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2016 Medicare Advantage Plan Benefit Details for the WellCare Essential (HMO)
This is archive material for research purposes. Please see PDPFinder.com or MAFinder.com for current plans.

2016 Medicare Advantage Plan Details
Medicare Plan Name:WellCare Essential (HMO)
Location:Marshall, Mississippi     Click to see other locations
Plan ID:H5698 - 028 - 0     Click to see other plans
Member Services:1-800-316-2273 TTY users 1-877-247-6272
— This plan information is for research purposes only. —
Click here to see plans for the current plan year
Medicare Contact Information:Please go to Medicare.gov or call 1-800-MEDICARE (1-800-633-4227) to get information on all of your options.
TTY users 1-877-486-2048
or contact your local SHIP for assistance
Email a copy of the WellCare Essential (HMO) benefit details
— Medicare Plan Features —
Monthly Premium:$40.00 (see Plan Premium Details below)
Annual Deductible:$0
Annual Initial Coverage Limit (ICL):$3,310
Health Plan Type:Local HMO
Maximum Out-of-Pocket Limit for Parts A & B (MOOP):$5,900
Additional Gap Coverage?No additional gap coverage, only the Donut Hole Discount
Total Number of Formulary Drugs:2,964 drugsBrowse the WellCare Essential (HMO) Formulary
This plan has 5 drug tiers. See cost-sharing for all pharmacies and tiers. 
Formulary Drug Details:Tier 1Tier 2Tier 3Tier 4Tier 5
• Preferred Pharmacy
  Cost-Sharing during
  initial coverage phase:		$4.00$20.00$47.00$99.0033%
• Number of Drugs per
  Tier:		324416898800526
Plan's Pharmacy Search:http://www.WellCare.com/our_pharmacies/default
Plan Offers Mail Order?Yes
Number of Members enrolled in this plan in Marshall, Mississippi:252 members
Number of Members enrolled in this plan in Mississippi:8,011 members
Number of Members enrolled in this plan in (H5698 - 028):8,023 members
Plan’s Summary Star Rating: 2.5 out of 5 Stars.
• Customer Service Rating: 4 out of 5 Stars.
• Member Experience Rating: 2 out of 5 Stars.
• Drug Cost Accuracy Rating: 3 out of 5 Stars.
— Plan Premium Details —
The Monthly Premium is Split as Follows: ❔
Total
Premium		Part C
Premium		Part D Base
Premium		Part D Supplemental
Premium
$40.00$26.50$13.50$0.00
Monthly Premium with Extra Help Low-Income Subsidy (LIS): ❔100%
Subsidy		75%
Subsidy		50%
Subsidy		25%
Subsidy
Monthly Part D Premium with LIS:$0.00$3.40$6.70$10.10
Total Monthly Premium with LIS (Parts C & D):$26.50$29.90$33.20$36.60
— Plan Health Benefits —
** Cost **
Monthly premium, deductible, and limits on how much you pay for covered services
$40 per month. In addition you must keep paying your Medicare Part B premium.
This plan does not have a deductible.
Yes. Like all Medicare health plans our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care.
Your yearly limit(s) in this plan:
  • $5 900 for services you receive from in-network providers.
If you reach the limit on out-of-pocket costs you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year.

Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs.
Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply.
** Doctor and Hospital Choice **
Acupuncture
Not covered
** Extra Benefits **
Inpatient mental health care
For inpatient mental health care see the "Mental Health Care" section.
Outpatient prescription drugs
For Part B drugs such as chemotherapy drugs1:  20% of the cost
Other Part B drugs1:  20% of the cost
You pay the following until your total yearly drug costs reach $3 310. Total yearly drug costs are the total drug costs paid by both you and our Part D plan.
You may get your drugs at network retail pharmacies and mail order pharmacies.
Standard Retail Cost-Sharing
TierOne-month supplyThree-month supply
Tier 1 (Preferred Generic)$4 copay$12 copay
Tier 2 (Generic)$20 copay$60 copay
Tier 3 (Preferred Brand)$47 copay$141 copay
Tier 4 (Non-Preferred Brand)$99 copay$297 copay
Tier 5 (Specialty Tier)33% of the costNot Offered
Standard Mail Order Cost-Sharing
TierOne-month supplyThree-month supply
Tier 1 (Preferred Generic)$4 copay$12 copay
Tier 2 (Generic)$20 copay$60 copay
Tier 3 (Preferred Brand)$47 copay$141 copay
Tier 4 (Non-Preferred Brand)$99 copay$297 copay
Tier 5 (Specialty Tier)33% of the costNot Offered
Preferred Mail Order Cost-Sharing
TierOne-month supplyThree-month supply
Tier 1 (Preferred Generic)$4 copay$0
Tier 2 (Generic)$20 copay$50 copay
Tier 3 (Preferred Brand)$47 copay$117.50 copay
Tier 4 (Non-Preferred Brand)$99 copay$247.50 copay
Tier 5 (Specialty Tier)33% of the costNot Offered
If you reside in a long-term care facility you pay the same as at a retail pharmacy.
You may get drugs from an out-of-network pharmacy but may pay more than you pay at an in-network pharmacy.
Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means that there's a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $3 310.

After you enter the coverage gap you pay 45% of the plan's cost for covered brand name drugs and 58% of the plan's cost for covered generic drugs until your costs total $4 850 which is the end of the coverage gap. Not everyone will enter the coverage gap.

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4 850 you pay the greater of:
  • 5% of the cost or
  • $2.95 copay for generic (including brand drugs treated as generic) and a $7.40 copayment for all other drugs.
** Important Information **
Monthly premium, deductible, and limits on how much you pay for covered services
$40 per month. In addition you must keep paying your Medicare Part B premium.
This plan does not have a deductible.
Yes. Like all Medicare health plans our plan protects you by having yearly limits on your out-of-pocket costs for medical and hospital care.
Your yearly limit(s) in this plan:
  • $5 900 for services you receive from in-network providers.
If you reach the limit on out-of-pocket costs you keep getting covered hospital and medical services and we will pay the full cost for the rest of the year.

Please note that you will still need to pay your monthly premiums and cost-sharing for your Part D prescription drugs.
Our plan has a coverage limit every year for certain in-network benefits. Contact us for the services that apply.
** Outpatient Care and Services **
Acupuncture
Not covered
Ambulance
$225 copay
Chiropractic care
Manipulation of the spine to correct a subluxation (when 1 or more of the bones of your spine move out of position):  $20 copay
Dental services
Limited dental services (this does not include services in connection with care treatment filling removal or replacement of teeth):  $40 copay
Preventive dental services:
  • Cleaning (for up to 1 every six months):  You pay nothing
  • Dental x-ray(s) (for up to 1):  You pay nothing
  • Oral exam (for up to 1 every six months):  You pay nothing
    • Diabetes supplies and services
    Diabetes monitoring supplies:  20% of the cost
    Diabetes self-management training:  You pay nothing
    Therapeutic shoes or inserts:  20% of the cost
    Diagnostic tests, lab and radiology services, and x-rays (Costs for these services may be different if received in an outpatient surgery setting)
    Diagnostic radiology services (such as MRIs CT scans):  $150-250 copay depending on the service
    Diagnostic tests and procedures:  $0-50 copay depending on the service
    Lab services:  You pay nothing
    Outpatient x-rays:  You pay nothing
    Therapeutic radiology services (such as radiation treatment for cancer):  $40 copay or 20% of the cost depending on the service
    Doctor's office visits
    Primary care physician visit:  $15 copay
    Specialist visit:  $40 copay
    Durable medical equipment (wheelchairs, oxygen, etc.)
    20% of the cost
    If you go to a preferred vendor your cost may be less. Contact us for a list of preferred vendors.
    Emergency care
    $75 copay
    If you are admitted to the hospital within 24 hours you do not have to pay your share of the cost for emergency care. See the "Inpatient Hospital Care" section for other costs.
    Foot care (podiatry services)
    Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions:  $40 copay
    Hearing services
    Exam to diagnose and treat hearing and balance issues:  $40 copay
    Routine hearing exam (for up to 1 every year):  You pay nothing
    Hearing aid fitting/evaluation (for up to 1 every year):  You pay nothing
    Hearing aid:  You pay nothing
    Our plan pays up to $350 every year for hearing aids.
    Home health care
    You pay nothing
    Mental health care
    Inpatient visit:
    Our plan covers up to 190 days in a lifetime for inpatient mental health care in a psychiatric hospital. The inpatient hospital care limit does not apply to inpatient mental services provided in a general hospital.
    Our plan covers 90 days for an inpatient hospital stay.
    Our plan also covers 60 "lifetime reserve days." These are "extra" days that we cover. If your hospital stay is longer than 90 days you can use these extra days. But once you have used up these extra 60 days your inpatient hospital coverage will be limited to 90 days.
    • $280 copay per day for days 1 through 5
    • You pay nothing per day for days 6 through 90
      • Outpatient group therapy visit:  $40 copay
      Outpatient individual therapy visit:  $40 copay
      Outpatient rehabilitation
      Cardiac (heart) rehab services (for a maximum of 2 one-hour sessions per day for up to 36 sessions up to 36 weeks):  $40 copay
      Occupational therapy visit:  $40 copay
      Physical therapy and speech and language therapy visit:  $40 copay
      Outpatient substance abuse
      Group therapy visit:  $40 copay
      Individual therapy visit:  $40 copay
      Outpatient surgery
      Ambulatory surgical center:  $200 copay
      Outpatient hospital:  $250 copay
      Over-the-counter items
      Please visit our website to see our list of covered over-the-counter items.
      Prosthetic devices (braces, artificial limbs, etc.)
      Prosthetic devices:  20% of the cost
      Related medical supplies:  You pay nothing
      Renal dialysis
      20% of the cost
      Transportation
      Not covered
      Urgently needed services
      $40 copay
      If you are admitted to the hospital within 24 hours you do not have to pay your share of the cost for urgently needed services. See the "Inpatient Hospital Care" section for other costs.
      Vision services
      Exam to diagnose and treat diseases and conditions of the eye (including yearly glaucoma screening):  $0-40 copay depending on the service
      Routine eye exam (for up to 1 every year):  You pay nothing
      Contact lenses (for up to 1 every year):  You pay nothing
      Eyeglasses (frames and lenses) (for up to 1 every year):  You pay nothing
      Eyeglass frames (for up to 1 every year):  You pay nothing
      Eyeglass lenses (for up to 1 every year):  You pay nothing
      Eyeglasses or contact lenses after cataract surgery:  You pay nothing
      Our plan pays up to $100 every year for eyewear.
      ** Hospice **
      Hospice
      You pay nothing for hospice care from a Medicare-certified hospice. You may have to pay part of the cost for drugs and respite care.
      ** Preventive Care **
      Preventive care
      You pay nothing
      Our plan covers many preventive services including:
      • Abdominal aortic aneurysm screening
      • Alcohol misuse counseling
      • Bone mass measurement
      • Breast cancer screening (mammogram)
      • Cardiovascular disease (behavioral therapy)
      • Cardiovascular screenings
      • Cervical and vaginal cancer screening
      • Colorectal cancer screenings (Colonoscopy Fecal occult blood test Flexible sigmoidoscopy)
      • Depression screening
      • Diabetes screenings
      • HIV screening
      • Medical nutrition therapy services
      • Obesity screening and counseling
      • Prostate cancer screenings (PSA)
      • Sexually transmitted infections screening and counseling
      • Tobacco use cessation counseling (counseling for people with no sign of tobacco-related disease)
      • Vaccines including Flu shots Hepatitis B shots Pneumococcal shots
      • "Welcome to Medicare" preventive visit (one-time)
      • Yearly "Wellness" visit
      Any additional preventive services approved by Medicare during the contract year will be covered.
      ** Inpatient Care **
      Inpatient hospital care
      Our plan covers 130 days for an inpatient hospital stay.
      Our plan also covers 60 "lifetime reserve days." These are "extra" days that we cover. If your hospital stay is longer than 130 days you can use these extra days. But once you have used up these extra 60 days your inpatient hospital coverage will be limited to 130 days.
      • $280 copay per day for days 1 through 5
      • You pay nothing per day for days 6 through 90
      • You pay nothing per day for days 91 through 130
        • Inpatient mental health care
        For inpatient mental health care see the "Mental Health Care" section.
        Skilled Nursing Facility (SNF)
        Our plan covers up to 100 days in a SNF.
        • You pay nothing per day for days 1 through 20
        • $160 copay per day for days 21 through 100
          • Outpatient prescription drugs
          For Part B drugs such as chemotherapy drugs1:  20% of the cost
          Other Part B drugs1:  20% of the cost
          You pay the following until your total yearly drug costs reach $3 310. Total yearly drug costs are the total drug costs paid by both you and our Part D plan.
          You may get your drugs at network retail pharmacies and mail order pharmacies.
          Standard Retail Cost-Sharing
          TierOne-month supplyThree-month supply
          Tier 1 (Preferred Generic)$4 copay$12 copay
          Tier 2 (Generic)$20 copay$60 copay
          Tier 3 (Preferred Brand)$47 copay$141 copay
          Tier 4 (Non-Preferred Brand)$99 copay$297 copay
          Tier 5 (Specialty Tier)33% of the costNot Offered
          Standard Mail Order Cost-Sharing
          TierOne-month supplyThree-month supply
          Tier 1 (Preferred Generic)$4 copay$12 copay
          Tier 2 (Generic)$20 copay$60 copay
          Tier 3 (Preferred Brand)$47 copay$141 copay
          Tier 4 (Non-Preferred Brand)$99 copay$297 copay
          Tier 5 (Specialty Tier)33% of the costNot Offered
          Preferred Mail Order Cost-Sharing
          TierOne-month supplyThree-month supply
          Tier 1 (Preferred Generic)$4 copay$0
          Tier 2 (Generic)$20 copay$50 copay
          Tier 3 (Preferred Brand)$47 copay$117.50 copay
          Tier 4 (Non-Preferred Brand)$99 copay$247.50 copay
          Tier 5 (Specialty Tier)33% of the costNot Offered
          If you reside in a long-term care facility you pay the same as at a retail pharmacy.
          You may get drugs from an out-of-network pharmacy but may pay more than you pay at an in-network pharmacy.
          Most Medicare drug plans have a coverage gap (also called the "donut hole"). This means that there's a temporary change in what you will pay for your drugs. The coverage gap begins after the total yearly drug cost (including what our plan has paid and what you have paid) reaches $3 310.

          After you enter the coverage gap you pay 45% of the plan's cost for covered brand name drugs and 58% of the plan's cost for covered generic drugs until your costs total $4 850 which is the end of the coverage gap. Not everyone will enter the coverage gap.

          After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4 850 you pay the greater of:
          • 5% of the cost or
          • $2.95 copay for generic (including brand drugs treated as generic) and a $7.40 copayment for all other drugs.
          ** Outpatient Care **
          Diabetes supplies and services
          Diabetes monitoring supplies:  20% of the cost
          Diabetes self-management training:  You pay nothing
          Therapeutic shoes or inserts:  20% of the cost
          Foot care (podiatry services)
          Foot exams and treatment if you have diabetes-related nerve damage and/or meet certain conditions:  $40 copay
          Hearing services
          Exam to diagnose and treat hearing and balance issues:  $40 copay
          Routine hearing exam (for up to 1 every year):  You pay nothing
          Hearing aid fitting/evaluation (for up to 1 every year):  You pay nothing
          Hearing aid:  You pay nothing
          Our plan pays up to $350 every year for hearing aids.
          ** Outpatient Medical Services and Supplies **
          Outpatient substance abuse
          Group therapy visit:  $40 copay
          Individual therapy visit:  $40 copay
          Prosthetic devices (braces, artificial limbs, etc.)
          Prosthetic devices:  20% of the cost
          Related medical supplies:  You pay nothing
          ** Additional Benefits **
          Inpatient mental health care
          For inpatient mental health care see the "Mental Health Care" section.




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