Wellcare No Premium (HMO) H2134-005-000 2024 Plan Details and Costs (2024)

Table of Contents
Basic Costs and Coverage Health Care Services and Medical Supplies Dental Benefits Vision Benefits Hearing Benefits Preventive Services and Health/Wellness Education Programs Prescription Drug Costs and Coverage Plan Documents New Mexico Counties Served References

New Mexico 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 New Mexico Medicare Advantage plans like the one below and find a plan that offers the benefits you want at an affordable price.

See Also
Preparing for Healthcare Costs in RetirementMedicare drug enrollment for 2018 to start Sunday; costs going upWellcare No Premium (HMO) | WellcareWhat Is the Medicare Annual Enrollment Period (AEP)?

Basic Costs and Coverage

CoverageDetails
Monthly plan premium$0.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible$150.00
Out-of-pocket maximum$3,650.00
Initial drug coverage limit$0.00
Catastrophic drug coverage limit$8,000.00
Primary care doctor visitIn-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0.00

Specialty doctor visitIn-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $30.00
Prior Authorization Required for Doctor Specialty Visit

Inpatient hospital careIn-Network:

Acute Hospital Services:
$275.00 per day for days 1 to 10
$0.00 per day for days 11 to 90
Prior Authorization Required for Acute Hospital Services

Urgent care
Urgent Care:
Copayment for Urgent Care $30.00
Copayment for Medicare Covered Urgent Care waived if you are admitted to hospital within 24 hours

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $135.00
Maximum Plan Benefit of $50,000

Emergency room visit
Emergency Care:
Copayment for Emergency Care $135.00
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital within 24 hours

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $135.00
Maximum Plan Benefit of $50,000

Ambulance transportationIn-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $275.00

Air Ambulance:
Copayment for Air Ambulance Services $275.00

Please see Evidence of Coverage for Prior Authorization rules

Health Care Services and Medical Supplies

Wellcare No Premium (HMO) covers a range of additional benefits. Learn more about Wellcare No Premium (HMO) benefits, some of which may not be covered by Original Medicare (Part A and Part B).

CoverageDetails
Chiropractic servicesIn-Network:

Chiropractic Services:
Copayment for Medicare-covered Chiropractic Services $20.00
Prior Authorization Required for Chiropractic Services

Diabetes supplies, training, nutrition therapy and monitoringIn-Network:

Diabetic Supplies and Services:
Copayment for Medicare-covered Diabetic Supplies $0.00
Coinsurance for Medicare-covered Diabetic Therapeutic Shoes or Inserts 20%
Prior Authorization Required for Diabetic Supplies and Services
Diabetic Supplies and Services limited to those from specified manufacturers(Please see Evidence of Coverage)

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-raysIn-Network:

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0.00 to $10.00
Copayment for Medicare-covered Lab Services $0.00 to $50.00
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services

Outpatient Diag/Therapeutic Rad Services:
Copayment for Medicare-covered Diagnostic Radiological Services $0.00 to $250.00
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $0.00
Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services

Home health careIn-Network:

Home Health Services:
Copayment for Medicare-covered Home Health Services $0.00
Prior Authorization Required for Home Health Services

Mental health inpatient careIn-Network:

Psychiatric Hospital Services:
$250.00 per day for days 1 to 10
$0.00 per day for days 11 to 90
Prior Authorization Required for Psychiatric Hospital Services

Mental health outpatient careIn-Network:

Outpatient Mental Health Services:
Copayment for Medicare-covered Individual Sessions $40.00
Copayment for Medicare-covered Group Sessions $40.00
Prior Authorization Required for Outpatient Mental Health Services

Outpatient services/surgeryIn-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0.00 to $275.00
Prior Authorization Required for Outpatient Hospital Services

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $135.00 to $275.00

Ambulatory Surgical Center Services:
Copayment for Ambulatory Surgical Center Services $200.00
Prior Authorization Required for Ambulatory Surgical Center Services

Outpatient substance abuse careIn-Network:

Outpatient Substance Abuse Services:
Copayment for Medicare-covered Individual Sessions $40.00
Copayment for Medicare-covered Group Sessions $40.00
Prior Authorization Required for Outpatient Substance Abuse Services

Over-the-counter itemsIn-Network:

Over-The-Counter (OTC) Items:
Copayment for Over-The-Counter (OTC) Items $0.00
Maximum Plan Benefit of $98.00 every three months
Nicotine Replacement Therapy (NRT) offerred as a Part C OTC benefit

Podiatry servicesIn-Network:

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $30.00
Prior Authorization Required for Podiatry Services

Skilled Nursing Facility (SNF) careIn-Network:

Skilled Nursing Facility Services:
$0.00 per day for days 1 to 20
$203.00 per day for days 21 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.

CoverageDetails
Dental careIn-Network:

Preventive Dental:
Copayment for Oral Exams $0.00

  • Maximum 2 visits every year
Copayment for Prophylaxis (Cleaning) $0.00
  • Maximum 2 visits every year
Copayment for Fluoride Treatment $0.00
  • Maximum 1 visit every year
Copayment for Dental X-Rays $0.00
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Referral Required for Preventive Dental

Comprehensive Dental:
Copayment for Medicare-covered Benefits $30.00
Coinsurance for Non-routine Services 40%

  • Maximum 1 visit (Please see Evidence of Coverage for details)
Coinsurance for Diagnostic Services 40%
  • Maximum 1 visit every year
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 Extractions 40%
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Coinsurance for Prosthodontics, Other Oral/Maxillofacial Surgery, Other Services 40%
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Maximum Plan Benefit of $2000.00 every year for Non-Medicare Covered Comprehensive
Prior Authorization Required for Comprehensive Dental

Vision Benefits

The following vision services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage

See Also
Survey: Americans Navigate Changes and Costs in 2024 Health Plans - GoodRx

CoverageDetails
Vision careIn-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $0.00 to $30.00
Copayment for Routine Eye Exams $0.00

  • Maximum 1 Routine Eye Exam every year
Prior Authorization Required for Eye Exams

Eyewear:
Copayment for Medicare-Covered Benefits $0.00
Maximum Plan Allowance of $100.00 every year for all Non-Medicare covered eyewear
Prior Authorization Required for Eyewear

Hearing Benefits

The following hearing services are covered, though there may be provider network restrictions. See the plan Evidence of Coverage.

CoverageDetails
Hearing careIn-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $30.00
Copayment for Routine Hearing Exams $0.00

  • Maximum 1 visit every year
Copayment for Fitting/Evaluation for Hearing Aid $0.00
  • Maximum 1 visit every year
Prior Authorization Required for Hearing Exams

Hearing Aids:
Copayment for Hearing Aids $0.00

  • Maximum 2 Hearing Aids every year
Maximum Plan Benefit of $500.00 every year per ear
Prior Authorization Required for Hearing Aids

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.

CoverageDetails
Preventive services and health/wellness education programsIn-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 & vagin*l 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

    Prescription Drug Costs and Coverage

    The Wellcare No Premium (HMO) offers prescription drug coverage, with an annual drug deductible of $150.00 (excludes Tiers 1, 2, and 6)

    Coverage & Cost

    Coverage

    Cost

    Annual drug deductible$150.00 (excludes Tiers 1, 2, and 6)
    Tier 1
    • Preferred retail $0.00
    • Standard retail $10.00
    • Preferred mail order $0.00
    • Standard mail order $10.00
    Tier 2
    • Preferred retail $9.00
    • Standard retail $20.00
    • Preferred mail order $9.00
    • Standard mail order $20.00
    Tier 6
    • Preferred retail $0.00
    • Standard retail $0.00
    • Preferred mail order $0.00
    • Standard mail order $0.00
    Annual drug deductible$150.00 (excludes Tiers 1, 2, and 6)
    Tier 1
    • Preferred retail $0.00
    • Standard retail $20.00
    • Preferred mail order $0.00
    • Standard mail order $20.00
    Tier 2
    • Preferred retail $18.00
    • Standard retail $40.00
    • Preferred mail order $18.00
    • Standard mail order $40.00
    Tier 6
    • Preferred retail $0.00
    • Standard retail $0.00
    • Preferred mail order $0.00
    • Standard mail order $0.00
    Annual drug deductible$150.00 (excludes Tiers 1, 2, and 6)
    Tier 1
    • Preferred retail $0.00
    • Standard retail $30.00
    • Preferred mail order $0.00
    • Standard mail order $30.00
    Tier 2
    • Preferred retail $27.00
    • Standard retail $60.00
    • Preferred mail order $0.00
    • Standard mail order $60.00
    Tier 6
    • Preferred retail $0.00
    • Standard retail $0.00
    • Preferred mail order $0.00
    • Standard mail order $0.00

    When reviewing New Mexico 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 New Mexico 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
    • Summary of benefits
    • Evidence of coverage
    • Star ratings

    New Mexico Counties Served

    • Bernalillo
    • Chaves
    • Cibola
    • Curry
    • Dona Ana
    • Eddy
    • Grant
    • Lea
    • Lincoln
    • Los Alamos
    • Luna
    • Mckinley
    • Otero
    • Quay
    • Rio Arriba
    • Roosevelt
    • San Juan
    • San Miguel
    • Sandoval
    • Santa Fe
    • Taos
    • Torrance
    • Valencia

    We represent carriers such as Humana, UnitedHealthcare®, Anthem Blue Cross and Blue Shield, Aetna, Cigna Healthcare, Wellcare, or Kaiser Permanente.

    Wellcare No Premium (HMO) H2134-005-000 2024 Plan Details and Costs (2024)

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