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Wellcare PeaceHealth Simple (HMO-POS) - H6815-040-000
$0.00
Monthly Premium
Wellcare PeaceHealth Simple (HMO-POS) is a HMO-POS Medicare Advantage (Medicare Part C) plan offered by Centene Corporation
Plan ID: H6815-040-000
* Every year, the Centers for Medicare & Medicaid Services (CMS) evaluates plans based on a 5-star rating system.
$0.00
Monthly Premium
Oregon Medicare beneficiaries may want to consider reviewing their Medicare Advantage (Medicare Part C) plan options. A Medicare Advantage plan combines your Original Medicare (Part A and Part B) benefits into a single plan.
Most Medicare Advantage plans cover prescription drugs, and many plans may offer other extra benefits Original Medicare doesn’t cover.
Learn more about Oregon Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.
Enrollment may be limited to certain times of the year. See why you may be able to enroll.
Basic Costs and Coverage
| Coverage | Details |
|---|---|
| Monthly plan premium | $0.00 |
| Vision coverage | |
| Dental coverage | |
| Hearing coverage | |
| Prescription drugs | |
| Medical deductible | $420.00 |
| Out-of-pocket maximum | $4,150.00 |
| Initial drug coverage limit | $0.00 |
| Catastrophic drug coverage limit | $2,000.00 |
| Primary care doctor visit | In-Network: Doctor Office Visit: Copayment for Primary Care Office Visit $0 to $60 Doctor Office Visit Primary Care Physician Services: The minimum cost share is for services received from a tier-1 PCP. The maximum cost share is for services received from a tier-2 PCP. |
| Specialty doctor visit | In-Network: Doctor Specialty Visit: Copayment for Physician Specialist Office Visit $10 to $60 Prior Authorization Required for Doctor Specialty Visit Doctor Specialty Visit Physician Specialist Services: The minimum cost share is for services received from a tier-1 provider. The maximum cost share is for services received from a tier-2 provider. |
| Inpatient hospital care | In-Network: Acute Hospital Services - Tier 1: $150 per day for days 1 to 4 $0 per day for days 5 to 90 Prior Authorization Required for Acute Hospital Services - Tier 1 Inpatient Hospital Care Inpatient Hospital Services-Acute: The minimum cost share is for services received in a tier-1 facility. The maximum cost share is for services received in a tier-2 facility. Acute Hospital Services - Tier 2: $500 per day for days 1 to 4 $0 per day for days 5 to 90 Prior Authorization Required for Acute Hospital Services - Tier 2 Inpatient Hospital Care Inpatient Hospital Services-Acute: The minimum cost share is for services received in a tier-1 facility. The maximum cost share is for services received in a tier-2 facility. |
| Urgent care | Urgent Care: Copayment for Urgent Care $55 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 | Emergency Care: 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 $305 Air Ambulance: Copayment for Air Ambulance Services $305 Prior Authorization Required for Air Ambulance |
Health Care Services and Medical Supplies
Wellcare PeaceHealth Simple (HMO-POS) covers a range of additional benefits. Learn more about Wellcare PeaceHealth Simple (HMO-POS) benefits, some of which may not be covered by Original Medicare (Part A and Part B).
| Coverage | Details |
|---|---|
| Chiropractic services | In-Network: Chiropractic Services: Copayment for Medicare-covered Chiropractic Services $0 Copayment for Routine Care $0
|
| Diabetes supplies, training, nutrition therapy and monitoring | In-Network: Diabetic Supplies and Services: Copayment for Medicare-covered Diabetic Supplies $0 Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20% |
| Durable medical equipment (DME) | In-Network: Durable Medical Equipment: Coinsurance for Medicare-covered Durable Medical Equipment 20% Prior Authorization Required for Durable Medical Equipment |
| 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 to $40 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 minimum cost share is for spirometry testing and specified testing-related services. The maximum cost share is for all other services received from a tier-2 provider. The cost share for services received from a tier-1 provider is $0. 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 $500 Coinsurance for Medicare-covered Therapeutic Radiological Services 20% Copayment for Medicare-covered X-Ray Services $25 |
| Home health care | In-Network: Home Health Services: Copayment for Medicare-covered Home Health Services $0 Prior Authorization Required for Home Health Services |
| Mental health inpatient care | In-Network: Psychiatric Hospital Services - Tier 1: $150 per day for days 1 to 4 $0 per day for days 5 to 90 Prior Authorization Required for Psychiatric Hospital Services - Tier 1 Inpatient Mental Health Care Inpatient Hospital Services-Psychiatric: The minimum cost share is for services received in a tier-1 facility. The maximum cost share is for services received in a tier-2 facility. Psychiatric Hospital Services - Tier 2: $475 per day for days 1 to 4 $0 per day for days 5 to 90 Prior Authorization Required for Psychiatric Hospital Services - Tier 2 Inpatient Mental Health Care Inpatient Hospital Services-Psychiatric: The minimum cost share is for services received in a tier-1 facility. The maximum cost share is for services received in a tier-2 facility. |
| Mental health outpatient care | In-Network: Outpatient Mental Health Services: 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 $500 Prior Authorization Required for Outpatient Hospital Services Outpatient Hospital and ASC Services Outpatient Hospital Services: The minimum cost share is for diagnostic colonoscopy. The maximum cost share is for all other services received from a tier-2 provider. The cost share for non-surgical services received from a tier-1 provider is $150. The cost share for surgical services received from a tier-1 provider is $200. Outpatient Observation Services: Copayment for Medicare Covered Observation Services - Per stay $140 to $200 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 $100 to $300 Prior Authorization Required for Ambulatory Surgical Center Services Outpatient Hospital and ASC Services Ambulatory Surgical Center (ASC) Services: The minimum cost share is for services received from a tier-1 provider. The maximum cost share is for services received from a tier-2 provider. |
| Outpatient substance abuse care | In-Network: Outpatient Substance Abuse Services: Copayment for Medicare-covered Individual Sessions $25 Copayment for Medicare-covered Group Sessions $25 Prior Authorization Required for Outpatient Substance Abuse Services |
| Over-the-counter items | OTC allowance of $122 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: Podiatry Services: Copayment for Medicare-Covered Podiatry Services $10 to $60 Copayment for Routine Foot Care $10
Podiatry Services Podiatry Services: The minimum cost share is for services received from a tier-1 provider. The maximum cost share is for services received from a tier-2 provider. |
| Skilled Nursing Facility (SNF) care | In-Network: Skilled Nursing Facility Services: $0 per day for days 1 to 20 $214 per day for days 21 to 70 $0 per day for days 71 to 100 Prior Authorization Required for Skilled Nursing Facility Services |
Dental Benefits
The following dental services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Dental care | In-Network: Medicare Covered Preventive Dental: Copayment for Office Visit $10 to $60 Prior Authorization Required for Medicare Covered Preventive Dental Dental Services Medicare Dental Services: The minimum cost share is for Medicare-covered dental services received from a tier-1 provider. The maximum cost share is for Medicare-covered dental services received from a tier-2 provider. 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
Comprehensive services max plan benefit apply to both in-network and out-of-network services. |
Vision Benefits
The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage
| Coverage | Details |
|---|---|
| Vision care | In-Network: Eye Exams: Copayment for Medicare Covered Benefits $0 to $60 Copayment for Routine Eye Exams $0
Eyewear: Copayment for Medicare-Covered Benefits $0 Maximum Plan Allowance of $200 every year |
Hearing Benefits
The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| Hearing care | In-Network: Hearing Exams: Copayment for Medicare Covered Benefits $10 to $60 Copayment for Routine Hearing Exams $0
Hearing Services Hearing Exams - Medicare: The minimum cost share is for Medicare-covered hearing exams received from a tier-1 provider. The maximum cost share is for Medicare-covered hearing exams received from a tier-2 provider. Hearing Aids: Copayment for Hearing Aids $0
|
Preventive Services and Health/Wellness Education Programs
The following services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.
| Coverage | Details |
|---|---|
| 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 PeaceHealth Simple (HMO-POS) offers prescription drug coverage, with an annual drug deductible of $420.00 (excludes Tiers 1, 2, and 6)
Coverage & Cost | |
|---|---|
| Coverage | Cost |
| Annual drug deductible | $420.00 (excludes Tiers 1, 2, and 6) |
| Tier 1 |
|
| Tier 2 |
|
| Tier 6 |
|
| Annual drug deductible | $420.00 (excludes Tiers 1, 2, and 6) |
| Tier 1 |
|
| Tier 2 |
|
| Tier 6 |
|
| Annual drug deductible | $420.00 (excludes Tiers 1, 2, and 6) |
| Tier 1 |
|
| Tier 2 |
|
| Tier 6 |
|
When reviewing Oregon Medicare plans, be sure to find out if your doctors are part of the plan network. If a Medicare Advantage plan covers prescription drugs, make sure the plan formulary (list of drugs covered by the plan) includes your drugs.
You may be able to find plans in your part of Oregon that offer similar benefits at similar or lower prices than the plan above. Call 1-800-557-6059 TTY 711, 24/7 to speak with a licensed insurance agent who can help you compare plans.
Plan Documents
| Links to plan documents |
Oregon Counties Served
We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield*, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.