MedicareCommons™

Neutral. Transparent. Retrieval-first.

array(20) { ["plan_name"]=> string(21) "Wellcare Assist (HMO)" ["plan_id"]=> string(9) "H2915-011" ["org_name"]=> string(19) "Wellcare by Allwell" ["plan_type"]=> string(3) "HMO" ["region"]=> string(15) "Statewide in PA" ["moop"]=> string(7) "5200.00" ["deductible"]=> string(12) "Data missing" ["inpatient_hospital"]=> string(125) "$450.00 (days 1–5), $0.00 (days 6–90), $0.00 (days –)
Prior Authorization Required, Referral Required" ["snf"]=> string(132) "$0.00 (days 1–20), $214.00 (days 21–60), $0.00 (days 61–100)
Prior Authorization Required, Referral Required" ["pcp"]=> string(47) "$0.00 Copay
Referral Required" ["specialist"]=> string(78) "$20.00 Copay
Prior Authorization Required, Referral Required" ["urgent_care"]=> string(78) "$25.00 Copay
Prior Authorization Required, Referral Required" ["er"]=> string(87) "$0.00 - $300.00 Copay
Prior Authorization Required, Referral Required" ["ambulance_ground"]=> string(79) "$295.00 Copay
Prior Authorization Required, Referral Required" ["ambulance_air"]=> string(79) "$295.00 Copay
Prior Authorization Required, Referral Required" ["dental"]=> string(73) "$0.00 max
$0.00 max
Referral Required" ["vision"]=> string(114) "$0.00 Copay
$400.00/yr eyewear
Prior Authorization Required, Referral Required" ["hearing"]=> string(47) "Not Covered
Referral Required" ["rx"]=> array(2) { ["deductible"]=> string(7) "$490.00" ["tiers"]=> array(6) { [0]=> array(11) { ["order"]=> int(1) ["name"]=> string(18) "Tier 1*" ["deductible"]=> string(8) "Excluded" ["deductible_flag"]=> string(8) "Excluded" ["retail_30"]=> string(3) "—" ["retail_90"]=> string(3) "—" ["mail_30"]=> string(3) "—" ["mail_90"]=> string(3) "—" ["ltc_30"]=> string(3) "—" ["out_network"]=> string(3) "—" ["post_oop"]=> string(3) "—" } [1]=> array(11) { ["order"]=> int(2) ["name"]=> string(6) "Tier 2" ["deductible"]=> string(7) "Applies" ["deductible_flag"]=> string(7) "Applies" ["retail_30"]=> string(3) "—" ["retail_90"]=> string(3) "—" ["mail_30"]=> string(3) "—" ["mail_90"]=> string(3) "—" ["ltc_30"]=> string(3) "—" ["out_network"]=> string(3) "—" ["post_oop"]=> string(3) "—" } [2]=> array(11) { ["order"]=> int(3) ["name"]=> string(6) "Tier 3" ["deductible"]=> string(7) "Applies" ["deductible_flag"]=> string(7) "Applies" ["retail_30"]=> string(3) "—" ["retail_90"]=> string(3) "—" ["mail_30"]=> string(3) "—" ["mail_90"]=> string(3) "—" ["ltc_30"]=> string(3) "—" ["out_network"]=> string(3) "—" ["post_oop"]=> string(3) "—" } [3]=> array(11) { ["order"]=> int(4) ["name"]=> string(6) "Tier 4" ["deductible"]=> string(7) "Applies" ["deductible_flag"]=> string(7) "Applies" ["retail_30"]=> string(3) "—" ["retail_90"]=> string(3) "—" ["mail_30"]=> string(3) "—" ["mail_90"]=> string(3) "—" ["ltc_30"]=> string(3) "—" ["out_network"]=> string(3) "—" ["post_oop"]=> string(3) "—" } [4]=> array(11) { ["order"]=> int(5) ["name"]=> string(6) "Tier 5" ["deductible"]=> string(7) "Applies" ["deductible_flag"]=> string(7) "Applies" ["retail_30"]=> string(3) "—" ["retail_90"]=> string(3) "—" ["mail_30"]=> string(3) "—" ["mail_90"]=> string(3) "—" ["ltc_30"]=> string(3) "—" ["out_network"]=> string(3) "—" ["post_oop"]=> string(3) "—" } [5]=> array(11) { ["order"]=> int(6) ["name"]=> string(18) "Tier 6*" ["deductible"]=> string(8) "Excluded" ["deductible_flag"]=> string(8) "Excluded" ["retail_30"]=> string(3) "—" ["retail_90"]=> string(3) "—" ["mail_30"]=> string(3) "—" ["mail_90"]=> string(3) "—" ["ltc_30"]=> string(3) "—" ["out_network"]=> string(3) "—" ["post_oop"]=> string(3) "—" } } } ["data_status"]=> string(2) "ok" }
🩺 Doctor’s Office Visits
Service 2026 2025
PrimaryComing soon$0.00 Copay
Referral Required
SpecialistComing soon$20.00 Copay
Prior Authorization Required, Referral Required
🏥 Emergency, Urgent, and Inpatient Hospital Coverage
Service 2026 2025
Emergency room careComing soon$0.00 - $300.00 Copay
Prior Authorization Required, Referral Required
Urgent careComing soon$25.00 Copay
Prior Authorization Required, Referral Required
Ground ambulanceComing soon$295.00 Copay
Prior Authorization Required, Referral Required
Inpatient hospital careComing soon$450.00 (days 1–5), $0.00 (days 6–90), $0.00 (days –)
Prior Authorization Required, Referral Required
Skilled Nursing FacilityComing soon$0.00 (days 1–20), $214.00 (days 21–60), $0.00 (days 61–100)
Prior Authorization Required, Referral Required
🦶 Foot Care
Service 2026 2025
Foot Exams and Treatments (Medicare-covered)Coming soon20% Coinsurance
Referral Required
Routine Foot CareComing soon0% - 20% Coinsurance
Prior Authorization Required, Referral Required
💆 Chiropractic Care
Service 2026 2025
Medicare-covered chiropracticComing soon20% Coinsurance
Prior Authorization Required, Referral Required
Routine chiropracticComing soon20% Coinsurance
Prior Authorization Required, Referral Required
🧠 Mental Health Services
Service 2026 2025
Outpatient individual therapyComing soon$15.00 Copay
Referral Required
Outpatient group therapyComing soon$15.00 Copay
Referral Required
Inpatient psychiatric hospital careComing soon$375.00 (days 1–5), $0.00 (days 6–90), $0.00 (days –)
Prior Authorization Required, Referral Required
🏋️ Rehabilitation Services
Service 2026 2025
Physical therapy and speech/language therapyComing soon$25.00 Copay
Prior Authorization Required, Referral Required
Occupational therapyComing soon$30.00 Copay
Prior Authorization Required, Referral Required
🧰 Medical Equipment and Supplies
Service 2026 2025
Diabetes suppliesComing soon$0.00 Copay
Prior Authorization Required, Referral Required
Durable medical equipmentComing soon$25.00 Copay
Prior Authorization Required, Referral Required
ProstheticsComing soon$0.00 - $25.00 Copay
Prior Authorization Required, Referral Required
🔬 Diagnostics, Lab Services, and Imaging
Service 2026 2025
Diagnostic radiology servicesComing soon$30.00 Copay
Prior Authorization Required, Referral Required
Lab servicesComing soon$25.00 Copay
Prior Authorization Required, Referral Required
Outpatient x-raysComing soon$0.00 - $55.00 Copay
Prior Authorization Required, Referral Required
Diagnostic tests and proceduresComing soon$25.00 Copay
Prior Authorization Required, Referral Required
💉 Medicare Part B Drugs
Service 2026 2025
ChemotherapyComing soon$0.00 Copay
Prior Authorization Required, Referral Required
Other Part B drugs (Medicare-covered)Coming soon20% Coinsurance
Prior Authorization Required, Referral Required

Supplemental Benefits

🦷 Dental Services
Service 2026 2025
Medicare Covered Preventive DentalComing soon$0.00 max
$0.00 max
Referral Required
Oral examComing soon$0.00 Copay
Referral Required
Dental x-raysComing soon$0.00 Copay
Referral Required
CleaningComing soon$0.00 Copay
Referral Required
PeriodonticsComing soon$0.00 Copay
Referral Required
EndodonticsComing soon$0.00 Copay
Referral Required
Restorative ServicesComing soon$0.00 Copay
Referral Required
Dental MaximumComing soonNot Covered
👂 Hearing Aids and Services
Service 2026 2025
Fitting/evaluationComing soon$0.00 Copay
Referral Required
Hearing aidsComing soon$0.00 Copay
Referral Required
Hearing examComing soon$0.00 max
$0.00 max
Prior Authorization Required, Referral Required
Hearing MaximumComing soon$0.00 max
👓 Vision Services
Service 2026 2025
Medicare-covered eye examComing soon$0.00 max
$0.00 max
Prior Authorization Required, Referral Required
Routine eye examComing soon$0.00 Copay
Referral Required
Eyewear benefitsComing soon$0.00 Copay
Referral Required
Vision Eyewear MaximumComing soon$400.00/yr eyewear
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Part D Plan Premium

The Part D prescription drug plan premium is included in your overall Medicare Advantage plan cost. However, additional expenses or subsidies may apply through the Low-Income Subsidy (LIS) program, also known as Extra Help. LIS, provided by Social Security, helps those with limited income and resources to lower or eliminate Part D costs. LIS benefits are not part of Medicare Advantage coverage.

{name} Prescription Drug Plan Premium Details
Basic Part D Premium: ${part_d_basic_premium}
Supplemental Part D Premium: ${part_d_supplemental_premium}
Total Part D Premium: ${part_d_total_premium}
Low-Income Premium Subsidy: ${part_d_lips_amount}
Low-Income Premium Subsidy Paid by CMS: ${part_d_lips_cms_pays}
Low-Income Subsidy Premium: ${part_d_lis_premium}

For more details, visit the Social Security Extra Help program.

Prescription Drug Plan Deductible

This plan has a ${deductible} annual Part D deductible. You'll pay this deductible at the pharmacy before {carrier} starts contributing towards your prescription costs.

Prescription Drug Plan Out-of-Pocket Costs

Beyond premiums and deductibles, {name} may have additional costs at pharmacies. The table below outlines out-of-pocket expenses by drug tier.

{name} Pharmacy Out-of-Pocket Costs by Drug Tier
Drug Tier Retail Mail Order
Tier 1<sup>*</sup>30-day: —
90-day: —		30-day: —
90-day: —
Tier 230-day: —
90-day: —		30-day: —
90-day: —
Tier 330-day: —
90-day: —		30-day: —
90-day: —
Tier 430-day: —
90-day: —		30-day: —
90-day: —
Tier 530-day: —
90-day: —		30-day: —
90-day: —
Tier 6<sup>*</sup>30-day: —
90-day: —		30-day: —
90-day: —
*Deductible does not apply.