Wellcare No Premium (HMO)
H9900 - 004 - 0
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Wellcare No Premium (HMO) is a Medicare Advantage Plan by Wellcare.
This page features plan details for 2024 Wellcare No Premium (HMO) H9900 – 004 – 0 available in Select counties in OK.
IMPORTANT: This page features the 2024 version of this plan. See the 2025 version using the link below:
No 2025 version found. You can use the location links below to find 2025 plans in your area.
Locations
Wellcare No Premium (HMO) is offered in the following locations.
Plan Overview
Wellcare No Premium (HMO) offers the following coverage and cost-sharing.
| Insurer: | Wellcare |
| Health Plan Deductible: | $0.00 |
| MOOP: | $4,500.00 |
| Drugs Covered: | Yes |
Ready to sign up for Wellcare No Premium (HMO) ?
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 No Premium (HMO) has a monthly premium of $0.00. 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 |
|---|---|---|---|---|
| $174.70 | $0.00 | $0.00 | $0.00 | $ |
- 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 No Premium (HMO) provides the following cost-sharing on drugs. Please check the plan’s formulary for specific drugs covered.
| Drug Deductible: | $0.00 |
| Initial Coverage Limit: | $5,030.00 |
| Catastrophic Coverage Limit: | $8,000.00 |
| Drug Benefit Type: | Enhanced Alternative |
| Additional Gap Coverage: | Yes |
| Formulary Link: | Formulary Link |
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 D | LIS Full |
|---|---|
| $0.00 | $ |
Initial Coverage Phase
After you pay your $0.00 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 $5,030.00. Once you reach that amount, you will enter the next coverage phase.
30 Day
60 Day
90 Day
30 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $0.00 copay | $0.00 copay | $0.00 copay |
| 2 (Generic) | $1.00 copay | $2.00 copay | $1.00 copay | $2.00 copay |
| 3 (Preferred Brand) | $42.00 copay | $47.00 copay | $42.00 copay | $47.00 copay |
| 4 (Non-Preferred Drug) | 50% | 50% | 50% | 50% |
| 5 (Specialty Tier) | 33% | 33% | 33% | 33% |
| 6 (Select Care Drugs) | $0.00 copay | $0.00 copay | $0.00 copay | $0.00 copay |
60 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | ||||
| 2 (Generic) | ||||
| 3 (Preferred Brand) | ||||
| 4 (Non-Preferred Drug) | ||||
| 5 (Specialty Tier) | ||||
| 6 (Select Care Drugs) |
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $0.00 copay | $0.00 copay | $0.00 copay |
| 2 (Generic) | $3.00 copay | $6.00 copay | $0.00 copay | $6.00 copay |
| 3 (Preferred Brand) | $126.00 copay | $141.00 copay | $84.00 copay | $141.00 copay |
| 4 (Non-Preferred Drug) | 50% | 50% | 50% | 50% |
| 5 (Specialty Tier) | ||||
| 6 (Select Care Drugs) | $0.00 copay | $0.00 copay | $0.00 copay | $0.00 copay |
Gap Coverage Phase
30 Day
90 Day
30 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $0.00 copay | $0.00 copay | $0.00 copay |
| 2 (Generic) | $1.00 copay | $2.00 copay | $1.00 copay | $2.00 copay |
| 6 (Select Care Drugs) * | $0.00 copay | $0.00 copay | $0.00 copay | $0.00 copay |
| Generic drugs | ||||
| Brand-name drugs |
90 Day
| Tier | Pref. Pharm | Std. Pharm | Pref. Mail | Std. Mail |
|---|---|---|---|---|
| 1 (Preferred Generic) | $0.00 copay | $0.00 copay | $0.00 copay | $0.00 copay |
| 2 (Generic) | $3.00 copay | $6.00 copay | $0.00 copay | $6.00 copay |
| 6 (Select Care Drugs) * | $0.00 copay | $0.00 copay | $0.00 copay | $0.00 copay |
| Generic drugs | ||||
| Brand-name drugs |
| Tier | Cost |
|---|---|
| All other tiers (Generic) | 25% |
| All other tiers (Brand-name) | 25% |
Catastrophic Coverage Phase
After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $8,000.00, 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 No Premium (HMO) also provides the following benefits.
| $0 |
| In-network | No |
| $4,500 In-network |
| No |
| In-network | No |
| $0-300 copay per visit (Authorization is required.) (Referral is not required.) |
| Primary | $0 copay (Not applicable.) (Not applicable.) |
| Specialist | $35 copay per visit (Authorization is required.) (Referral is not required.) |
| $0 copay (Authorization is not required.) (Referral is not required.) |
| Emergency | $120 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Urgent care | $35 copay per visit (always covered) (Not applicable.) (Not applicable.) |
| Diagnostic tests and procedures | $0-35 copay (Authorization is required.) (Referral is not required.) |
| Lab services | $0-50 copay (Authorization is required.) (Referral is not required.) |
| Diagnostic radiology services (e.g., MRI) | $0-300 copay (Authorization is required.) (Referral is not required.) |
| Outpatient x-rays | $0 copay (Authorization is required.) (Referral is not required.) |
| Hearing exam | $35 copay (Authorization is required.) (Referral is not required.) |
| Fitting/evaluation | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Hearing aids | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Oral exam | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Cleaning | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Fluoride treatment | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Dental x-ray(s) | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Non-routine services | 20% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Diagnostic services | 20% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Restorative services | 20% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Endodontics | 20% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Periodontics | 20% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Extractions | 20% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Prosthodontics, other oral/maxillofacial surgery, other services | 20% coinsurance (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Routine eye exam | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Other | Not covered (There are no limits.) (Not applicable.) (Not applicable.) |
| Contact lenses | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Eyeglasses (frames and lenses) | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Eyeglass frames | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Eyeglass lenses | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Upgrades | $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Occupational therapy visit | $35 copay (Authorization is required.) (Referral is not required.) |
| Physical therapy and speech and language therapy visit | $35 copay (Authorization is required.) (Referral is not required.) |
| $275 copay (Not applicable.) (Not applicable.) |
| $0 copay (Limits may apply.) (Authorization is required.) (Referral is not required.) |
| Foot exams and treatment | $35 copay (Authorization is required.) (Referral is not required.) |
| Routine foot care | Not covered (Not applicable.) (Not applicable.) |
| Durable medical equipment (e.g., wheelchairs, oxygen) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| Prosthetics (e.g., braces, artificial limbs) | 20% coinsurance per item (Authorization is required.) (Not applicable.) |
| Diabetes supplies | $0 copay per item (Authorization is required.) (Not applicable.) |
| Covered (Authorization is not required.) (Referral is not required.) |
| Chemotherapy | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| Other Part B drugs | 0-20% coinsurance (Authorization is required.) (Not applicable.) |
| Part B Insulin drugs | $35 copay (Authorization is required.) (Not applicable.) |
| $275 per day for days 1 through 5 $0 per day for days 6 through 90 $0 per day for days 90 through 120 (Authorization is required.) (Referral is not required.) |
| Inpatient hospital – psychiatric | $275 per day for days 1 through 5 $0 per day for days 6 through 90 (Authorization is required.) (Referral is not required.) |
| Outpatient group therapy visit with a psychiatrist | $25 copay (Authorization is required.) (Referral is not required.) |
| Outpatient individual therapy visit with a psychiatrist | $25 copay (Authorization is required.) (Referral is not required.) |
| Outpatient group therapy visit | $25 copay (Authorization is required.) (Referral is not required.) |
| Outpatient individual therapy visit | $25 copay (Authorization is required.) (Referral is not required.) |
| $0 per day for days 1 through 20 $203 per day for days 21 through 50 $0 per day for days 51 through 100 (Authorization is required.) (Referral is not required.) |
Ready to sign up for Wellcare No Premium (HMO) ?
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
Table of Contents
Need more information on Wellcare No Premium (HMO)? See 2025 Wellcare No Premium (HMO) at MedicareAdvantageRX.com.
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Medicare Advantage and Part D plans and benefits offered by the following carriers: Aetna Medicare, Anthem Blue Cross Blue Shield, Anthem Blue Cross, Aspire Health Plan, Capital Blue Cross, Cigna Healthcare, Dean Health Plan, Devoted Health, Florida Blue Medicare, GlobalHealth, Health Care Service Corporation, Healthy Blue, Humana, Molina Healthcare, Mutual of Omaha, Premera Blue Cross, Medica Central Health Plan, SCAN Health Plan, Baylor Scott & White Health Plan, Simply, UnitedHealthcare(R), Wellcare, WellPoint
SMID: MULTIPLAN_HCIHNDOGMED01PY25_M
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