Wellcare Dual Select (HMO D-SNP) H2174-001 2024 Plan Details and Costs (2024)

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Wellcare Dual Select (HMO D-SNP) H2174-001 2024 Plan Details and Costs (1)

Wellcare Dual Select (HMO D-SNP) H2174-001 Plan Details

3 out of 5 stars

Wellcare Dual Select (HMO D-SNP) is a HMO Medicare Advantage (Medicare Part C) plan offered by Wellcare Health Plans, Inc.
Plan ID: H2174-001

$0.00

Monthly Premium

Wellcare Dual Select (HMO D-SNP) is a HMO Medicare Advantage (Medicare Part C) plan offered by Wellcare Health Plans, Inc.
Plan ID: H2174-001

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Wellcare Dual Select (HMO D-SNP) H2174-001 2024 Plan Details and Costs (2)

Wellcare Dual Select (HMO D-SNP) H2174-001 Plan Details

3 out of 5 stars

Wellcare Dual Select (HMO D-SNP) is a HMO Medicare Advantage (Medicare Part C) plan offered by Wellcare Health Plans, Inc.
Plan ID: H2174-001

Have Medicare questions?

Talk to a licensed agent today to find a plan that fits your needs.

Get Medicare Help

$0.00

Monthly Premium

Oregon Counties Served

Lane

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $0
Out of Pocket Max In-Network: $8850
Out-of-Network: N/A
Initial Coverage Limit $5030
Catastrophic Coverage Limit $8,000
Primary Care Doctor Visit

In-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0.00

Specialty Doctor Visit

In-Network:

Doctor Specialty Visit:
Coinsurance for Physician Specialist Office Visit 20%
Prior Authorization Required for Doctor Specialty Visit
Prior authorization required

Inpatient Hospital Care

In-Network:

Acute Hospital Services:
Copayment for Acute Hospital Services per Stay $0.00
Prior Authorization Required for Acute Hospital Services
Prior authorization required

Urgent Care

Copayment for Urgent Care $0.00
Copayment for Medicare Covered Urgent Care waived if you are admitted to hospital within 24 hours

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $100.00
Maximum Plan Benefit of $50,000

Emergency Room Visit

Copayment for Emergency Care $0.00
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $100.00
Maximum Plan Benefit of $50,000

Ambulance Transportation

In-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $0.00

Air Ambulance:
Copayment for Air Ambulance Services $0.00

Please see Evidence of Coverage for Prior Authorization rules
Prior authorization required

Health Care Services and Medical Supplies

Wellcare Dual Select (HMO D-SNP) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).

Coverage Cost
Chiropractic Services

In-Network:
Copayment for Medicare-covered Chiropractic Services $0.00
Copayment for Routine Care $0.00

  • Maximum 24 Routine Care every year

Prior Authorization Required for Chiropractic Services
Prior authorization required

Diabetes Supplies, Training, Nutrition Therapy and Monitoring

In-Network:
Copayment for Medicare-covered Diabetic Supplies $0.00
Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0.00
Prior Authorization Required for Diabetic Supplies and Services
Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage)
Prior authorization required

Durable Medical Eqipment (DME)

In-Network:
Copayment for Medicare-covered Durable Medical Equipment $0.00
Prior Authorization Required for Durable Medical Equipment
Prior authorization required

Diagnostic Tests, Lab and Radiology Services, and X-Rays

In-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0.00
Copayment for Medicare-covered Lab Services $0.00
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $0.00
Copayment for Medicare-covered Therapeutic Radiological Services $0.00
Copayment for Medicare-covered X-Ray Services $0.00
Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services
Prior authorization required

Home Health Care

In-Network:
Copayment for Medicare-covered Home Health Services $0.00
Prior Authorization Required for Home Health Services
Prior authorization required

Mental Health Inpatient Care

In-Network:

Psychiatric Hospital Services:
Copayment for Psychiatric Hospital Services per Stay $0.00
Prior Authorization Required for Psychiatric Hospital Services
Prior authorization required

Mental Health Outpatient Care

In-Network:
Copayment for Medicare-covered Individual Sessions $0.00
Copayment for Medicare-covered Group Sessions $0.00
Prior Authorization Required for Outpatient Mental Health Services
Prior authorization required

Outpatient Services / Surgery

In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0.00
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $0.00

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $0.00
Prior Authorization Required for Ambulatory Surgical Center Services
Prior authorization required

Outpatient Substance Abuse Care

In-Network:
Copayment for Medicare-covered Individual Sessions $0.00
Copayment for Medicare-covered Group Sessions $0.00
Prior Authorization Required for Outpatient Substance Abuse Services
Prior authorization required

Over-the-counter (OTC) Items

In-Network:

Over-The-Counter (OTC) Items:
Copayment for Over-The-Counter (OTC) Items $0.00
Maximum Plan Benefit of $85.00 every month
Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit

Podiatry Services

In-Network:
Copayment for Medicare-Covered Podiatry Services $0.00
Prior Authorization Required for Podiatry Services
Prior authorization required

Skilled Nursing Facility Care

In-Network:

Skilled Nursing Facility Services:
$0.00 per day for days 1 to 20
$0.00 per day for days 21 to 100
Prior Authorization Required for Skilled Nursing Facility Services
Prior authorization required

Dental Benefits

The following dental services are covered from in-network providers.

Coverage Cost
Dental Care

In-Network:

Preventive Dental:
Copayment for Oral Exams $0.00

  • Maximum 2 visits every year

Copayment for Prophylaxis (Cleaning) $0.00

  • Maximum 2 visits every year

Copayment for Fluoride Treatment $0.00

  • Maximum 1 visit every year

Copayment for Dental X-Rays $0.00

  • Maximum 1 visit (Please see Evidence of Coverage for details)

Referral Required for Preventive Dental

Comprehensive Dental:
Copayment for Medicare-covered Benefits $0.00
Copayment for Non-routine Services $0.00

  • Maximum 1 visit (Please see Evidence of Coverage for details)

Copayment for Diagnostic Services $0.00

  • Maximum 1 visit every year

Copayment for Restorative Services $0.00

  • Maximum 1 visit (Please see Evidence of Coverage for details)

Copayment for Endodontics $0.00

  • Maximum 1 visit (Please see Evidence of Coverage for details)

Copayment for Periodontics $0.00

  • Maximum 1 visit (Please see Evidence of Coverage for details)

Copayment for Extractions $0.00

  • Maximum 1 visit (Please see Evidence of Coverage for details)

Copayment for Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services $0.00

  • Maximum 1 visit (Please see Evidence of Coverage for details)

Maximum Plan Benefit of $5000.00 every year for Non-Medicare Covered Comprehensive
Prior Authorization Required for Comprehensive Dental
Prior authorization required

Vision Benefits

The following vision services are covered from in-network providers.

Coverage Cost
Vision Benefits

In-Network:

Eye Exams:
Coinsurance for Medicare Covered Benefits 20%
Copayment for Routine Eye Exams $0.00

  • Maximum 1 Routine Eye Exam every year

Prior Authorization Required for Eye Exams

Eyewear:
Copayment for Medicare-Covered Benefits $0.00
Maximum Plan Allowance of $300.00 every year for all Non-Medicare covered eyewear
Prior Authorization Required for Eyewear
Prior authorization required

Hearing Benefits

The following hearing services are covered from in-network providers.

Coverage Cost
Hearing Benefits

In-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $0.00
Copayment for Routine Hearing Exams $0.00

  • Maximum 1 visit every year

Copayment for Fitting/Evaluation for Hearing Aid $0.00

  • Maximum 1 visit every year

Prior Authorization Required for Hearing Exams

Hearing Aids:
Copayment for Hearing Aids $0.00

  • Maximum 2 Hearing Aids every year

Maximum Plan Benefit of $1000.00 every year per ear
Prior Authorization Required for Hearing Aids
Prior authorization required

Preventive Services and Health/Wellness Education Programs

The following services are covered from in-network providers.

Coverage Cost
Preventive Services and Health/Wellness Education Programs

In-Network:
$0.00 copay for Medicare Covered Preventive Services:

Abdominal aortic aneurysm screening
Alcohol misuse screenings & counseling
Bone mass measurements (bone density)
Cardiovascular disease screenings
Cardiovascular disease (behavioral therapy)
Cervical & vagin*l cancer screening
Colorectal cancer screenings
Depression screenings
Diabetes screenings
Diabetes self-management training
Glaucoma tests
Hepatitis B (HBV) infection screening
Hepatitis C screening test
HIV screening
Lung cancer screening
Mammograms (screening)
Nutrition therapy services
Obesity screenings & counseling
One-time Welcome to Medicare preventive visit
Prostate cancer screenings(PSA)
Sexually transmitted infections screening & counseling
Shots:

  • COVID-19 shots
  • Flu shots
  • Hepatitis B shots
  • Pneumococcal shots
  • Tobacco use cessation
    Yearly "Wellness" visit

    Prescription Drug Costs and Coverage

    The Wellcare Dual Select (HMO D-SNP) plan offers the following prescription drug coverage, with an annual drug deductible of $0 per year.

    Coverage

    Cost

    Coverage & Cost

    Annual Drug Deductible $0
    Preferred Generic
    • Standard retail $0.00
    • Standard mail order $0.00
    • Preferred cost-share mail order $0.00
    • Preferred cost-share retail $0.00
    Generic
    • Standard retail $0.00
    • Standard mail order $0.00
    • Preferred cost-share mail order $0.00
    • Preferred cost-share retail $0.00
    Preferred Brand
    • Standard retail $0.00
    • Standard mail order $0.00
    • Preferred cost-share mail order $0.00
    • Preferred cost-share retail $0.00
    Non-Preferred Drug
    • Standard retail $0.00
    • Standard mail order $0.00
    • Preferred cost-share mail order $0.00
    • Preferred cost-share retail $0.00
    Specialty Tier
    • Standard retail $0.00
    • Standard retail $0.00
    • Standard retail $0.00
    • Standard mail order $0.00
    • Standard mail order $0.00
    • Standard mail order $0.00
    • Preferred cost-share mail order $0.00
    • Preferred cost-share mail order $0.00
    • Preferred cost-share mail order $0.00
    • Preferred cost-share retail $0.00
    • Preferred cost-share retail $0.00
    • Preferred cost-share retail $0.00
    Annual Drug Deductible $0
    Preferred Generic
    • Standard retail $0.00
    • Standard mail order $0.00
    • Preferred cost-share mail order $0.00
    • Preferred cost-share retail $0.00
    Generic
    • Standard retail $0.00
    • Standard mail order $0.00
    • Preferred cost-share mail order $0.00
    • Preferred cost-share retail $0.00
    Preferred Brand
    • Standard retail $0.00
    • Standard mail order $0.00
    • Preferred cost-share mail order $0.00
    • Preferred cost-share retail $0.00
    Non-Preferred Drug
    • Standard retail $0.00
    • Standard mail order $0.00
    • Preferred cost-share mail order $0.00
    • Preferred cost-share retail $0.00
    Specialty Tier
    • Standard retail $0.00
    • Standard retail $0.00
    • Standard retail $0.00
    • Standard mail order $0.00
    • Standard mail order $0.00
    • Standard mail order $0.00
    • Preferred cost-share mail order $0.00
    • Preferred cost-share mail order $0.00
    • Preferred cost-share mail order $0.00
    • Preferred cost-share retail $0.00
    • Preferred cost-share retail $0.00
    • Preferred cost-share retail $0.00
    Annual Drug Deductible $0
    Preferred Generic
    • Standard retail $0.00
    • Standard mail order $0.00
    • Preferred cost-share mail order $0.00
    • Preferred cost-share retail $0.00
    Generic
    • Standard retail $0.00
    • Standard mail order $0.00
    • Preferred cost-share mail order $0.00
    • Preferred cost-share retail $0.00
    Preferred Brand
    • Standard retail $0.00
    • Standard mail order $0.00
    • Preferred cost-share mail order $0.00
    • Preferred cost-share retail $0.00
    Non-Preferred Drug
    • Standard retail $0.00
    • Standard mail order $0.00
    • Preferred cost-share mail order $0.00
    • Preferred cost-share retail $0.00
    Specialty Tier
    • Standard retail $0.00
    • Standard retail $0.00
    • Standard retail $0.00
    • Standard mail order $0.00
    • Standard mail order $0.00
    • Standard mail order $0.00
    • Preferred cost-share mail order $0.00
    • Preferred cost-share mail order $0.00
    • Preferred cost-share mail order $0.00
    • Preferred cost-share retail $0.00
    • Preferred cost-share retail $0.00
    • Preferred cost-share retail $0.00

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    Wellcare Dual Select (HMO D-SNP) H2174-001 2024 Plan Details and Costs (2024)

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