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Wellcare Giveback Open (PPO) - H1914-010-000
$0.00
Monthly Premium
Wellcare Giveback Open (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by WellCare Health Plans, Inc.
Plan ID: H1914-010-000
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$0.00
Monthly Premium
North Carolina 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 North Carolina 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 | $410.00 |
| Out-of-pocket maximum | $8,300.00 |
| 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 $0 |
| Specialty doctor visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $45 Prior Authorization Required for Doctor Specialty Visit |
| Inpatient hospital care | In-Network: Acute Hospital Services: $325 per day for days 1 to 8 $0 per day for days 9 to 90 Prior Authorization Required for Acute Hospital Services |
| Urgent care | Urgent Care: Copayment for Urgent Care $40 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 $110 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 | Out-of-Network: Ambulance Services: Copayment for Medicare Covered Ambulance Services - Ground $300 Copayment for Medicare Covered Ambulance Services - Air $300 |
Health Care Services and Medical Supplies
Wellcare Giveback Open (PPO) covers a range of additional benefits. Learn more about Wellcare Giveback Open (PPO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).
| Coverage | Details |
|---|---|
| Chiropractic services | Out-of-Network: Medicare Covered Chiropractic Services: Coinsurance for Medicare Covered Chiropractic Services 40% |
| Diabetes supplies, training, nutrition therapy and monitoring | Out-of-Network: Medicare Covered Diabetic Supplies and Services: Coinsurance for Medicare Covered Diabetic Supplies 20% Coinsurance for Medicare Covered Diabetic Therapeutic Shoes or Inserts 40% |
| Durable medical equipment (DME) | Out-of-Network: Medicare Covered Durable Medical Equipment Services: Coinsurance for Medicare Covered Durable Medical Equipment 20% |
| 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 to $75 Copayment for Medicare-covered Lab Services $0 to $50 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services Diagnostic Tests, Lab and Radiology Services, and X-Rays Outpatient Diagnostic Procedures/Tests: The minimum cost share is for spirometry testing and specified testing-related services. The maximum cost share is for all other services. The removal of abnormal tissue and/or polyps during a colonoscopy performed as a preventive screening for colorectal cancer will be covered at a $0 co-payment. Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $0 to $350 Coinsurance for Medicare-covered Therapeutic Radiological Services 20% Copayment for Medicare-covered X-Ray Services $100 |
| 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 $1850 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 40% Coinsurance for Medicare Covered Group Sessions 40% |
| Outpatient services/surgery | Out-of-Network: Medicare Covered Outpatient Hospital Services: Coinsurance for Medicare Covered Outpatient Hospital Services 40% Coinsurance for Medicare Covered Ambulatory Surgical Center Services 40% 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 $350. |
| Outpatient substance abuse care | In-Network: Outpatient Substance Abuse Services: Copayment for Medicare-covered Individual Sessions $40 Copayment for Medicare-covered Group Sessions $40 Prior Authorization Required for Outpatient Substance Abuse Services |
| Podiatry services | Out-of-Network: Medicare Covered Podiatry Services: Coinsurance for Medicare Covered Podiatry Services 40% |
| Skilled Nursing Facility (SNF) care | In-Network: Skilled Nursing Facility Services: $0 per day for days 1 to 20 $214 per day for days 21 to 70 $0 per day for days 71 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 | In-Network: Medicare Covered Preventive Dental: Copayment for Office Visit $45 Prior Authorization Required for Medicare Covered Preventive Dental Non-Medicare Covered Preventive Dental: Copayment for Non-medicare preventive $0 Copayment for Oral exams $0
Non-Medicare Covered Comprehensive Dental: Copayment for Non-medicare comprehensive $0 Copayment for Adjunctive general services $0
|
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 to $45 Coinsurance for Medicare Covered Eyewear 40% |
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: Copayment for Medicare Covered Hearing Exams $45 |
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 |
Prescription Drug Costs and Coverage
The Wellcare Giveback Open (PPO) offers prescription drug coverage, with an annual drug deductible of $410.00 (excludes Tiers 1, 2, and 6)
Coverage & Cost | |
|---|---|
| Coverage | Cost |
| Annual drug deductible | $410.00 (excludes Tiers 1, 2, and 6) |
| Tier 1 |
|
| Tier 2 |
|
| Tier 6 |
|
| Annual drug deductible | $410.00 (excludes Tiers 1, 2, and 6) |
| Tier 1 |
|
| Tier 2 |
|
| Tier 6 |
|
| Annual drug deductible | $410.00 (excludes Tiers 1, 2, and 6) |
| Tier 1 |
|
| Tier 2 |
|
| Tier 6 |
|
When reviewing North Carolina 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 North Carolina 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 |
North Carolina Counties Served
- Alexander
- Alleghany
- Anson
- Ashe
- Avery
- Bladen
- Buncombe
- Burke
- Cabarrus
- Caldwell
- Caswell
- Catawba
- Chatham
- Clay
- Cleveland
- Columbus
- Cumberland
- Davidson
- Davie
- Duplin
- Durham
- Forsyth
- Franklin
- Gaston
- Graham
- Granville
- Greene
- Guilford
- Harnett
- Haywood
- Henderson
- Hoke
- Iredell
- Jackson
- Johnston
- Lincoln
- Macon
- Madison
- Mcdowell
- Mecklenburg
- Mitchell
- Montgomery
- Moore
- Orange
- Person
- Polk
- Richmond
- Rowan
- Rutherford
- Sampson
- Scotland
- Stanly
- Stokes
- Swain
- Transylvania
- Union
- Vance
- Wake
- Warren
- Watauga
- Wilkes
- Yadkin
- Yancey
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