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2020 WellCare Today's Options Advantage Plus 550B (PPO) in Somerset, Maine

Medicare Advantage Plan Benefit Details in Plain Text

The following Medicare Advantage plan benefits apply to the WellCare Today's Options Advantage Plus 550B (PPO) (H2775 - 109) in Somerset, Maine .

This plan is administered by AMERICAN PROGRESSIVE LIFE & HLTH INS COMPANY OF NY. To switch to a different Medicare Advantage plan or to change your location, click here.

Click here to see the WellCare Today's Options Advantage Plus 550B (PPO) health and prescription benefit details in chart format

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Plan Premium

This plan has a $0.00 monthly premium. Although you pay no additional monthly premium, you must continue to pay your Medicare Part B premium. If you have a premium penalty, your premium will be higher. Or if you have a higher income you would be subject to the Income Related Adjustment Amount (IRMAA).

This Medicare Advantage Plan with Prescription Drug Coverage is a Local PPO plan.

Plan Membership and Plan Ratings

The WellCare Today's Options Advantage Plus 550B (PPO) (H2775 - 109) currently has 8,145 members. There are 971 members enrolled in this plan in Somerset, Maine, and 8,132 members in Maine.

The Centers for Medicare and Medicaid Services (CMS) has given this plan carrier a summary rating of 3.5 stars. The detail CMS plan carrier ratings are as follows:

Customer Service Rating of 4 out of 5 stars
Member Experience Rating of 2 out of 5 stars
Drug Cost Information Accuracy Rating of 5 out of 5 stars

Prescription Drug Coverage: Deductible, Cost-sharing, Formulary

This plan does NOT have a deductible for the prescription drug coverage. That means that you have first dollar coverage. Some plans have a deductible that must be paid (in full) prior to the prescription coverage assisting in your prescription costs (see cost-sharing below). The maximum deductible for 2020 is $435. This plan (WellCare Today's Options Advantage Plus 550B (PPO)) has no deductible.

The following information is about the WellCare Today's Options Advantage Plus 550B (PPO) formulary (or drug list). There are 3102 drugs on the WellCare Today's Options Advantage Plus 550B (PPO) formulary. Click here to browse the WellCare Today's Options Advantage Plus 550B (PPO) Formulary.

The Initial Coverage Phase (ICP) can be thought of as the cost-sharing phase of the plan. During this phase, you and the insurance company share your prescription costs. Since this plan has no deductible, your coverage (initial coverage phase) will start right away. All medication are divided into tiers within the plans formulary. This helps the plan to organize and manage the prescription cost-sharing. The WellCare Today's Options Advantage Plus 550B (PPO)’s formulary is divided into 5 tiers. Every plan can name their tiers differently, and can place medications on any tier. The cost-sharing for this plan is divided as follows:

Tier 1 (Preferred Generic) contains 383 drugs and has a co-payment of $2.00.
Tier 2 (Generic) contains 511 drugs and has a co-payment of $7.00.
Tier 3 (Preferred Brand) contains 892 drugs and has a co-payment of $37.00.
Tier 4 (Non-Preferred Drug) contains 786 drugs and has a co-payment of $90.00.
Tier 5 (Specialty Tier) contains 619 drugs and has a co-insurance of 33% of the drug cost.

Click here to browse the WellCare Today's Options Advantage Plus 550B (PPO) Formulary.

The Coverage Gap, which is also known as the Donut (Doughnut) Hole is the phase of your Medicare Part D plan where you are responsible for 100% of your medication costs. Healthcare Reform mandates that the insurance carrier pay 75% of your generic drug prescription costs in the donut hole on your behalf.

The brand-name drug manufacturer will pay 70% and your plan will pay an additional 5% of the cost of your brand-name drugs purchased in the Donut Hole, for a total of 75% discount. The 70% paid by the brand-name drug manufacturer is paid on your behalf and therefore counts toward your TrOOP (or True Out-of-Pocket) costs. The portion paid by your plan, does not count toward TrOOP. Some Medicare Part D plans offer coverage during the Coverage Gap that is beyond the mandated discounts. Any drug not covered by the plan’s Gap Coverage will still receive the discounts noted above -- even if the plan has "No Gap Coverage". This plan (WellCare Today's Options Advantage Plus 550B (PPO)) offers No Coverage during the Coverage Gap phase.

The WellCare Today's Options Advantage Plus 550B (PPO) offers many Health and Prescription Drug Coverage Benefits. The following section will describe these benefits in detail.

Base Plan
Premium
• Health plan premium: $0
• Drug plan premium: $0
• You must continue to pay your Part B premium.
• Part B premium reduction: No
Deductible
• Health plan deductible: $0
• Other health plan deductibles: In-network: No
• Drug plan deductible: No annual deductible
Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)
• $4,000 In and Out-of-network $4,000 In-network
Optional supplemental benefits
• No
Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?
• In-network: No
Doctor visits
• Primary In-network: $10 copay per visit
• Primary Out-of-network: $25 copay per visit
• Specialist In-network: $35 copay per visit (authorization and referral required)
• Specialist Out-of-network: $60 copay per visit (authorization and referral required)
Diagnostic procedures/lab services/imaging
• Diagnostic tests and procedures In-network: $0 copay (authorization and referral required)
• Diagnostic tests and procedures Out-of-network: 30% coinsurance (authorization and referral required)
• Lab services In-network: $0 copay (authorization and referral required)
• Lab services Out-of-network: 30% coinsurance (authorization and referral required)
• Diagnostic radiology services (e.g., MRI) In-network: $0-200 copay (authorization and referral required)
• Diagnostic radiology services (e.g., MRI) Out-of-network: 30% coinsurance (authorization and referral required)
• Outpatient x-rays In-network: $15 copay (authorization and referral required)
• Outpatient x-rays Out-of-network: 30% coinsurance (authorization and referral required)
Emergency care/Urgent care
• Emergency: $90 copay per visit (always covered)
• Urgent care: $35 copay per visit (always covered)
Inpatient hospital coverage
• In-network: $300 per day for days 1 through 6 $0 per day for days 7 through 90 (authorization and referral required)
• Out-of-network: $300 per day for days 1 through 7 $0 per day for days 8 through 120 (authorization and referral required)
Outpatient hospital coverage
• In-network: $300 copay per visit (authorization and referral required)
• Out-of-network: 30% coinsurance per visit (authorization and referral required)
Skilled Nursing Facility
• In-network: $0 per day for days 1 through 20 $165 per day for days 21 through 100 (authorization and referral required)
• Out-of-network: $0 per day for days 1 through 20 $250 per day for days 21 through 100 (authorization and referral required)
Preventive care
• In-network: $0 copay
• Out-of-network: $0 copay
Ground ambulance
• In-network: $300 copay
• Out-of-network: $300 copay
Rehabilitation services
• Occupational therapy visit In-network: $40 copay (authorization and referral required)
• Occupational therapy visit Out-of-network: 30% coinsurance (authorization and referral required)
• Physical therapy and speech and language therapy visit In-network: $40 copay (authorization and referral required)
• Physical therapy and speech and language therapy visit Out-of-network: 30% coinsurance (authorization and referral required)
Mental health services
• Inpatient hospital - psychiatric In-network: $295 per day for days 1 through 5 $0 per day for days 6 through 90 (authorization and referral required)
• Inpatient hospital - psychiatric Out-of-network: $300 per day for days 1 through 7 $0 per day for days 8 through 90 (authorization and referral required)
• Outpatient group therapy visit with a psychiatrist In-network: $40 copay (authorization and referral required)
• Outpatient group therapy visit with a psychiatrist Out-of-network: 30% coinsurance (authorization and referral required)
• Outpatient individual therapy visit with a psychiatrist In-network: $40 copay (authorization and referral required)
• Outpatient individual therapy visit with a psychiatrist Out-of-network: 30% coinsurance (authorization and referral required)
• Outpatient group therapy visit In-network: $40 copay (authorization and referral required)
• Outpatient group therapy visit Out-of-network: 30% coinsurance (authorization and referral required)
• Outpatient individual therapy visit In-network: $40 copay (authorization and referral required)
• Outpatient individual therapy visit Out-of-network: 30% coinsurance (authorization and referral required)
Opioid treatment program services
• In-network: $35.00 copay (authorization and referral required)
• Out-of-network: 30% coinsurance (authorization and referral required)
Medical equipment/supplies
• Durable medical equipment (e.g., wheelchairs, oxygen) In-network: 20% coinsurance per item (authorization required)
• Durable medical equipment (e.g., wheelchairs, oxygen) Out-of-network: 30% coinsurance per item (authorization required)
• Prosthetics (e.g., braces, artificial limbs) In-network: 20% coinsurance per item (authorization required)
• Prosthetics (e.g., braces, artificial limbs) Out-of-network: 30% coinsurance per item (authorization required)
• Diabetes supplies In-network: $0 copay per item (authorization required)
• Diabetes supplies Out-of-network: 30% coinsurance per item (authorization required)
Dialysis
• 20% coinsurance (referral required)
Hearing
• Hearing exam In-network: $35 copay (authorization and referral required)
• Hearing exam Out-of-network: $60 copay (authorization and referral required)
• Fitting/evaluation In-network: $0 copay (limits apply, authorization and referral required)
• Fitting/evaluation Out-of-network: 50% coinsurance (limits apply, authorization and referral required)
• Hearing aids In-network: $0 copay (limits apply, authorization and referral required)
• Hearing aids Out-of-network: 50% coinsurance (limits apply, authorization and referral required)
Preventive dental
• Oral exam In-network: $0 copay (limits apply, authorization and referral required)
• Oral exam Out-of-network: 20-40% coinsurance (limits apply, authorization and referral required)
• Cleaning In-network: $0 copay (limits apply, authorization and referral required)
• Cleaning Out-of-network: 20-40% coinsurance (limits apply, authorization and referral required)
• Fluoride treatment In-network: $0 copay (limits apply, authorization and referral required)
• Fluoride treatment Out-of-network: 20-40% coinsurance (limits apply, authorization and referral required)
• Dental x-ray(s) In-network: $0 copay (limits apply, authorization and referral required)
• Dental x-ray(s) Out-of-network: 20-40% coinsurance (limits apply, authorization and referral required)
Comprehensive dental
• Non-routine services: Not covered
• Diagnostic services: Not covered
• Restorative services In-network: $0 copay (limits apply, authorization and referral required)
• Restorative services Out-of-network: 20-40% coinsurance (limits apply, authorization and referral required)
• Endodontics: Not covered
• Periodontics In-network: 20% coinsurance (limits apply, authorization and referral required)
• Periodontics Out-of-network: 20-40% coinsurance (limits apply, authorization and referral required)
• Extractions In-network: 20% coinsurance (limits apply, authorization and referral required)
• Extractions Out-of-network: 20-40% coinsurance (limits apply, authorization and referral required)
• Prosthodontics, other oral/maxillofacial surgery, other services In-network: 20% coinsurance (limits apply, authorization and referral required)
• Prosthodontics, other oral/maxillofacial surgery, other services Out-of-network: 20-40% coinsurance (limits apply, authorization and referral required)
Vision
• Routine eye exam In-network: $0 copay (limits apply, authorization and referral required)
• Routine eye exam Out-of-network: 30% coinsurance (limits apply, authorization and referral required)
• Other: Not covered
• Contact lenses In-network: $0 copay (limits apply, authorization and referral required)
• Contact lenses Out-of-network: 30% coinsurance (limits apply, authorization and referral required)
• Eyeglasses (frames and lenses) In-network: $0 copay (limits apply, authorization and referral required)
• Eyeglasses (frames and lenses) Out-of-network: 30% coinsurance (limits apply, authorization and referral required)
• Eyeglass frames In-network: $0 copay (limits apply, authorization and referral required)
• Eyeglass frames Out-of-network: 30% coinsurance (limits apply, authorization and referral required)
• Eyeglass lenses In-network: $0 copay (limits apply, authorization and referral required)
• Eyeglass lenses Out-of-network: 30% coinsurance (limits apply, authorization and referral required)
• Upgrades: Not covered
Wellness programs (e.g., fitness, nursing hotline)
• Covered
Transportation
• Not covered
Foot care (podiatry services)
• Foot exams and treatment In-network: $35 copay (authorization and referral required)
• Foot exams and treatment Out-of-network: $60 copay (authorization and referral required)
• Routine foot care: Not covered
Medicare Part B drugs
• Chemotherapy In-network: 20% coinsurance (authorization required)
• Chemotherapy Out-of-network: 30% coinsurance (authorization required)
• Other Part B drugs In-network: 20% coinsurance (authorization required)
• Other Part B drugs Out-of-network: 30% coinsurance (authorization required)
Medically-approved non-opioid pain management services
• Chiropractic services: Not covered
• Acupuncture: Not covered
• Therapeutic Massage: Not covered
• Alternative Therapies: Not covered
More benefits
• Over-the-counter drug benefits: Some coverage
• Meals for short duration: Some coverage
• Annual physical exams: Some coverage
• Telehealth: Some coverage
• WorldWide emergency coverage: Some coverage
• WorldWide emergency urgent care: Some coverage
• Fitness Benefit: Some coverage
• In-Home Support Services: Not covered
• Bathroom Safety Devices: Not covered
• Health Education: Not covered
• In-Home Safety Assessment: Not covered
• Personal Emergency Response System (PERS): Some coverage
• Medical Nutrition Therapy (MNT): Some coverage
• Post discharge In-Home Medication Reconciliation: Not covered
• Re-admission Prevention: Not covered
• Wigs for Hair Loss Related to Chemotherapy: Not covered
• Weight Management Programs: Not covered
• Adult Day Health Services: Not covered
• Nutritional/Dietary Benefit: Not covered
• Home-Based Palliative Care: Not covered
• Support for Caregivers of Enrollees: Not covered
• Additional Sessions of Smoking and Tobacco Cessation Counseling: Not covered
• Enhanced Disease Management: Some coverage
• Telemonitoring Services: Not covered
• Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline): Some coverage
• Counseling Services: Not covered

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