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Wellcare Dual Access Open (PPO D-SNP) - H2128-005-000
$0.00
Monthly Premium
Wellcare Dual Access Open (PPO D-SNP) is a PPO D-SNP Medicare Advantage (Medicare Part C) plan offered by WellCare Health Plans, Inc.
Plan ID: H2128-005-000
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$0.00
Monthly Premium
Pennsylvania Medicare beneficiaries may want to consider reviewing their Medicare Advantage (Medicare Part C) plan options. A Medicare Advantage plan combines your Original Medicare (Part A and Part B) benefits into a single plan.
Most Medicare Advantage plans cover prescription drugs, and many plans may offer other extra benefits Original Medicare doesn’t cover.
Learn more about Pennsylvania Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.
Basic Costs and Coverage
| Coverage | Details |
|---|---|
| Monthly plan premium | $0.00 |
| Vision coverage | |
| Dental coverage | |
| Hearing coverage | |
| Prescription drugs | |
| Medical deductible | $0.00 |
| Out-of-pocket maximum | $9,350.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $2,000.00 |
| Primary care doctor visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0 |
| Specialty doctor visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $0 Prior Authorization Required for Doctor Specialty Visit |
| Inpatient hospital care | Out-of-Network: Acute Hospital Services: Copayment for Acute Hospital Services per Stay $0 - $1695 |
| Urgent care | Urgent Care: Copayment for Urgent Care $0 Copayment for Medicare Covered Urgent Care waived if you are admitted to hospital within 24 hours Worldwide Coverage: Copayment for Worldwide Urgent Coverage $110 Maximum Plan Benefit of $50,000 |
| Emergency room visit | Emergency Care: Copayment for Emergency Care $0 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital with in 24 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $110 Maximum Plan Benefit of $50,000 |
| Ambulance transportation | In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $0 Air Ambulance: Copayment for Air Ambulance Services $0 Prior Authorization Required for Air Ambulance |
Health Care Services and Medical Supplies
Wellcare Dual Access Open (PPO D-SNP) covers a range of additional benefits. Learn more about Wellcare Dual Access Open (PPO D-SNP) benefits, some of which may not be covered by Original Medicare (Part A and Part B).
| Coverage | Details |
|---|---|
| Chiropractic services | In-Network: Chiropractic Services: Copayment for Medicare-covered Chiropractic Services $0 Prior Authorization Required for Chiropractic Services |
| Diabetes supplies, training, nutrition therapy and monitoring | Out-of-Network: Medicare Covered Diabetic Supplies and Services: Coinsurance for Medicare Covered Diabetic Supplies 0% - 20% Coinsurance for Medicare Covered Diabetic Therapeutic Shoes or Inserts 0% - 20% |
| Durable medical equipment (DME) | In-Network: Durable Medical Equipment: Copayment for Medicare-covered Durable Medical Equipment $0 Prior Authorization Required for Durable Medical Equipment |
| 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 Copayment for Medicare-covered Lab Services $0 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $0 Copayment for Medicare-covered Therapeutic Radiological Services $0 Copayment for Medicare-covered X-Ray Services $0 |
| Home health care | In-Network: Home Health Services: Copayment for Medicare-covered Home Health Services $0 Prior Authorization Required for Home Health Services |
| Mental health inpatient care | In-Network: Psychiatric Hospital Services: Copayment for Psychiatric Hospital Services per Stay $0 Prior Authorization Required for Psychiatric Hospital Services |
| Mental health outpatient care | In-Network: Outpatient Mental Health Services: Copayment for Medicare-covered Individual Sessions $0 Copayment for Medicare-covered Group Sessions $0 |
| Outpatient services/surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0 Prior Authorization Required for Outpatient Hospital Services Outpatient Hospital and ASC Services Outpatient Hospital Services: The $0 co-payment is for diagnostic colonoscopy. The coinsurance is for all other outpatient services. Outpatient Observation Services: Copayment for Medicare Covered Observation Services $0 Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $0 Prior Authorization Required for Ambulatory Surgical Center Services |
| Outpatient substance abuse care | In-Network: Outpatient Substance Abuse Services: Copayment for Medicare-covered Individual Sessions $0 Copayment for Medicare-covered Group Sessions $0 Prior Authorization Required for Outpatient Substance Abuse Services |
| Over-the-counter items | (Out-of-Network) Over-the-Counter Items OTC allowance of $78 every month is loaded into the Wellcare Spendables card on a monthly basis. Benefit is designed to allow members the flexibility to purchase OTC items at participating retailers, online, phone order, or catalog order. Benefit rolls over to the following month if not used. Please refer to the Evidence of Coverage for more details on Wellcare Spendables |
| Podiatry services | In-Network: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $0 Prior Authorization Required for Podiatry Services |
| Skilled Nursing Facility (SNF) care | In-Network: Skilled Nursing Facility Services: $0 per day for days 1 to 20 $0 per day for days 21 to 100 Prior Authorization Required for Skilled Nursing Facility Services |
Dental Benefits
The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Dental care | Out-of-Network: Medicare Covered Preventive Dental Services: Coinsurance for Medicare Covered Preventive Dental 0% - 20% |
Vision Benefits
The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage
| Coverage | Details |
|---|---|
| Vision care | Out-of-Network: Medicare Covered Eye Exams Services: Copayment for Medicare Covered Eye Exams $0 or 0 Coinsurance for Medicare Covered Eye Exams 0 or 20% Coinsurance for Medicare Covered Eyewear 0% - 20% |
Hearing Benefits
The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Hearing care | Out-of-Network: Medicare Covered Hearing Exams Services: Coinsurance for Medicare Covered Hearing Exams 0% - 20% |
Preventive Services and Health/Wellness Education Programs
The following services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Preventive services and health/wellness education programs | Out-of-Network: Medicare Covered Medicare-covered Preventive Services: Copayment for Medicare Covered Medicare-covered Preventive Services $0 |
When reviewing Pennsylvania Medicare plans, be sure to find out if your doctors are part of the plan network. If a Medicare Advantage plan covers prescription drugs, make sure the plan formulary (list of drugs covered by the plan) includes your drugs.
You may be able to find plans in your part of Pennsylvania that offer similar benefits at similar or lower prices than the plan above. Call 1-800-557-6059 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.
Plan Documents
| Links to plan documents |
Pennsylvania Counties Served
- Adams
- Allegheny
- Armstrong
- Beaver
- Bedford
- Berks
- Blair
- Bradford
- Bucks
- Butler
- Cambria
- Cameron
- Carbon
- Centre
- Chester
- Clarion
- Clearfield
- Clinton
- Crawford
- Cumberland
- Dauphin
- Delaware
- Elk
- Erie
- Fayette
- Forest
- Franklin
- Fulton
- Greene
- Huntingdon
- Indiana
- Jefferson
- Juniata
- Lackawanna
- Lancaster
- Lawrence
- Lebanon
- Lehigh
- Luzerne
- Lycoming
- Mckean
- Mercer
- Mifflin
- Monroe
- Montgomery
- Montour
- Northampton
- Perry
- Philadelphia
- Potter
- Schuylkill
- Snyder
- Somerset
- Sullivan
- Susquehanna
- Tioga
- Union
- Venango
- Warren
- Washington
- Wayne
- Westmoreland
- Wyoming
- York
We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.