WellCare Prime (PPO)

Medicare Advantage Plan for South Carolina

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PARTCRX

Plan Summary

Insurance TypeMedicare Advantage Plan (Part C w/ RX)
Insurance ProviderWellCare
Plan IDH7326-2-0
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

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 $6,000 In-network
Other health plan deductibles?
No
Health Plan Deductible
$0
Monthly Drug Plan Premium
$15.20
Monthly Health Plan Premium
$14.80

Benefits

Service
Cost
Inpatient hospital coverage
In-Network:
$250 for days 1 through 7
$0 for days 8 through 90
Out-of-Network:
$250 for days 1 through 7
$0 for days 8 through 180
Outpatient hospital coverage
In-Network:
$225-400 per visit
Out-of-Network:
$175-450 per visit
Doctor visits
Primary:
In-Network:
$5 per visit
Out-of-Network:
$5-55 per visit
Specialist:
In-Network:
$35 per visit
Out-of-Network:
$5-55 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:
$0-100
Out-of-Network:
$0-100
Lab services:
In-Network:
$0 copay
Out-of-Network:
$5-55
Diagnostic radiology services (e.g., MRI):
In-Network:
$350
Out-of-Network:
$175-450
Outpatient x-rays:
In-Network:
$0
Out-of-Network:
$5-55
Mental health services
In-Network:
$1,590 per stay
Out-of-Network:
20% for days 1 through 90
Outpatient group therapy visit with a psychiatrist:
In-Network:
$40
Out-of-Network:
$5-55
Outpatient individual therapy visit with a psychiatrist:
In-Network:
$40
Out-of-Network:
$5-55
Outpatient group therapy visit:
In-Network:
$40
Out-of-Network:
$5-55
Outpatient individual therapy visit:
In-Network:
$40
Out-of-Network:
$5-55
Skilled Nursing Facility
In-Network:
$0 for days 1 through 20
$167.50 for days 21 through 100
Out-of-Network:
20% for days 1 through 100
Rehabilitation services
Occupational therapy visit:
In-Network:
$40
Out-of-Network:
$5-55
Physical therapy and speech and language therapy visit:
In-Network:
$40
Out-of-Network:
$5-55
Ambulance
In-Network:
$250
Out-of-Network:
$175-450
Transportation
Not covered
Foot care (podiatry services)
Foot exams and treatment:
In-Network:
$35
Out-of-Network:
$5-55
Routine foot care:
Not covered
Medical equipment/supplies
Durable medical equipment (e.g., wheelchairs, oxygen):
In-Network:
20% per item
Out-of-Network:
20-50% per item
Prosthetics (e.g., braces, artificial limbs):
In-Network:
20% per item
Out-of-Network:
20-50% per item
Diabetes supplies:
In-Network:
$0 per item
Out-of-Network:
20-50% per item
Wellness programs (e.g., fitness, nursing hotline)
Covered
Medicare Part B drugs
Chemotherapy:
In-Network:
20%
Out-of-Network:
20-50%
Other Part B drugs:
In-Network:
20%
Out-of-Network:
20-50%

Coverage Area for WellCare Prime (PPO)

StateSouth Carolina
CountyRichland

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$10 copay$10 copay
Tier 3: Preferred Brand NameNot offered$47 copay$47 copay
Tier 4: Non-Preferred Brand NameNot offered35% coinsurance35% 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$30 copay$25 copay
Tier 3: Preferred Brand NameNot offered$141 copay$117.5 copay
Tier 4: Non-Preferred Brand NameNot offered35% coinsurance35% coinsurance
Tier 5: Specialty Tier

Physician Finder

Physicians that accept WellCare Prime (PPO) for South Carolina

/
ELMORE, JAMES
3000 NE MEDICAL PARK
COLUMBIA, SC 29223
MARION, HENRY
76 POLO RD
COLUMBIA, SC 29223
HOOK, JEFFREY
4214 HARDSCRABBLE ROAD
COLUMBIA, SC 29223
PARKER, REGINALD
115 BLARNEY DR
COLUMBIA, SC 29223
FINCH, MICHAEL
110 SUMMIT CENTRE DR
COLUMBIA, SC 29229
DUBOSE, THEODORE
110 SUMMIT CENTRE DR
COLUMBIA, SC 29229
HASELDEN, EDWARD
4540 TRENHOLM RD
COLUMBIA, SC 29206
Details
JAMES ELMORE, M.D.
Phone Number
(803) 462-9200
Office Locations
3000 NE MEDICAL PARK
COLUMBIA, SC 29223
3000 NE MEDICAL PARK COLUMBIA SC, 29223

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