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Wellcare Premium Ultra Open (PPO) - H2775-105-000

2.5 out of 5 stars* for plan year 2025

$114.00

Monthly Premium

Wellcare Premium Ultra Open (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by WellCare Health Plans, Inc.

Plan ID: H2775-105-000

* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.

$114.00

Monthly Premium

New York 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 New York 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

CoverageDetails
Monthly plan premium$114.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible$420.00
Out-of-pocket maximum$3,400.00
Initial drug coverage limit$0.00
Catastrophic drug coverage limit$2,000.00
Primary care doctor visit
Out-of-Network:

Doctor Office Visit Services:
Copayment for Medicare Covered Primary Care Office Visit $25
Specialty doctor visit
Out-of-Network:

Doctor Specialty Visit Services:
Copayment for Medicare Covered Physician Specialist Office Visit $35
Inpatient hospital care
Out-of-Network:

Acute Hospital Services:
20% per day for days 1 to 90
$0 per day for days 91 to 100
Urgent care
Urgent Care:
Copayment for Urgent Care $35
Copayment for Medicare Covered Urgent Care waived if you are admitted to hospital within 24 hours

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $140
Maximum Plan Benefit of $50,000
Emergency room visit
Emergency Care:
Copayment for Emergency Care $140
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 $140
Maximum Plan Benefit of $50,000
Ambulance transportation
Out-of-Network:

Ambulance Services:
Copayment for Medicare Covered Ambulance Services - Ground $350
Copayment for Medicare Covered Ambulance Services - Air $350

Health Care Services and Medical Supplies

Wellcare Premium Ultra Open (PPO) covers a range of additional benefits. Learn more about Wellcare Premium Ultra Open (PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).

CoverageDetails
Chiropractic services
Out-of-Network:

Medicare Covered Chiropractic Services:
Coinsurance for Medicare Covered Chiropractic Services 30%
Diabetes supplies, training, nutrition therapy and monitoring
Out-of-Network:

Medicare Covered Diabetic Supplies and Services:
Coinsurance for Medicare Covered Diabetic Supplies 30%
Coinsurance for Medicare Covered Diabetic Therapeutic Shoes or Inserts 30%
Durable medical equipment (DME)
Out-of-Network:

Medicare Covered Durable Medical Equipment Services:
Coinsurance for Medicare Covered Durable Medical Equipment 30%
Diagnostic tests, lab and radiology services, and X-raysIn-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0
Copayment for Medicare-covered Lab Services $0 to $50
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $0 to $375
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $25
Home health careIn-Network:

Home Health Services:
Copayment for Medicare-covered Home Health Services $0
Prior Authorization Required for Home Health Services
Mental health inpatient careIn-Network:

Psychiatric Hospital Services:
$425 per day for days 1 to 3
$0 per day for days 4 to 90
Prior Authorization Required for Psychiatric Hospital Services
Mental health outpatient care
Out-of-Network:

Medicare Covered Mental Health Services:
Coinsurance for Medicare Covered Individual Sessions 30%
Coinsurance for Medicare Covered Group Sessions 30%
Outpatient services/surgeryIn-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0 to $450
Prior Authorization Required for Outpatient Hospital Services
Outpatient Hospital and ASC Services Outpatient Hospital Services: The $0 cost share is for diagnostic colonoscopy. The maximum cost share is for outpatient surgical services. The cost share for outpatient non-surgical services, including outpatient palliative care is $375.

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $140 to $450
Outpatient Services/Surgery Observation Services: The minimum cost share is charged when a member enters observation status through the ER/ED. The maximum cost share is charged when a member enters observation status through an outpatient facility.

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $150
Prior Authorization Required for Ambulatory Surgical Center Services
Outpatient substance abuse care
Out-of-Network:

Medicare Covered Outpatient Substance Abuse Services:
Coinsurance for Medicare Covered Individual Sessions 30%
Coinsurance for Medicare Covered Group Sessions 30%
Over-the-counter itemsOTC allowance of $50 every quarter is loaded into the Wellcare Spendables card on a quarterly basis. Benefit is designed to allow members the flexibility to purchase OTC items at participating retailers, online, phone order, or catalog order. Benefit expires at end of quarter if unused.
Podiatry servicesIn-Network:

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $10
Prior Authorization Required for Podiatry Services
Skilled Nursing Facility (SNF) careIn-Network:

Skilled Nursing Facility Services:
$0 per day for days 1 to 20
$214 per day for days 21 to 50
$0 per day for days 51 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.

CoverageDetails
Dental careIn-Network:

Medicare Covered Preventive Dental:
Copayment for Office Visit $10
Prior Authorization Required for Medicare Covered Preventive Dental

Non-Medicare Covered Preventive Dental:
Copayment for Non-medicare preventive $0
Copayment for Oral exams $0
  • Maximum 2 visits every year
Copayment for Dental x-rays $0
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Other diagnostic services $0
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Prophylaxis $0
  • Maximum 2 visits every year
Copayment for Fluoride treatment $0
  • Maximum 1 visit every year
Copayment for Other preventive services $0
  • Maximum 1 visit (Please see Evidence of Coverage for details)

Non-Medicare Covered Comprehensive Dental:
Copayment for Non-medicare comprehensive $0
Copayment for Restorative services $0
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Endodontics $0
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Periodontics $0
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Prothodontics, removable $0
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Prothodontics, fixed $0
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Maxillofacial surgery $0
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Adjunctive general services $0
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Maximum Plan Benefit of $1,000 every year

Vision Benefits

The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage

CoverageDetails
Vision care
Out-of-Network:

Medicare Covered Eye Exams Services:
Copayment for Medicare Covered Eye Exams $0 to $35
Coinsurance for Medicare Covered Eyewear 30%

Hearing Benefits

The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

CoverageDetails
Hearing care
Out-of-Network:

Medicare Covered Hearing Exams Services:
Copayment for Medicare Covered Hearing Exams $35

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.

CoverageDetails
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

Prescription Drug Costs and Coverage

The Wellcare Premium Ultra Open (PPO) offers prescription drug coverage, with an annual drug deductible of $420.00 (excludes Tiers 1, 2, and 6)

Coverage & Cost
Coverage
Cost
Annual drug deductible$420.00 (excludes Tiers 1, 2, and 6)
Tier 1
  • Preferred retail $0.00
  • Preferred retail $0.00
  • Standard retail $5.00
  • Standard retail $5.00
  • Preferred mail order $0.00
  • Preferred mail order $0.00
  • Standard mail order $5.00
  • Standard mail order $5.00
Tier 2
  • Preferred retail $0.00
  • Preferred retail $0.00
  • Standard retail $10.00
  • Standard retail $10.00
  • Preferred mail order $0.00
  • Preferred mail order $0.00
  • Standard mail order $10.00
  • Standard mail order $10.00
Tier 6
  • Preferred retail $0.00
  • Preferred retail $0.00
  • Standard retail $0.00
  • Standard retail $0.00
  • Preferred mail order $0.00
  • Preferred mail order $0.00
  • Standard mail order $0.00
  • Standard mail order $0.00
Annual drug deductible$420.00 (excludes Tiers 1, 2, and 6)
Tier 1
  • Preferred retail $0.00
  • Preferred retail $0.00
  • Standard retail $10.00
  • Standard retail $10.00
  • Preferred mail order $0.00
  • Preferred mail order $0.00
  • Standard mail order $10.00
  • Standard mail order $10.00
Tier 2
  • Preferred retail $0.00
  • Preferred retail $0.00
  • Standard retail $20.00
  • Standard retail $20.00
  • Preferred mail order $0.00
  • Preferred mail order $0.00
  • Standard mail order $20.00
  • Standard mail order $20.00
Tier 6
  • Preferred retail $0.00
  • Preferred retail $0.00
  • Standard retail $0.00
  • Standard retail $0.00
  • Preferred mail order $0.00
  • Preferred mail order $0.00
  • Standard mail order $0.00
  • Standard mail order $0.00
Annual drug deductible$420.00 (excludes Tiers 1, 2, and 6)
Tier 1
  • Preferred retail $0.00
  • Preferred retail $0.00
  • Standard retail $15.00
  • Standard retail $15.00
  • Preferred mail order $0.00
  • Preferred mail order $0.00
  • Standard mail order $15.00
  • Standard mail order $15.00
Tier 2
  • Preferred retail $0.00
  • Preferred retail $0.00
  • Standard retail $30.00
  • Standard retail $30.00
  • Preferred mail order $0.00
  • Preferred mail order $0.00
  • Standard mail order $30.00
  • Standard mail order $30.00
Tier 6
  • Preferred retail $0.00
  • Preferred retail $0.00
  • Standard retail $0.00
  • Standard retail $0.00
  • Preferred mail order $0.00
  • Preferred mail order $0.00
  • Standard mail order $0.00
  • Standard mail order $0.00

When reviewing New York 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 New York 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

New York Counties Served

We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.

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