services/imaging
Diagnostic tests and procedures:
In-Network:
$0-75
Out-of-Network:
35%
Lab services:
In-Network:
$0-50
Out-of-Network:
35%
Diagnostic radiology services (e.g., MRI):
In-Network:
$100-250
Out-of-Network:
35%
Outpatient x-rays:
In-Network:
$0-50
Out-of-Network:
35%
Mental health services
In-Network:
Tier 1
$324 for days 1 through 5
$0 for days 6 through 90
Tier 2
$400 for days 1 through 3
$0 for days 4 through 90
Out-of-Network:
35% for days 1 through 90
Outpatient group therapy visit with a psychiatrist:
In-Network:
$35-40
Out-of-Network:
35%
Outpatient individual therapy visit with a psychiatrist:
In-Network:
$35-40
Out-of-Network:
35%
Outpatient group therapy visit:
In-Network:
$35-40
Out-of-Network:
35%
Outpatient individual therapy visit:
In-Network:
$35-40
Out-of-Network:
35%
Skilled Nursing Facility
In-Network:
$0 for days 1 through 20
$167.50 for days 21 through 100
Out-of-Network:
35% for days 1 through 100
Rehabilitation services
Occupational therapy visit:
In-Network:
$35-40
Out-of-Network:
35%
Physical therapy and speech and language therapy visit:
In-Network:
$35-40
Out-of-Network:
35%
Ambulance
In-Network:
$300
Out-of-Network:
$300
Transportation
Not covered
Foot care (podiatry services)
Foot exams and treatment:
In-Network:
$35-50
Out-of-Network:
35%
Routine foot care:
Not covered
Medical equipment/supplies
Durable medical equipment (e.g., wheelchairs, oxygen):
In-Network:
20% per item
Out-of-Network:
35% per item
Prosthetics (e.g., braces, artificial limbs):
In-Network:
20% per item
Out-of-Network:
35% per item
Diabetes supplies:
In-Network:
$0 per item
Out-of-Network:
35% per item
Wellness programs (e.g., fitness, nursing hotline)
Covered
Medicare Part B drugs
Chemotherapy:
In-Network:
20%
Out-of-Network:
35%
Other Part B drugs:
In-Network:
20%
Out-of-Network:
35%

Coverage Area for WellCare Premier (PPO)

StateNew York
CountyKings

Cost Sharing Information

All cost-sharing assumes in-network healthcare providers.

Prescription Drug Copay/Coninsurance Details - Initial Coverage Limit

30 Day SupplyPreferred Retail PharmaciesNon-Preferred Retail PharmaciesMail-Order Pharmacies
Tier 1: Preferred GenericNot offereds$0 copay$0 copay
Tier 2: Non-Preferred GenericNot offered$15 copay$15 copay
Tier 3: Preferred Brand NameNot offered$47 copay$47 copay
Tier 4: Non-Preferred Brand NameNot offered48% coinsurance48% coinsurance
Tier 5: Specialty TierNot offered33% coinsurance33% coinsurance
90 Day SupplyPreferred Retail PharmaciesNon-Preferred Retail PharmaciesMail-Order Pharmacies
Tier 1: Preferred GenericNot offered$0 copay$0 copay
Tier 2: Non-Preferred GenericNot offered$45 copay$37.5 copay
Tier 3: Preferred Brand NameNot offered$141 copay$117.5 copay
Tier 4: Non-Preferred Brand NameNot offered48% coinsurance48% coinsurance
Tier 5: Specialty Tier

Physician Finder

Physicians that accept WellCare Premier (PPO) for New York

/
Perez, Walter
2146 Beverley Rd
Brooklyn, NY 11226
Sharobeem, Victor
Victor R. Sharobeem, Md
Brooklyn, NY 11230
Montas, Fred
182 8th Ave
Brooklyn, NY 11215
Sussman, David
1 Hanson Pl
Brooklyn, NY 11243
Byer, Erroll
650 Fulton St
Brooklyn, NY 11217
Saini, Rajiv
1 Brookdale Plz
Brooklyn, NY 11212
Avruskin, Theodore
1 Brookdale Plz
Brooklyn, NY 11212
Rosenberg, Herman
4303 14th Av Enue
Brooklyn, NY 11219
Adeosun, Olanrewaju
8925 Flatlands Ave
Brooklyn, NY 11236
Einhorn, James
2616 Avenue U
Brooklyn, NY 11229
Zaidi, Ali
76 Broadway
Brooklyn, NY 11206
Man-wong, Kathy
757 55th Street
Brooklyn, NY 11220
Martin, George
150 55th Street
Brooklyn, NY 11220
Shoub, Jeffrey
339 Hicks St
Brooklyn, NY 11201
Haralson, Barbara
300 Cadman Plaza West
Brooklyn, NY 11201
Grabovetsky, Mikhail
3000 Ocean Pkwy
Brooklyn, NY 11235
Jahangir, Abdul
1435 86th Street
Brooklyn, NY 11228
Barricelli, Louis
36 Skillman Avenue
Brooklyn, NY 11211
Details
Walter Perez, D.P.M.
Phone Number
(718) 675-1717
Office Locations
2146 Beverley Rd
Brooklyn, NY 11226
2146 Beverley Rd Brooklyn NY, 11226

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