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Wellcare Low Premium Open (PPO)

H5439 - 019 - 0
3 out of 5 stars (3 / 5)

Wellcare Low Premium Open (PPO) is a Medicare Advantage Plan by Wellcare by Health Net.

This page features plan details for 2025 Wellcare Low Premium Open (PPO) H5439 – 019 – 0 available in Select counties in OR and WA.

Locations

Wellcare Low Premium Open (PPO) is offered in the following locations.

Benton County, Oregon
Clackamas County, Oregon
Clark County, Washington

Click to see more locations

Plan Overview

Wellcare Low Premium Open (PPO) offers the following coverage and cost-sharing.

Insurer:Wellcare by Health Net
Health Plan Deductible:$225 annual deductible
MOOP:$10,000 In and Out-of-network
$6,800 In-network
Drugs Covered:Yes

Ready to sign up for Wellcare Low Premium Open (PPO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

Premium Breakdown

Wellcare Low Premium Open (PPO) has a monthly premium of $38.00. This amount includes your Part C and D premiums but does not include your Part B premium. The following is a breakdown of your monthly premium with Part B costs included.
Part B Part C Part D Part B Give Back Total
$185.00 $31.00 $7.00 $ $
Please Note:
  • Your Part B premium may differ based on factors including late enrollment, income, and disability status.
  • You may also qualify for “Extra Help” on drug costs. See the Part D Premium Reduction section below for more details.

Drug Info

Wellcare Low Premium Open (PPO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.

Drug Deductible: $420.00
Drug Out-Of-Pocket maximum: $2,000.00
Drug Benefit Type: Enhanced Alternative

Part D Premium Reduction

The Low-Income Subsidy (also known as LIS or “Extra Help”) helps people with Medicare lower the cost of prescription drugs.

The table below shows how the LIS impacts the Part D premium of this plan.

Part DLIS Full
$7.00$7.00

Initial Coverage Phase

After you pay your $420.00 drug deductible, you will pay the following costs for drugs in each tier until your total drug costs (including what this plan has paid and what you have paid) reach $2,000.00. Once you reach that amount, you will enter the next coverage phase.

Catastrophic Coverage Phase

After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $2,000.00, you pay nothing for Medicare Part D covered drugs. However, you may still pay a share of the costs for excluded drugs covered under any enhanced benefit. Please note, that this plan has a Enhanced Alternative benefit type.

Additional Benefits

Wellcare Low Premium Open (PPO) also provides the following benefits.

Additional benefits and/or reduced cost-sharing for enrollees with certain health conditions?

    • In-Network: No

Comprehensive Dental

  • Adjunctive General Services
    • In-Network: No Coins – 0.00 Copay (Authorization Required)
    • Out-of-Network: 50% Coins – No Copay (Authorization Required)

Diagnostic and Preventive Dental

  • Dental X-Rays
    • In-Network: No Coins – 0.00 Copay (Authorization Required)
    • Out-of-Network: 50% Coins – No Copay (Authorization Required)
  • Fluoride Treatment
    • In-Network: No Coins – 0.00 Copay (Authorization Required)
    • Out-of-Network: 50% Coins – No Copay (Authorization Required)
  • Oral Exams
    • In-Network: No Coins – 0.00 Copay (Authorization Required)
    • Out-of-Network: 50% Coins – No Copay (Authorization Required)
  • Other Diagnostic Dental Services
    • In-Network: No Coins – 0.00 Copay (Authorization Required)
    • Out-of-Network: 50% Coins – No Copay (Authorization Required)
  • Other Preventive Dental Services
    • In-Network: No Coins – 0.00 Copay (Authorization Required)
    • Out-of-Network: 50% Coins – No Copay (Authorization Required)
  • Prophylaxis (cleaning)
    • In-Network: No Coins – 0.00 Copay (Authorization Required)
    • Out-of-Network: 50% Coins – No Copay (Authorization Required)

Diagnostic procedures/lab services/imaging

  • Diagnostic radiology services (e.g., MRI)
    • In-Network: $0-500 copay (Authorization Required)
    • Out-of-Network: 20% coinsurance (Authorization Required)
  • Outpatient x-rays
    • Out-of-Network: 20% coinsurance (Authorization Required)
  • Lab services
    • Out-of-Network: 20% coinsurance (Authorization Required)
  • Diagnostic tests and procedures
    • In-Network: $0 copay or 20% coinsurance (Authorization Required)
    • Out-of-Network: 20% coinsurance (Authorization Required)
  • Lab services
    • In-Network: $0-50 copay (Authorization Required)
  • Outpatient x-rays
    • In-Network: $50 copay (Authorization Required)

Doctor visits

  • Primary
    • Out-of-Network: $30 copay per visit
  • Specialist
    • In-Network: $30 copay per visit (Authorization Required)
  • Primary
    • In-Network: $0 copay
  • Specialist
    • Out-of-Network: $60 copay per visit (Authorization Required)

Emergency care/Urgent care

  • Emergency
    • $110 copay per visit (always covered)
  • Urgent care
    • $45 copay per visit (always covered)

Foot care (podiatry services)

  • Routine foot care
    • Not covered
  • Foot exams and treatment
    • In-Network: $30 copay (Authorization Required)
    • Out-of-Network: 20% coinsurance (Authorization Required)

Ground ambulance

    • Out-of-Network: $325 copay
    • In-Network: $325 copay

Health plan deductible

    • $225 annual deductible

Hearing

  • Hearing aids OTC
    • Not covered
  • Fitting/evaluation
    • Out-of-Network: 40% coinsurance (Limits Apply, Authorization Required)
  • Hearing aids
    • Out-of-Network: 40% coinsurance (Limits Apply, Authorization Required)
  • Fitting/evaluation
    • In-Network: $0 copay (Limits Apply, Authorization Required)
  • Medicare-Covered Hearing Exam
    • In-Network: $30 copay (Authorization Required)
    • Out-of-Network: $60 copay (Authorization Required)
  • Hearing aids
    • In-Network: $0 copay (Limits Apply, Authorization Required)

Inpatient hospital coverage

    • In-Network: $475 per day for days 1 through 5
      $0 per day for days 6 through 90 (Authorization Required)
    • Out-of-Network: 40% per day for days 1 through 90 (Authorization Required)

Maximum out-of-pocket enrollee responsibility (does not include prescription drugs)

    • $10,000 In and Out-of-network
      $6,800 In-network

Medical equipment/supplies

  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • Out-of-Network: 20% coinsurance per item (Authorization Required)
  • Prosthetics (e.g., braces, artificial limbs)
    • Out-of-Network: 20% coinsurance per item (Authorization Required)
  • Diabetes supplies
    • In-Network: $0 copay per item (Authorization Required)
    • Out-of-Network: $0 copay (Authorization Required)
  • Durable medical equipment (e.g., wheelchairs, oxygen)
    • In-Network: 20% coinsurance per item (Authorization Required)
  • Prosthetics (e.g., braces, artificial limbs)
    • In-Network: 20% coinsurance per item (Authorization Required)

Medicare Part B drugs

  • Chemotherapy
    • In-Network: 0-20% coinsurance (Authorization Required)
    • Out-of-Network: 0-20% coinsurance (Authorization Required)
  • Other Part B drugs
    • In-Network: 0-20% coinsurance (Authorization Required)
    • Out-of-Network: 0-20% coinsurance (Authorization Required)

Mental health services

  • Inpatient hospital – psychiatric
    • In-Network: $405 per day for days 1 through 5
      $0 per day for days 6 through 90 (Authorization Required)
  • Outpatient group therapy visit
    • In-Network: $25 copay (Authorization Required)
    • Out-of-Network: 20% coinsurance (Authorization Required)
  • Outpatient group therapy visit with a psychiatrist
    • In-Network: $25 copay (Authorization Required)
  • Inpatient hospital – psychiatric
    • Out-of-Network: 40% per day for days 1 through 90 (Authorization Required)
  • Outpatient group therapy visit with a psychiatrist
    • Out-of-Network: 20% coinsurance (Authorization Required)
  • Outpatient individual therapy visit with a psychiatrist
    • In-Network: $25 copay (Authorization Required)
  • Outpatient individual therapy visit
    • Out-of-Network: 20% coinsurance (Authorization Required)
    • In-Network: $25 copay (Authorization Required)
  • Outpatient individual therapy visit with a psychiatrist
    • Out-of-Network: 20% coinsurance (Authorization Required)

Optional supplemental benefits

    • No

Other health plan deductibles?

    • In-Network: No

Outpatient hospital coverage

    • Out-of-Network: 20% coinsurance per visit (Authorization Required)
    • In-Network: $0-500 copay per visit (Authorization Required)

Preventive care

    • Out-of-Network: $0 copay
    • In-Network: $0 copay

Rehabilitation services

  • Occupational therapy visit
    • In-Network: $30 copay (Authorization Required)
    • Out-of-Network: 20% coinsurance (Authorization Required)
  • Physical therapy and speech and language therapy visit
    • In-Network: $30 copay (Authorization Required)
    • Out-of-Network: 20% coinsurance (Authorization Required)

Skilled Nursing Facility

    • Out-of-Network: 30% per day for days 1 through 100 (Authorization Required)
    • In-Network: $0 per day for days 1 through 20
      $214 per day for days 21 through 60
      $0 per day for days 61 through 100 (Authorization Required)

Transportation

    • Not covered

Vision

  • Contact lenses
    • In-Network: $0 copay (Limits Apply, Authorization Required)
  • Eyeglass frames
    • In-Network: $0 copay (Limits Apply, Authorization Required)
  • Eyeglasses (frames and lenses)
    • Out-of-Network: 40% coinsurance (Limits Apply, Authorization Required)
  • Routine eye exam
    • In-Network: $0 copay (Limits Apply, Authorization Required)
  • Contact lenses
    • Out-of-Network: 40% coinsurance (Limits Apply, Authorization Required)
  • Eyeglass frames
    • Out-of-Network: 40% coinsurance (Limits Apply, Authorization Required)
  • Eyeglass lenses
    • Out-of-Network: 40% coinsurance (Limits Apply, Authorization Required)
  • Upgrades
    • Out-of-Network: 40% coinsurance (Limits Apply, Authorization Required)
  • Eyeglass lenses
    • In-Network: $0 copay (Limits Apply, Authorization Required)
  • Eyeglasses (frames and lenses)
    • In-Network: $0 copay (Limits Apply, Authorization Required)
  • Other
    • Not covered
  • Routine eye exam
    • Out-of-Network: 40% coinsurance (Limits Apply, Authorization Required)
  • Upgrades
    • In-Network: $0 copay (Limits Apply, Authorization Required)

Wellness programs (e.g., fitness, nursing hotline)

    • Covered

Ready to sign up for Wellcare Low Premium Open (PPO) ?

Get help from a licensed insurance agent.

Call 1-877-354-4611 / TTY 711.

M-F: 8:00 am – 10:00 pm EST

Sat-Sun: 8:00 am – 9:00 pm EST

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