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

WellCare Premier (PPO)

$0/mo

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Zip Code11226
Applicant10/18/1983 Male
Coverage Start10/20/2018
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Benefits & Coverage

Insurance TypeMedicare Advantage Plan (Part C w/ RX)
Insurance ProviderUniversal American
Plan IDH0088-1-0
Plan Year2018
CMS RatingNot Rated
Plan TypePPO
Annual Deductible$0.00

What To Know About This Plan
  • This plan has health and drug coverage
  • This plan is available for 2019. see plan

Why We Like This Plan
  • has both Health and Drug Coverage
  • has no additional premium costs outside of your Medicare Part B premium

Costs and Other Important Information

Plan Year2018
Optional Supplemental BenefitsNo
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

SERVICECOST
Inpatient hospital coverageIn-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 coverageIn-Network:
$75-300 per visit
Out-of-Network:
35% per visit
Doctor visitsPrimary:
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 careIn-Network:
$0 copay
Out-of-Network:
$0 copay
Emergency care/Urgent careEmergency:
$80 per visit (always covered)
Urgent care:
$30 per visit (always covered)
Diagnostic procedures/lab services/imagingDiagnostic 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 servicesIn-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 FacilityIn-Network:
$0 for days 1 through 20
$167.50 for days 21 through 100
Out-of-Network:
35% for days 1 through 100
Rehabilitation servicesOccupational 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%
AmbulanceIn-Network:
$300
Out-of-Network:
$300
TransportationNot covered
Foot care (podiatry services)Foot exams and treatment:
In-Network:
$35-50
Out-of-Network:
35%
Routine foot care:
Not covered
Medical equipment/suppliesDurable 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 drugsChemotherapy:
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

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

Physicians that accept WellCare Premier (PPO) for New York

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Perez, Walter
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Sharobeem, Victor
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Montas, Fred
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Sussman, David
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Kessler, David
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Byer, Erroll
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Avruskin, Theodore
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Saini, Rajiv
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Rosenberg, Herman
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Adeosun, Olanrewaju
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Einhorn, James
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Zaidi, Ali
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Martin, George
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Man-wong, Kathy
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Haralson, Barbara
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Shoub, Jeffrey
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Grabovetsky, Mikhail
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Jahangir, Abdul
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Barricelli, Louis
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Walter Perez, D.P.M.
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  • Phone Number
    (718) 675-1717
  • Office Locations
    2146 Beverley Rd
    Brooklyn, NY 11226
2146 Beverley Rd Brooklyn NY, 11226

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