Wellcare Premium Ultra Open (PPO)

Wellcare Health Plans, Inc.
Wellcare Premium Ultra Open (PPO) H5439-011 Plan Details
3 out of 5 stars

Wellcare Premium Ultra Open (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Wellcare Health Plans, Inc.
Plan ID: H5439-011

HelpAdvisor Editorial Team analysis of data from the 2025 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.

$146.00
Monthly Premium

Wellcare Premium Ultra Open (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Wellcare Health Plans, Inc.
Plan ID: H5439-011

HelpAdvisor Editorial Team analysis of data from the 2025 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.

Wellcare Health Plans, Inc.
Wellcare Premium Ultra Open (PPO) H5439-011 Plan Details
3 out of 5 stars

Wellcare Premium Ultra Open (PPO) is a PPO Medicare Advantage (Medicare Part C) plan offered by Wellcare Health Plans, Inc.
Plan ID: H5439-011

HelpAdvisor Editorial Team analysis of data from the 2025 MA Landscape Source Files and carrier-provided plan data supplied by SunFire, Inc., a private company that creates software solutions for agents and brokers to compare Medicare plans. For more information, visit www.sunfireinc.com.

$146.00
Monthly Premium

Basic Costs and Coverage

Coverage Cost
Monthly Deductible $420
Out of Pocket Max In-Network: $4000
Out-of-Network: N/A
Initial Coverage Limit $2000
Catastrophic Coverage Limit $2,000
Primary Care Doctor Visit
In-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0
Out-of-Network:

Doctor Office Visit Services:
Coinsurance for Medicare Covered Primary Care Office Visit 30%
Specialty Doctor Visit
In-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $25
Prior Authorization Required for Doctor Specialty Visit
Prior authorization required
Out-of-Network:

Doctor Specialty Visit Services:
Coinsurance for Medicare Covered Physician Specialist Office Visit 30%
Inpatient Hospital Care
In-Network:

Acute Hospital Services:
$325 per day for days 1 to 7
$0 per day for days 8 to 90
Prior Authorization Required for Acute Hospital Services
Prior authorization required
Out-of-Network:

Acute Hospital Services:
30% per day for days 1 to 90
Urgent Care
Copayment for Urgent Care $60
Copayment for Medicare Covered Urgent Care waived if you are admitted to hospital within 24 hours

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $140
Maximum Plan Benefit of $50,000
Emergency Room Visit
Copayment for Emergency Care $140
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital with in 24 hours

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $140
Maximum Plan Benefit of $50,000
Ambulance Transportation
In-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $350

Air Ambulance:
Copayment for Air Ambulance Services $350
Prior Authorization Required for Air Ambulance
Prior authorization required
Out-of-Network:

Ambulance Services:
Copayment for Medicare Covered Ambulance Services - Ground $350
Copayment for Medicare Covered Ambulance Services - Air $350

Health Care Services and Medical Supplies

Wellcare Premium Ultra Open (PPO) covers additional benefits and services, some of which may not be covered by Original Medicare (Medicare Part A and Part B).

Coverage Cost
Chiropractic Services
In-Network:
Copayment for Medicare-covered Chiropractic Services $20
Copayment for Routine Care $20
  • Maximum 24 Routine Care every year
Prior Authorization Required for Chiropractic Services
Prior authorization required
Out-of-Network:

Medicare Covered Chiropractic Services:
Coinsurance for Medicare Covered Chiropractic Services 30%
Diabetes Supplies, Training, Nutrition Therapy and Monitoring
In-Network:
Copayment for Medicare-covered Diabetic Supplies $0
Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20%
Out-of-Network:

Medicare Covered Diabetic Supplies and Services:
Coinsurance for Medicare Covered Diabetic Supplies 30%
Coinsurance for Medicare Covered Diabetic Therapeutic Shoes or Inserts 30%
Durable Medical Eqipment (DME)
In-Network:
Coinsurance for Medicare-covered Durable Medical Equipment 20%
Prior Authorization Required for Durable Medical Equipment
Prior authorization required
Out-of-Network:

Medicare Covered Durable Medical Equipment Services:
Coinsurance for Medicare Covered Durable Medical Equipment 30%
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
Coinsurance for Medicare-covered Diagnostic Procedures/Tests 20%
Copayment for Medicare-covered Lab Services $0 to $50
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services
Diagnostic Tests, Lab and Radiology Services, and X-Rays Outpatient Diagnostic Procedures/Tests: The co-payment is for spirometry testing and specified testing-related services. The coinsurance is for all other services. The removal of abnormal tissue and/or polyps during a colonoscopy performed as a preventive screening for colorectal cancer will be covered at a $0 co-payment.

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $0 to $275
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $25
Prior authorization required
Out-of-Network:

Medicare Covered Diagnostic Procedures/Tests Services:
Coinsurance for Medicare Covered Diagnostic Procedures/Tests
30%
Coinsurance for Medicare Covered Lab Services
30%
Coinsurance for Medicare Covered Diagnostic Radiological Services 30%
Coinsurance for Medicare Covered Therapeutic Radiological Services 30%
Coinsurance for Medicare Covered Outpatient X-Ray Services 30%
Diagnostic Tests, Lab and Radiology Services, and X-Rays Outpatient Diagnostic Procedures/Tests: The co-payment is for spirometry testing and specified testing-related services. The coinsurance is for all other services. The removal of abnormal tissue and/or polyps during a colonoscopy performed as a preventive screening for colorectal cancer will be covered at a $0 co-payment.
Home Health Care
In-Network:
Copayment for Medicare-covered Home Health Services $0
Prior Authorization Required for Home Health Services
Prior authorization required
Out-of-Network:

Medicare Covered Home Health Services:
Coinsurance for Medicare Covered Home Health 30%
Mental Health Inpatient Care
In-Network:

Psychiatric Hospital Services:
$265 per day for days 1 to 7
$0 per day for days 8 to 90
Prior Authorization Required for Psychiatric Hospital Services
Prior authorization required
Out-of-Network:

Psychiatric Hospital Services:
30% per day for days 1 to 90
Mental Health Outpatient Care
In-Network:
Copayment for Medicare-covered Individual Sessions $25
Copayment for Medicare-covered Group Sessions $25
Out-of-Network:

Medicare Covered Mental Health Services:
Coinsurance for Medicare Covered Individual Sessions 30%
Coinsurance for Medicare Covered Group Sessions 30%
Outpatient Services / Surgery
In-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0 to $275
Prior Authorization Required for Outpatient Hospital Services
Outpatient Hospital and ASC Services Outpatient Hospital Services: The $0 cost share is for diagnostic colonoscopy. The maximum cost share is for all other outpatient hospital services.

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $140 to $275
Outpatient Services/Surgery Observation Services: The minimum cost share is charged when a member enters observation status through the ER/ED. The maximum cost share is charged when a member enters observation status through an outpatient facility.

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $200
Prior Authorization Required for Ambulatory Surgical Center Services
Prior authorization required
Out-of-Network:

Medicare Covered Outpatient Hospital Services:
Coinsurance for Medicare Covered Outpatient Hospital Services 30%
Coinsurance for Medicare Covered Ambulatory Surgical Center Services 30%
Outpatient Hospital and ASC Services Outpatient Hospital Services: The $0 cost share is for diagnostic colonoscopy. The maximum cost share is for all other outpatient hospital services.
Outpatient Substance Abuse Care
In-Network:
Copayment for Medicare-covered Individual Sessions $25
Copayment for Medicare-covered Group Sessions $25
Prior Authorization Required for Outpatient Substance Abuse Services
Prior authorization required
Out-of-Network:

Medicare Covered Outpatient Substance Abuse Services:
Coinsurance for Medicare Covered Individual Sessions 30%
Coinsurance for Medicare Covered Group Sessions 30%
Podiatry Services
In-Network:
Copayment for Medicare-Covered Podiatry Services $25
Prior Authorization Required for Podiatry Services
Prior authorization required
Out-of-Network:

Medicare Covered Podiatry Services:
Coinsurance for Medicare Covered Podiatry Services 30%
Skilled Nursing Facility Care
In-Network:

Skilled Nursing Facility Services:
$0 per day for days 1 to 20
$214 per day for days 21 to 50
$0 per day for days 51 to 100
Prior Authorization Required for Skilled Nursing Facility Services
Prior authorization required
Out-of-Network:

Skilled Nursing Facility Services:
30% per day for days 1 to 100

Dental Benefits

The following dental services are covered from in-network providers.

Coverage Cost
Dental Care
In-Network:

Medicare Covered Preventive Dental:
Copayment for Office Visit $25
Prior Authorization Required for Medicare Covered Preventive Dental

Non-Medicare Covered Preventive Dental:
Copayment for Non-medicare preventive $0
Copayment for Oral exams $0
  • Maximum 2 visits every year
Copayment for Dental x-rays $0
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Other diagnostic services $0
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Prophylaxis $0
  • Maximum 2 visits every year
Copayment for Fluoride treatment $0
  • Maximum 1 visit every year
Copayment for Other preventive services $0
  • Maximum 1 visit (Please see Evidence of Coverage for details)

Non-Medicare Covered Comprehensive Dental:
Copayment for Non-medicare comprehensive $0
Coinsurance for Restorative services 40%
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Coinsurance for Endodontics 40%
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Coinsurance for Periodontics 40%
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Coinsurance for Maxillofacial surgery 40%
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Coinsurance for Adjunctive general services 40%
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Maximum Plan Benefit of $2,000 every year
Prior authorization required
Out-of-Network:

Medicare Covered Preventive Dental Services:
Coinsurance for Medicare Covered Preventive Dental 30%

Vision Benefits

The following vision services are covered from in-network providers.

Coverage Cost
Vision Benefits
In-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $0 to $25
Copayment for Routine Eye Exams $0
  • Maximum 1 Routine Eye Exam every year

Eyewear:
Copayment for Medicare-Covered Benefits $0
Maximum Plan Allowance of $200 every year
Out-of-Network:

Medicare Covered Eye Exams Services:
Copayment for Medicare Covered Eye Exams $0
Coinsurance for Medicare Covered Eye Exams 30%
Coinsurance for Medicare Covered Eyewear 30%

Hearing Benefits

The following hearing services are covered from in-network providers.

Coverage Cost
Hearing Benefits
In-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $25
Copayment for Routine Hearing Exams $0
  • Maximum 1 visit every year
Copayment for Fitting/Evaluation for Hearing Aid $0
  • Maximum 1 visit every year
Prior Authorization Required for Hearing Exams

Hearing Aids:
Copayment for Hearing Aids $0
  • Maximum 2 Hearing Aids every year
Maximum Plan Benefit of $750 every year per ear
Prior authorization required
Out-of-Network:

Medicare Covered Hearing Exams Services:
Coinsurance for Medicare Covered Hearing Exams 30%

Preventive Services and Health/Wellness Education Programs

The following services are covered from in-network providers.

Coverage Cost
Preventive Services and Health/Wellness Education Programs
In-Network:
$0.00 copay for Medicare Covered Preventive Services:

Abdominal aortic aneurysm screening
Alcohol misuse screenings & counseling
Bone mass measurements (bone density)
Cardiovascular disease screenings
Cardiovascular disease (behavioral therapy)
Cervical & vaginal cancer screening
Colorectal cancer screenings
Depression screenings
Diabetes screenings
Diabetes self-management training
Glaucoma tests
Hepatitis B (HBV) infection screening
Hepatitis C screening test
HIV screening
Lung cancer screening
Mammograms (screening)
Nutrition therapy services
Obesity screenings & counseling
One-time Welcome to Medicare preventive visit
Prostate cancer screenings(PSA)
Sexually transmitted infections screening & counseling
Shots:
  • COVID-19 shots
  • Flu shots
  • Hepatitis B shots
  • Pneumococcal shots
  • Tobacco use cessation
    Yearly "Wellness" visit
    Out-of-Network:

    Medicare Covered Medicare-covered Preventive Services:
    Copayment for Medicare Covered Medicare-covered Preventive Services $0

    Prescription Drug Costs and Coverage

    The Wellcare Premium Ultra Open (PPO) plan offers the following prescription drug coverage, with an annual drug deductible of $420 (excludes Tiers 1, 2 and 6) per year.

    Coverage
    Cost
    Coverage & Cost
    Annual Drug Deductible $420 (excludes Tiers 1, 2 and 6)
    Preferred Generic
    • Preferred cost-share mail order $0.00
    • Standard retail $5.00
    • Preferred cost-share retail $0.00
    • Standard mail order $5.00
    Generic
    • Preferred cost-share mail order $0.00
    • Standard retail $10.00
    • Preferred cost-share retail $0.00
    • Standard mail order $10.00
    Select Care Drugs
    • Preferred cost-share mail order $0.00
    • Standard retail $0.00
    • Preferred cost-share retail $0.00
    • Standard mail order $0.00
    Annual Drug Deductible $420 (excludes Tiers 1, 2 and 6)
    Preferred Generic
    • Preferred cost-share mail order $0.00
    • Standard retail $10.00
    • Preferred cost-share retail $0.00
    • Standard mail order $10.00
    Generic
    • Preferred cost-share mail order $0.00
    • Standard retail $20.00
    • Preferred cost-share retail $0.00
    • Standard mail order $20.00
    Select Care Drugs
    • Preferred cost-share mail order $0.00
    • Standard retail $0.00
    • Preferred cost-share retail $0.00
    • Standard mail order $0.00
    Annual Drug Deductible $420 (excludes Tiers 1, 2 and 6)
    Preferred Generic
    • Preferred cost-share mail order $0.00
    • Standard retail $15.00
    • Preferred cost-share retail $0.00
    • Standard mail order $15.00
    Generic
    • Preferred cost-share mail order $0.00
    • Standard retail $30.00
    • Preferred cost-share retail $0.00
    • Standard mail order $30.00
    Select Care Drugs
    • Preferred cost-share mail order $0.00
    • Standard retail $0.00
    • Preferred cost-share retail $0.00
    • Standard mail order $0.00