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2023 Medicare Advantage Plan Benefit Details for the WellCare Giveback (HMO) - H1032-193-0
2023 Medicare Advantage Plan Details
Medicare Plan Name:Wellcare Giveback (HMO)
Location:Brevard, Florida     Click to see other locations
Plan ID:H1032 - 193 - 0     Click to see other plans
Member Services:1-833-444-9088 TTY users 711
— 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 Giveback (HMO) benefit details
— Medicare Plan Features —
Monthly Premium:$0.00 (see Plan Premium Details below)
Medicare Part B Premium Reduction:This plan has a $95 Part B monthly premium rebate (or giveback). However, you must continue to pay your Medicare Part B premium.
Annual Deductible:$0
Annual Initial Coverage Limit (ICL):$4,660
Health Plan Type:Local HMO
Maximum Out-of-Pocket Limit for Parts A & B (MOOP):$3,400
Additional Gap Coverage?Yes, some additional gap coverage.
Total Number of Formulary Drugs:3,440 drugsBrowse the Wellcare Giveback (HMO) Formulary
This plan has 6 drug tiers. See cost-sharing for all pharmacies and tiers. 
Insulin on a Medicare Part D plan's formulary will have a monthly copay of $35 or less.
Formulary Drug Details:Tier 1Tier 2Tier 3Tier 4Tier 5
• Preferred Pharmacy
  Cost-Sharing during
  initial coverage phase:		$0.00$0.00$30.00$80.0033%
• Number of Drugs per
  Tier:		3471542278297736
Plan Offers Mail Order?Yes
Medicare Plan Pharmacy Numbers: BIN: 004336   PCN: MEDDADV   See BIN/PCNs for all plans
Number of Members enrolled in this plan in Brevard, Florida:1,737 members
Number of Members enrolled in this plan in (H1032 - 193):5,120 members
Plan’s Summary Star Rating: 3 out of 5 Stars.
• Customer Service Rating: 3 out of 5 Stars.
• Member Experience Rating: 3 out of 5 Stars.
• Drug Cost Accuracy Rating: 4 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
$0.00$0.00$0.00$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$0.00$0.00$0.00
Total Monthly Premium with LIS (Parts C & D):$0.00$0.00$0.00$0.00
— Plan Health Benefits —
** Base Plan **
Premium
• Health plan premium: $0
• Drug plan premium: $0
• You must continue to pay your Part B premium.
• Part B premium reduction: $95
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)
• $3,400 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: $0 copay
• Specialist: $25 copay per visit (authorization and referral required)
Diagnostic procedures/lab services/imaging
• Diagnostic tests and procedures: $0-40 copay (authorization and referral required)
• Lab services: $0 copay (authorization and referral required)
• Diagnostic radiology services (e.g., MRI): $0-200 copay (authorization and referral required)
• Outpatient x-rays: $0 copay (authorization and referral required)
Emergency care/Urgent care
• Emergency: $125 copay per visit (always covered)
• Urgent care: $25 copay per visit (always covered)
Inpatient hospital coverage
• $250 per day for days 1 through 6
$0 per day for days 7 through 90 (authorization and referral required)
Outpatient hospital coverage
• $200 copay per visit (authorization and referral required)
Skilled Nursing Facility
• $0 per day for days 1 through 20
$175 per day for days 21 through 40
$0 per day for days 41 through 100 (authorization and referral required)
Preventive care
• $0 copay
Ground ambulance
• $250 copay
Rehabilitation services
• Occupational therapy visit: $25 copay (authorization and referral required)
• Physical therapy and speech and language therapy visit: $25 copay (authorization and referral required)
Mental health services
• Inpatient hospital - psychiatric: $250 per day for days 1 through 6
$0 per day for days 7 through 90 (authorization and referral required)
• Outpatient group therapy visit with a psychiatrist: $40 copay (authorization and referral required)
• Outpatient individual therapy visit with a psychiatrist: $40 copay (authorization and referral required)
• Outpatient group therapy visit: $40 copay (authorization and referral required)
• Outpatient individual therapy visit: $40 copay (authorization and referral required)
Medical equipment/supplies
• Durable medical equipment (e.g., wheelchairs, oxygen): 20% coinsurance per item (authorization required)
• Prosthetics (e.g., braces, artificial limbs): 20% coinsurance per item (authorization required)
• Diabetes supplies: $0 copay per item (authorization required)
Hearing
• Hearing exam: $25 copay (authorization and referral required)
• Fitting/evaluation: $0 copay (limits apply, authorization and referral required)
• Hearing aids: $0 copay (limits apply, authorization and referral required)
Preventive dental
• Oral exam: $0 copay (limits apply, authorization required)
• Cleaning: $0 copay (limits apply, authorization required)
• Fluoride treatment: $0 copay (limits apply, authorization required)
• Dental x-ray(s): $0 copay (limits apply, authorization required)
Comprehensive dental
• Non-routine services: $0 copay (limits apply, authorization required)
• Diagnostic services: $0 copay (limits apply, authorization required)
• Restorative services: $0 copay (limits apply, authorization required)
• Endodontics: $0 copay (limits apply, authorization required)
• Periodontics: $0 copay (limits apply, authorization required)
• Extractions: $0 copay (limits apply, authorization required)
• Prosthodontics, other oral/maxillofacial surgery, other services: $0 copay (limits apply, authorization required)
Vision
• Routine eye exam: $0 copay (limits apply, authorization and referral required)
• Other: Not covered
• Contact lenses: $0 copay (limits apply, authorization and referral required)
• Eyeglasses (frames and lenses): $0 copay (limits apply, authorization and referral required)
• Eyeglass frames: $0 copay (limits apply, authorization and referral required)
• Eyeglass lenses: $0 copay (limits apply, authorization and referral required)
• Upgrades: $0 copay (limits apply, authorization and referral 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
• Transportation services: Some coverage
• Over-the-counter drug benefits: Some coverage
• Meals for short duration: Not covered
• 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): Not covered
• Medical Nutrition Therapy (MNT): Not covered
• 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: Some coverage
• Home-Based Palliative Care: Not covered
• Support for Caregivers of Enrollees: Not covered
• Additional Sessions of Smoking and Tobacco Cessation Counseling: Some coverage
• Enhanced Disease Management: Not covered
• Telemonitoring Services: Not covered
• Remote Access Technologies (including Web/Phone-based technologies and Nursing Hotline): Some coverage
• Counseling Services: Not covered
Wellness programs (e.g., fitness, nursing hotline)
• Covered
Transportation
• $0 copay (limits apply, authorization required)
Foot care (podiatry services)
• Foot exams and treatment: $25 copay (authorization and referral required)
• Routine foot care: Not covered
Medicare Part B drugs
• Chemotherapy: 20% coinsurance (authorization required)
• Other Part B drugs: 20% coinsurance (authorization required)




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