Plan ID: H4699-001

What You Need to Know:

  • WellCare Premier (PPO) is a Medicare Advantage Health Maintenance Organization Local PPO plan.
  • It must provide all of the same hospital and medical benefits as Medicare Part A and Part B, however, costs may be different.
  • It has additional benefits not included in Medicare Part A and Part B, including prescription drug coverage.
  • The plan's monthly premium is $0, which does not include your monthly Medicare Part B premium.
  • The annual deductible for this health plan is .
  • The plan includes an out-of-pocket maximum of $5,000 per year (in-network).
  • WellCare Premier (PPO) includes a Part D prescription drug plan for prescription medication coverage. The annual deductible is .
  • This plan's Part D Initial Coverage Limit is $0.

$0

Monthly Premium

Medicare Plan Features
Monthly Premium: $0
Part C Premium: $0
Monthly Premium: Part C Premium: Part D Drug Premium: Part D Supplemental Premium: Total Part D Premium: Drug Deductible: Tiers with No Deductible:
$0 $0 $0 $0 $0 $0 0.0
Gap Coverage: Yes
Benchmark: not below the regional benchmark
Type of Medicare Health: Enhanced Alternative
Health Plan Type: Local PPO
Similar Plan: H4699-002
Special Needs Type: NULL
Chronic Condition: NULL
Additional Gap Coverage: Yes, some additional gap coverage.
Maximum Out-of-Pocket Limit for Parts A & B (Moop): $5,000
Annual Deductible: NULL
Annual Initial Coverage Limit ICL: $4,130
Number of Members enrolled in this plan in Newport, Rhode Island: Plans Summary Star Rating: Customer Service Rating: Drug Cost Rating:
22 members New plan - No summary rating as of yet. New plan - not yet rated. New plan - not yet rated.
Plan Offers Mail Order: Yes
Plan Health Benefits
Total # of Formulary Drugs: 3,390 drugs
Number of Members Enrolled in this Plan in Newport, Rhode Island: 214 members
Number of Drugs Per Tier: NULL
Preferred Pharmacy Cost Sharing During Initial Coverage Phase: NULL
Special Needs Plan SNP Eligibility Requirement: NULL
Monthly Premium Split as Follows:
Part C Premium Part D Base Premium Part D Supplemental Premium Total Premium
$0.00 $0.00 $0.00 $0.00
Monthly Premium with Extra Help Low Income Subsidy:
LIS100 Subsidy Total Monthly Premium with LIS Parts CD LIS25 Subsidy Monthly PartD Premium with LIS LIS25 Subsidy Total Monthly Premium with LIS Parts CD LIS50 Monthly PartD Premium with LIS LIS50 Subsidy Total Monthly Premium with LIS Parts CD LIS75 Monthly PartD Premium with LIS LIS75 Subsidy Total Monthly Premium with LIS Parts CD
$0.00 $0.00 $0.00 $0.00 $0.00 $0.00 $0.00
Formulary Drug Details:
Tier 1 # of Drugs per Tier Tier 1 Preferred Pharmacy Cost Sharing (initial coverage phase) Tier 2 # of Drugs per Tier Tier 2 Preferred Pharmacy Cost Sharing (initial coverage phase) Tier 3 # of Drugs per Tier Tier 3 Preferred Pharmacy Cost Sharing (initial coverage phase) Tier 4 # of Drugs per Tier Tier 4 Preferred Pharmacy Cost Sharing (initial coverage phase) Tier 5 # of Drugs per Tier Tier 6 Preferred Pharmacy Cost Sharing (initial coverage phase)
405 $0.00 433 $10.00 987 $47.00 893 45% 672 33%

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5
BlueCHiP for Medicare Standard with Drugs (HMO) (2023)Local HMO$4,500$100
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BlueCHiP for Medicare Advance (HMO) (2023)Local HMO$5,000$200
5
BlueCHiP for Medicare Extra (HMO-POS) (2023)Local HMO$4,125$0
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BlueCHiP for Medicare Value (HMO-POS) (2023)Local HMO$5,000$0
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WellCare Absolute (PPO) (2023)Local PPO$7,550$150
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Aetna Medicare Value Plan (HMO) (2023)Local HMO$5,900$0
5
WellCare Value (HMO) (2023)Local HMO$5,000$0
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Aetna Medicare Explorer Plan (PPO) (2023)Local PPO$5,900$0
5
AARP Medicare Advantage Choice (Regional PPO) (2023)Regional PPO$6,700$295
5
Medicare Advantage Plans by WellCare
WellCare Absolute (PPO) (2023)Local PPO$7,550$150
New plan - not yet rated.
WellCare Value (HMO) (2023)Local HMO$5,000$0
New plan - not yet rated.

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