Wellcare No Premium (HMO-POS) H0913-002-000 2024 Plan Details and Costs

New Jersey 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 Jersey 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	$350.00
Out-of-pocket maximum	$8,300.00
Initial drug coverage limit	$0.00
Catastrophic drug coverage limit	$8,000.00
Primary care doctor visit	In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $10.00
Specialty doctor visit	In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $45.00 Prior Authorization Required for Doctor Specialty Visit
Inpatient hospital care	Out-of-Network: 50% per day for days 1 to 90
Urgent care	Urgent Care: Copayment for Urgent Care $25.00 Copayment for Medicare Covered Urgent Care waived if you are admitted to hospital within 24 hours Worldwide Coverage: Copayment for Worldwide Urgent Coverage $100.00 Maximum Plan Benefit of $50,000
Emergency room visit	Emergency Care: Copayment for Emergency Care $100.00 Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours Worldwide Coverage: Copayment for Worldwide Emergency Coverage $100.00 Maximum Plan Benefit of $50,000
Ambulance transportation	In-Network: Ground Ambulance: Copayment for Ground Ambulance Services $270.00 Air Ambulance: Copayment for Air Ambulance Services $270.00 Please see Evidence of Coverage for Prior Authorization rules

Health Care Services and Medical Supplies

Wellcare No Premium (HMO-POS) covers a range of additional benefits. Learn more about Wellcare No Premium (HMO-POS) 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 $15.00 Prior Authorization Required for Chiropractic Services
Diabetes supplies, training, nutrition therapy and monitoring	POS (Out-of-Network): Diabetic Supplies and Services: Coinsurance for Medicare Covered Diabetic Supplies and Services 50%
Durable medical equipment (DME)	POS (Out-of-Network): Durable Medical Equipment: Coinsurance for Medicare Covered Durable Medical Equipment 50%
Diagnostic tests, lab and radiology services, and X-rays	In-Network: Outpatient Diag Procs/Tests/Lab Services: Copayment for Medicare-covered Diagnostic Procedures/Tests $0.00 to $40.00 Copayment for Medicare-covered Lab Services $0.00 to $50.00 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $0.00 to $400.00 Coinsurance for Medicare-covered Therapeutic Radiological Services 20% Copayment for Medicare-covered X-Ray Services $30.00 Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services
Home health care	POS (Out-of-Network): Home Health Services: Coinsurance for Medicare Covered Home Health 50%
Mental health inpatient care	In-Network: Psychiatric Hospital Services: Copayment for Psychiatric Hospital Services per Stay $1850.00 Prior Authorization Required for Psychiatric Hospital Services
Mental health outpatient care	In-Network: Outpatient Mental Health Services: Copayment for Medicare-covered Individual Sessions $25.00 Copayment for Medicare-covered Group Sessions $25.00 Prior Authorization Required for Outpatient Mental Health Services
Outpatient services/surgery	POS (Out-of-Network): Outpatient Hospital and ASC Services: Coinsurance for Medicare Covered Outpatient Hospital Services 50% Coinsurance for Medicare Covered Ambulatory Surgical Center Services 50%
Outpatient substance abuse care	In-Network: Outpatient Substance Abuse Services: Copayment for Medicare-covered Individual Sessions $25.00 Copayment for Medicare-covered Group Sessions $25.00 Prior Authorization Required for Outpatient Substance Abuse Services
Podiatry services	POS (Out-of-Network): Podiatry Services: Coinsurance for Medicare Covered Podiatry Services 50%
Skilled Nursing Facility (SNF) care	Out-of-Network: 50% per day for days 1 to 100

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	POS (Out-of-Network): Medicare Covered Dental Services: Coinsurance for Medicare Covered Comprehensive Dental 50%

Vision Benefits

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

Coverage	Details
Vision benefits	POS (Out-of-Network): Medicare Covered Vision Services: Coinsurance for Medicare Covered Eye Exams 50% Coinsurance for Medicare Covered Eyewear 50%

Hearing Benefits

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

Coverage	Details
Hearing benefits	POS (Out-of-Network): Medicare Covered Hearing Services: Coinsurance for Medicare Covered Hearing Exams 50%

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	POS (Out-of-Network): Medicare-covered Zero Dollar Preventive Services: Coinsurance for Medicare Covered Medicare-covered Preventive Services 50%

Prescription Drug Costs and Coverage

The Wellcare No Premium (HMO-POS) offers prescription drug coverage, with an annual drug deductible of $350.00 (excludes Tiers 1, 2 and 6)

Coverage	Cost
Coverage & Cost
Annual drug deductible	$350.00 (excludes Tiers 1, 2 and 6)
Tier 1	Preferred retail $0.00 Standard retail $2.00 Preferred mail order $0.00 Standard mail order $2.00
Tier 2	Preferred retail $5.00 Standard retail $10.00 Preferred mail order $5.00 Standard mail order $10.00
Tier 6	Preferred retail $0.00 Standard retail $0.00 Preferred mail order $0.00 Standard mail order $0.00
Annual drug deductible	$350.00 (excludes Tiers 1, 2 and 6)
Tier 1	Preferred retail $0.00 Standard retail $4.00 Preferred mail order $0.00 Standard mail order $4.00
Tier 2	Preferred retail $10.00 Standard retail $20.00 Preferred mail order $10.00 Standard mail order $20.00
Tier 6	Preferred retail $0.00 Standard retail $0.00 Preferred mail order $0.00 Standard mail order $0.00
Annual drug deductible	$350.00 (excludes Tiers 1, 2 and 6)
Tier 1	Preferred retail $0.00 Standard retail $6.00 Preferred mail order $0.00 Standard mail order $6.00
Tier 2	Preferred retail $15.00 Standard retail $30.00 Preferred mail order $0.00 Standard mail order $30.00
Tier 6	Preferred retail $0.00 Standard retail $0.00 Preferred mail order $0.00 Standard mail order $0.00

When reviewing New Jersey 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 Jersey that offer similar benefits at similar or lower prices than the plan above. Call 1-877-890-1409 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.

Plan Documents

Links to plan documents	Summary of benefits Evidence of coverage Star ratings

Links to plan documents

New Jersey Counties Served

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