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Wellcare Premium Enhanced (PFFS)
Benefits Summary and Overview
This page is a benefits summary and overview of key plan information for Wellcare Premium Enhanced (PFFS). The information on this page is a summary only.
For a complete listing of all available benefits and cost information on Wellcare Premium Enhanced (PFFS) in 2025, please refer to our full plan details page.
Wellcare Premium Enhanced (PFFS) is a PFFS plan offered by Centene Corporation available for enrollment in 2025 to people living in Select counties in NY. This plan received an overall rating of 3.5 out of 5 stars in 2025.
It's important to know that Wellcare Premium Enhanced (PFFS) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.
Key Plan Facts
Below are a few key facts and commonly-asked questions about Wellcare Premium Enhanced (PFFS).
Plan Costs:
The cost of a Medicare Advantage Plan is made up of four main parts.
- First, the monthly premium — the amount you pay every month.
- Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
- Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
- Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.
For Wellcare Premium Enhanced (PFFS), the main costs are as follows:
Monthly Premium
The Monthly Premium for this plan is $40.00. This is the amount you must pay every month.
This plan does not come with a Part B Premium reduction. You must continue to pay your Part B premium.
Deductibles
This plan does not have a health deductible. Your insurance coverage on covered health services will start immediately.
This plan has a $420.00 drug deductible. You will need to pay this amount towards covered prescriptions before your insurance coverage for prescription medications kicks in.
Out-of-Pocket Maximums
This plan has a combined Maximum Out-Of-Pocket cost of $3400.00 (in-network or out-of-network combined). You will pay copays, coinsurance, and deductibles toward this amount. Once your total out-of-pocket costs reach $3400.00 for covered services, the plan will pay 100% of covered costs for the rest of the year.
The plan may have separate out-pocket-maximums for in-network and out-of-network services. See our full plan details page for more information.
You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.
Common Services:
Doctor Visits:
Specialist Visits:
Emergency Room:
Urgent Care:
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Drug Coverage
The Wellcare Premium Enhanced (PFFS) plan has a $420 deductible for prescription drugs. After the deductible, you will pay a copay or coinsurance depending on the drug tier and pharmacy. For preferred generic drugs, there is no copay at preferred pharmacies and mail order, while standard pharmacies have a $10 copay. For specialty tier drugs, there is no copay. You will enter the catastrophic coverage phase after your total drug costs reach $2000.
Additional Benefits
The Wellcare Premium Enhanced (PFFS) plan offers comprehensive coverage with varying cost-sharing arrangements. Inpatient hospital stays have a copay of $295 for days 1-5, with no copay for subsequent days, while outpatient services and emergency services have copays ranging from $0 to $350. The plan also provides coverage for primary care, preventive, hearing, vision, and dental services, often with no copay or a low copay, along with additional benefits like home health services, and medical equipment with coinsurance.
Inpatient Hospital See details
Inpatient Hospital benefits, including Inpatient Hospital-Acute and Inpatient Hospital Psychiatric, are covered. For days 1-5, the copay is $295, and for days 6-90, there is no copay. Additional days for Inpatient Hospital-Acute are covered with no copay for days 91-150. Non-Medicare-covered stays and upgrades for Inpatient Hospital-Acute, and Additional Days and Non-Medicare-covered stays for Inpatient Hospital Psychiatric are not covered.
Outpatient Services See details
Outpatient Services include coverage for all outpatient hospital services with a copay between $0 and $300, observation services with a copay between $140 and $300, ambulatory surgical center services with a $250 copay, and outpatient substance abuse services with a $20 copay for both individual and group sessions. Additionally, outpatient blood services are covered with no copay.
Partial Hospitalization See details
Partial hospitalization is covered under the Wellcare Premium Enhanced (PFFS) plan with a copay of $55.
Ambulance and Transportation Services See details
Ambulance and Transportation Services are covered by the Wellcare Premium Enhanced (PFFS) plan, including both ground and air ambulance services, each with a $350 copay, and no coinsurance. Transportation Services to any health-related location are not covered.
Emergency Services See details
Emergency Services, Urgently Needed Services, and Worldwide Emergency Coverage are covered by the Wellcare Premium Enhanced (PFFS) plan. Emergency Services and Worldwide Emergency Coverage have a $140 copay, while Urgently Needed Services have a $35 copay, and all have no coinsurance. Worldwide Emergency Transportation is not covered.
Primary Care See details
The Wellcare Premium Enhanced (PFFS) plan covers primary care physician services with no copay, chiropractic services with a $20 copay for routine care, occupational therapy services with a $20 copay, and physician specialist services with a $20 copay. The plan also covers mental health specialty services, psychiatric services, and opioid treatment program services with a $20 copay for individual and group sessions. Additionally, physical therapy and speech-language pathology services have a $20 copay, and additional telehealth benefits range from no copay to a $35 copay.
Preventive Services See details
Preventive services include an annual physical exam with no copay, while additional preventive services may have a copay. Kidney disease education services have a 20% coinsurance, and other preventive services include glaucoma screening, diabetes self-management training, barium enemas, digital rectal exams, and EKG following the Welcome Visit, all with no copay. Some services, such as Health Education, In-Home Safety Assessment, and others, are not covered.
Hearing Services See details
The Wellcare Premium Enhanced (PFFS) plan covers hearing exams with a $20 copay, routine hearing exams with no copay, and fitting/evaluation for hearing aids with no copay. Prescription hearing aids are covered up to $350 per year, with no copay for all types of prescription hearing aids (except for inner ear, outer ear, and over the ear hearing aids, which are not covered), and OTC hearing aids are not covered.
Vision Services See details
Vision services include eye exams and eyewear. Eye exams have a copay of $0-$20, while routine eye exams have no copay. Eyewear, contact lenses, eyeglasses (lenses and frames), eyeglass lenses, eyeglass frames, and upgrades have no copay, with a combined maximum benefit of $100 per year for eyewear.
Dental Services See details
Dental services include coverage for Medicare dental services with a $20 copay, and other dental services including oral exams, dental x-rays, other diagnostic dental services, prophylaxis (cleaning), fluoride treatment, other preventive dental services, restorative services, adjunctive general services, endodontics, periodontics, prosthodontics (removable and fixed), and oral and maxillofacial surgery, all with no copay. Orthodontic services are covered up to a maximum of $2000 per year, while maxillofacial prosthetics, implant services, and orthodontics are not covered.
Home Infusion bundled Services See details
Home Infusion bundled Services are covered, including Medicare Part B Insulin Drugs with a $35 copay. Medicare Part B Chemotherapy/Radiation Drugs and Other Medicare Part B Drugs have a coinsurance between 0% and 20%.
Dialysis Services See details
Dialysis Services are covered under the Wellcare Premium Enhanced (PFFS) plan. The coinsurance for these services is 20%.
Medical Equipment See details
Medical Equipment is covered by the Wellcare Premium Enhanced (PFFS) plan, including Durable Medical Equipment (DME), Prosthetics/Medical Supplies, and Diabetic Equipment. DME has a 20% coinsurance, and Durable Medical Equipment for use outside the home is not covered. Prosthetics/Medical Supplies has a 20% coinsurance, and Diabetic Supplies have no copay, while Diabetic Therapeutic Shoes/Inserts have a 20% coinsurance.
Diagnostic and Radiological Services See details
Diagnostic and Radiological Services are covered, including diagnostic procedures and tests with no copay, and lab services with no copay. Outpatient X-ray services have no copay, while diagnostic radiological services have a copay of at most $300, and therapeutic radiological services have a coinsurance of at least 20%.
Home Health Services See details
Home Health Services are covered by the Wellcare Premium Enhanced (PFFS) plan with no copay and no coinsurance. Additional Hours of Care and Personal Care Services are not covered.
Cardiac Rehabilitation Services See details
Cardiac Rehabilitation Services are covered, but the plan does not cover Medicare-covered Intensive Cardiac Rehabilitation Services, Medicare-covered Pulmonary Rehabilitation Services, Medicare-covered Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD) Services, or Additional Cardiac Rehabilitation Services. There is a copay for some services, but the exact amount is not specified.
Skilled Nursing Facility (SNF) See details
Skilled Nursing Facility (SNF) services are covered by the Wellcare Premium Enhanced (PFFS) plan, with no copay for days 1-20 and days 41-100, and a $203 copay for days 21-40. Additional days beyond Medicare-covered for SNF and non-Medicare-covered SNF stays are not covered.
Other Services See details
Other Services includes a meal benefit with no copay, while acupuncture, over-the-counter items, and dual eligible SNPs with highly integrated services are not covered.
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