Wellcare TexanPlus Classic Simple (HMO-POS) H4506-003-000 2025 Plan Details and Costs (2025)

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 Texas Counties Served Enrolling in H4506-003-000 Medicare Advantage Plans in Texas References

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

See Also
Wellcare TexanPlus Classic No Premium (HMO) - 2024 WellcareMedicare Advantage Plans | Kelsey-Seybold ClinicWellcare TexanPlus Classic Simple (HMO-POS) - 2025 Centene Corporation

Basic Costs and Coverage

CoverageDetails
Monthly plan premium$0.00
Vision coverage
Dental coverage
Hearing coverage
Prescription drugs
Medical deductible$420.00
Out-of-pocket maximum$3,400.00
Initial drug coverage limit$0.00
Catastrophic drug coverage limit$2,000.00
Primary care doctor visitIn-Network:

Doctor Office Visit:
Copayment for Primary Care Office Visit $0

Specialty doctor visitIn-Network:

Doctor Specialty Visit:
Copayment for Physician Specialist Office Visit $15
Prior Authorization Required for Doctor Specialty Visit
Referral Required for Doctor Specialty Visit

Inpatient hospital careIn-Network:

Acute Hospital Services:
Copayment for Acute Hospital Services per Stay $325
Prior Authorization Required for Acute Hospital Services
Referral Required for Acute Hospital Services

Urgent care
Urgent Care:
Copayment for Urgent Care $25
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 transportationIn-Network:

Ground Ambulance:
Copayment for Ground Ambulance Services $250

Air Ambulance:
Copayment for Air Ambulance Services $250
Prior Authorization Required for Air Ambulance

Health Care Services and Medical Supplies

Wellcare TexanPlus Classic Simple (HMO-POS) covers a range of additional benefits. Learn more about Wellcare TexanPlus Classic Simple (HMO-POS) 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 $15
Prior Authorization Required for Chiropractic Services
Referral Required for Chiropractic Services

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

Outpatient Diag Procs/Tests/Lab Services:
Copayment for Medicare-covered Diagnostic Procedures/Tests $0 to $25
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
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. 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 $200
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $25

Home health careIn-Network:

Home Health Services:
Copayment for Medicare-covered Home Health Services $0
Prior Authorization Required for Home Health Services
Referral Required for Home Health Services

Mental health inpatient careIn-Network:

Psychiatric Hospital Services:
Copayment for Psychiatric Hospital Services per Stay $325
Prior Authorization Required for Psychiatric Hospital Services
Referral Required for Psychiatric Hospital Services

Mental health outpatient careIn-Network:

Outpatient Mental Health Services:
Copayment for Medicare-covered Individual Sessions $25
Copayment for Medicare-covered Group Sessions $25

Outpatient services/surgeryIn-Network:

Outpatient Hospital Services:
Copayment for Medicare Covered Outpatient Hospital Services $0 to $225
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 $200.

Outpatient Observation Services:
Copayment for Medicare Covered Observation Services - Per stay $140 to $225
Referral Required for Outpatient Observation Services
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 $125
Prior Authorization Required for Ambulatory Surgical Center Services
Referral Required for Ambulatory Surgical Center Services

Outpatient substance abuse careIn-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
Referral Required for Outpatient Substance Abuse Services

Over-the-counter itemsOTC allowance of $89 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 servicesIn-Network:

Podiatry Services:
Copayment for Medicare-Covered Podiatry Services $15
Prior Authorization Required for Podiatry Services
Referral Required for Podiatry Services

Skilled Nursing Facility (SNF) careIn-Network:

Skilled Nursing Facility Services:
$0 per day for days 1 to 20
$214 per day for days 21 to 60
$0 per day for days 61 to 100
Prior Authorization Required for Skilled Nursing Facility Services
Referral 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:

Medicare Covered Preventive Dental:
Copayment for Office Visit $15
Prior Authorization Required for Medicare Covered Preventive Dental

Non-Medicare Covered Preventive Dental:
Copayment for Non-medicare preventive $0
Copayment for Oral exams $0

  • Maximum 2 visits every year
Copayment for Dental x-rays $0
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Other diagnostic services $0
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Prophylaxis $0
  • Maximum 2 visits every year
Copayment for Fluoride treatment $0
  • Maximum 1 visit every year
Copayment for Other preventive services $0
  • Maximum 1 visit (Please see Evidence of Coverage for details)

Non-Medicare Covered Comprehensive Dental:
Copayment for Non-medicare comprehensive $0
Copayment for Restorative services $0
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Endodontics $0
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Periodontics $0
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Prothodontics, removable $0
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Prothodontics, fixed $0
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Maxillofacial surgery $0
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Copayment for Adjunctive general services $0
  • Maximum 1 visit (Please see Evidence of Coverage for details)
Maximum Plan Benefit of $2,000 every year
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

CoverageDetails
Vision careIn-Network:

Eye Exams:
Copayment for Medicare Covered Benefits $0 to $15
Copayment for Routine Eye Exams $0

  • Maximum 1 Routine Eye Exam every year

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.

CoverageDetails
Hearing careIn-Network:

Hearing Exams:
Copayment for Medicare Covered Benefits $15
Copayment for Routine Hearing Exams $0

  • Maximum 1 visit every year
Copayment for Fitting/Evaluation for Hearing Aid $0
  • Maximum 1 visit every year
Prior Authorization Required for Hearing Exams

Hearing Aids:
Copayment for Hearing Aids $0

  • Maximum 2 Hearing Aids every year
Maximum Plan Benefit of $750 every year per ear

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 & 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:

  • COVID-19 shots
  • Flu shots
  • Hepatitis B shots
  • Pneumococcal shots
    • Tobacco use cessation
    Yearly "Wellness" visit

    Prescription Drug Costs and Coverage

    The Wellcare TexanPlus Classic 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
    • Preferred retail $0.00
    • Standard retail $5.00
    • Preferred mail order $0.00
    • Standard mail order $5.00
    Tier 2
    • Preferred retail $0.00
    • Standard retail $10.00
    • Preferred mail order $0.00
    • Standard mail order $10.00
    Tier 6
    • Preferred retail $0.00
    • Standard retail $0.00
    • Preferred mail order $0.00
    • Standard mail order $0.00
    Annual drug deductible$420.00 (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 $0.00
    • Standard retail $20.00
    • Preferred mail order $0.00
    • 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$420.00 (excludes Tiers 1, 2, and 6)
    Tier 1
    • Preferred retail $0.00
    • Standard retail $15.00
    • Preferred mail order $0.00
    • Standard mail order $15.00
    Tier 2
    • Preferred retail $0.00
    • Standard retail $30.00
    • Preferred mail order $0.00
    • Standard mail order $30.00
    Tier 6
    • Preferred retail $0.00
    • Standard retail $0.00
    • Preferred mail order $0.00
    • Standard mail order $0.00

    When reviewing Texas 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 Texas 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

    Texas Counties Served

    • Austin
    • Brazoria
    • Chambers
    • Fort Bend
    • Galveston
    • Hardin
    • Harris
    • Jackson
    • Jefferson
    • Lavaca
    • Liberty
    • Montgomery
    • Orange
    • Walker
    • Waller
    • Washington

    Enrolling in H4506-003-000 Medicare Advantage Plans in Texas

    Medicare beneficiaries from Plano to Dallas and Fort Worth and in counties around Texas, may have access to Medicare Advantage plans from Wellcare and other insurance companies.

    Get help comparing your local plan options by calling to speak with a licensed insurance agent who can help you find out if your doctor and prescription drugs are covered by a Medicare Advantage plan in your area.

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

    Wellcare TexanPlus Classic Simple (HMO-POS) H4506-003-000 2025 Plan Details and Costs (2025)

    References

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