Wellcare Simple (HMO)
Wellcare Simple (HMO) H5087-005 Plan Details
Wellcare Simple (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Wellcare Health Plans, Inc.
Plan ID: H5087-005
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.
$0.00
Monthly Premium
Wellcare Simple (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Wellcare Health Plans, Inc.
Plan ID: H5087-005
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 Simple (HMO) H5087-005 Plan Details
Wellcare Simple (HMO) is a HMO Medicare Advantage (Medicare Part C) plan offered by Wellcare Health Plans, Inc.
Plan ID: H5087-005
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.
$0.00
Monthly Premium
California Counties Served
Basic Costs and Coverage
| Coverage | Cost |
|---|---|
| Monthly Deductible | $420 |
| Out of Pocket Max |
In-Network: $1000 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 |
| Specialty Doctor Visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $0 Prior Authorization Required for Doctor Specialty Visit Referral Required for Doctor Specialty Visit Prior authorization required |
| Inpatient Hospital Care | In-Network: Acute Hospital Services: $50 per day for days 1 to 2 $0 per day for days 3 to 90 Prior Authorization Required for Acute Hospital Services Referral Required for Acute Hospital Services Prior authorization required |
| Urgent Care | Copayment for Urgent Care $0 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 $150 Air Ambulance: Copayment for Air Ambulance Services $150 Prior Authorization Required for Air Ambulance Prior authorization required |
Health Care Services and Medical Supplies
Wellcare Simple (HMO) 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 $0 Copayment for Routine Care $0
Referral Required for Chiropractic Services Prior authorization required |
| 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% |
| Durable Medical Eqipment (DME) | In-Network: Coinsurance for Medicare-covered Durable Medical Equipment 20% Prior Authorization Required for Durable Medical Equipment Prior authorization required |
| 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 Copayment for Medicare-covered Lab Services $0 to $50 Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services Referral Required for Outpatient Diag Procs/Tests/Lab Services Outpatient Diag/Therapeutic Rad Services: Copayment for Medicare-covered Diagnostic Radiological Services $0 Coinsurance for Medicare-covered Therapeutic Radiological Services 20% Copayment for Medicare-covered X-Ray Services $25 Prior authorization required |
| Home Health Care | In-Network: Copayment for Medicare-covered Home Health Services $0 Prior Authorization Required for Home Health Services Referral Required for Home Health Services Prior authorization required |
| Mental Health Inpatient Care | In-Network: Psychiatric Hospital Services: $50 per day for days 1 to 2 $0 per day for days 3 to 90 Prior Authorization Required for Psychiatric Hospital Services Referral Required for Psychiatric Hospital Services Prior authorization required |
| Mental Health Outpatient Care | In-Network: Copayment for Medicare-covered Individual Sessions $25 Copayment for Medicare-covered Group Sessions $25 |
| Outpatient Services / Surgery | In-Network: Outpatient Hospital Services: Copayment for Medicare Covered Outpatient Hospital Services $0 to $75 Prior Authorization Required for Outpatient Hospital Services Referral 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 outpatient surgical services. The cost share for outpatient non-surgical services, including outpatient palliative care is $0. Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $75 to $140 Referral Required for Outpatient Observation Services Outpatient Services/Surgery Observation Services: The minimum cost share is charged when a member enters observation status through an outpatient facility. The maximum cost share is charged when a member enters observation status through the ER/ED. Ambulatory Surgical Center Services: Copayment for Ambulatory Surgical Center Services $0 Prior Authorization Required for Ambulatory Surgical Center Services Referral Required for Ambulatory Surgical Center Services Prior authorization required |
| 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 Referral Required for Outpatient Substance Abuse Services Prior authorization required |
| Over-the-counter (OTC) Items | OTC allowance of $77 every quarter is loaded into the Wellcare Spendables card on a quarterly basis. Benefit is designed to allow members the flexibility to purchase OTC items at participating retailers, online, phone order, or catalog order. Benefit expires at end of quarter if unused. |
| Podiatry Services | In-Network: Copayment for Medicare-Covered Podiatry Services $0 Copayment for Routine Foot Care $0
Referral Required for Podiatry Services Prior authorization required |
| 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 30 $0 per day for days 31 to 100 Prior Authorization Required for Skilled Nursing Facility Services Referral Required for Skilled Nursing Facility Services Prior authorization required |
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 $0 Prior Authorization Required for Medicare Covered Preventive Dental Non-Medicare Covered Preventive Dental: Copayment for Non-medicare preventive $0 Copayment for Oral exams $0
Non-Medicare Covered Comprehensive Dental: Copayment for Non-medicare comprehensive $0 Copayment for Restorative services $0
Prior authorization required |
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 Copayment for Routine Eye Exams $0
Eyewear: Copayment for Medicare-Covered Benefits $0 Maximum Plan Allowance of $300 every year |
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 $0 Copayment for Routine Hearing Exams $0
Hearing Aids: Maximum Plan Allowance of $500 every year per ear Prior authorization required |
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:
Yearly "Wellness" visit |
Prescription Drug Costs and Coverage
The Wellcare Simple (HMO) 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 |
|
| Generic |
|
| Select Care Drugs |
|
| Annual Drug Deductible | $420 (excludes Tiers 1, 2 and 6) |
| Preferred Generic |
|
| Generic |
|
| Select Care Drugs |
|
| Annual Drug Deductible | $420 (excludes Tiers 1, 2 and 6) |
| Preferred Generic |
|
| Generic |
|
| Select Care Drugs |
|
