2019 Summary of Benefits · 3/2/2019 · 2019 Summary of Benefits January 1, 2019 – December 31,...
Transcript of 2019 Summary of Benefits · 3/2/2019 · 2019 Summary of Benefits January 1, 2019 – December 31,...
2019 Summary of Benefits Medicare Advantage Plans
Texas
Bexar, El Paso
H0174 | Plan 003
WellCare TexanPlus Classic (HMO)
H0174_WCM_16320E_M ©WellCare 2018 TX9UXRSOB16320E_0003
2019
Sum
mar
y of B
enef
itsJa
nuar
y 1, 2
019
– D
ecem
ber 3
1, 2
019
All
Wel
lCar
e Tex
anPl
us C
lass
ic (H
MO
) mem
bers
can
be su
re o
f on
e thi
ng: T
he q
ualit
y of
thei
r hea
lthca
re is
our
top
prio
rity.
Thi
s is
a sum
mar
y of d
rug
and
healt
h se
rvice
s tha
t are
cove
red
by W
ellC
are
Tex
anPl
us C
lass
ic (H
MO
). T
his b
ookl
et w
ill g
ive y
ou a
brie
f ove
rvie
w of
wha
t we c
over
and
what
m
embe
rs ca
n ex
pect
to p
ay, b
ut d
oes n
ot li
st ev
ery b
enef
it, li
mita
tion
or
exclu
sion.
To
rece
ive a
com
plet
e list
of w
hat t
he p
lan co
vers
, call
C
usto
mer
Ser
vice
and
ask
for t
he p
lan's
"Evi
denc
e of C
over
age"
or
view
a co
py o
n ou
r web
site a
t www
.wel
lcar
e.co
m/m
edic
are.
Li
ke al
l Med
icare
hea
lth p
lans,
our p
lans a
lso co
ver e
very
thin
g th
at
Orig
inal
Med
icare
cove
rs w
ith ad
ditio
nal b
enef
its to
supp
ort y
our
well-
bein
g. T
his i
nclu
des o
ur N
urse
Adv
ice L
ine w
hose
on-
call
nurse
s ar
e ava
ilabl
e 24-
hour
s a d
ay to
answ
er q
uesti
ons a
bout
you
r hea
lth
care
nee
ds.
You
can
com
pare
the c
over
age a
nd co
sts in
this
book
let w
ith th
e co
vera
ge an
d co
sts o
ffere
d by
Orig
inal
Med
icare
by
look
ing
in y
our
curre
nt "M
edica
re &
You
" han
dboo
k. Y
ou ca
n vi
ew it
onl
ine a
t ht
tp://
www.
med
icar
e.go
v or
get
a co
py b
y ca
lling
1-
800-
ME
DIC
AR
E (1
-800
-633
-422
7), 2
4 ho
urs a
day
, 7 d
ays a
we
ek. T
TY
user
s sho
uld
call
1-87
7-48
6-20
48.
Whi
ch d
octo
rs, h
ospi
tals
and
phar
mac
ies c
an I
use?
W
ellC
are T
exan
Plus
Cla
ssic
(HM
O) h
as a
netw
ork
of d
octo
rs,
hosp
itals,
pha
rmac
ies a
nd o
ther
pro
vide
rs. Y
ou ca
n sa
ve m
oney
by
us
ing p
rovi
ders
in th
e plan
's ne
twor
k. E
xcep
t in
emer
genc
y situ
atio
ns,
if yo
u us
e pro
vide
rs th
at ar
e not
in o
ur n
etwo
rk, t
he p
lan m
ay n
ot p
ay
for t
hese
serv
ices.
How
will
I de
term
ine m
y dru
g co
sts?
If
your
plan
offe
rs a
drug
ben
efit,
you
will
gen
erall
y ha
ve to
use
one
of
our
net
work
pha
rmac
ies to
fill
your
pre
scrip
tions
cove
red
by P
art D
. Yo
u wi
ll ne
ed to
use
our
plan
's fo
rmul
ary
(list
of co
vere
d dr
ugs)
to
loca
te w
hat t
ier y
our d
rug
is on
to d
eter
min
e how
muc
h it
will
cost
yo
u. E
ach
med
icatio
n wi
ll be
gro
uped
into
one
of t
he fi
ve “t
iers
.” T
he
amou
nt y
ou p
ay d
epen
ds o
n th
e dru
g’s ti
er an
d wh
at st
age o
f the
be
nefit
you
have
reac
hed.
Lat
er in
this
docu
men
t we d
iscus
s the
dru
g
bene
fit st
ages
that
occ
ur, i
f app
licab
le: D
educ
tible,
Initi
al C
over
age,
C
over
age G
ap, a
nd C
atas
troph
ic C
over
age.
You
can
see o
ur p
lan's
prov
ider
and
phar
mac
y di
rect
ory
and
our
com
plet
e plan
form
ular
y (li
st of
Par
t D p
resc
riptio
n dr
ugs)
at o
ur
webs
ite: w
ww.w
ellc
are.
com
/med
icar
e. O
r call
us a
nd w
e'll s
end
you
a c
opy.
We’r
e her
e with
our
mem
bers
ever
y ste
p of
the w
ay.
Who
can
join
? T
o jo
in W
ellC
are T
exan
Plus
Cla
ssic
(HM
O),
you
mus
t be e
ntitl
ed
to M
edica
re P
art A
, enr
olled
in M
edica
re P
art B
and
live i
n ou
r ser
vice
area
. Our
serv
ice ar
ea in
clude
s the
follo
wing
coun
ties i
n T
X: B
exar
, E
l Pas
o.
Thi
s doc
umen
t is a
vaila
ble i
n lan
guag
es o
ther
than
Eng
lish.
For
ad
ditio
nal i
nfor
mat
ion,
call
us at
1-8
77-3
74-4
056,
(TT
Y 71
1).
Thi
s boo
klet
is al
so av
ailab
le in
diff
eren
t for
mat
s, in
cludi
ng B
raill
e,
large
prin
t and
audi
o co
mpa
ct d
isc (C
D).
1
2
Sum
mar
y of B
enef
its
Janu
ary 1
, 201
9– D
ecem
ber 3
1, 2
019
Wel
lCar
e Tex
anPl
us C
lass
ic (H
MO
)
PL
AN
BA
SIC
S $0
.00
Mon
thly
Pla
n Pr
emiu
m
Wha
t You
Sho
uld
Kno
w:
You
mus
t con
tinue
to p
ay y
our M
edica
re P
art B
pre
miu
m.
$0.0
0 Pa
rt B
Pre
miu
m R
educ
tion
Wha
t You
Sho
uld
Kno
w:
Thi
s plan
doe
s not
offe
r a P
art B
Pre
miu
m R
educ
tion.
$0
.00
Ann
ual M
edic
al D
educ
tible
W
hat Y
ou S
houl
d K
now:
T
his p
lan d
oes n
ot h
ave a
n A
nnua
l Med
ical D
educ
tible.
Se
e Pre
scrip
tion
Dru
g Be
nefit
s belo
w fo
r Par
t D P
resc
riptio
n D
rug
D
educ
tible
. $5
,000
annu
ally
Max
imum
Out
-of-
Pock
et R
espo
nsib
ility
(doe
s not
inclu
de p
resc
riptio
n
drug
s) W
hat Y
ou S
houl
d K
now:
O
ur p
lan p
rote
cts y
ou b
y ha
ving
yea
rly li
mits
on
your
out
-of-
pock
et co
sts
for m
edica
l and
hos
pita
l car
e. T
his i
s the
mos
t you
pay
for c
o-pa
ys, c
oins
uran
ce an
d ot
her c
osts
for
in-n
etwo
rk h
ospi
tal a
nd m
edica
l ser
vice
s.
3
Wel
lCar
e Tex
anPl
us C
lass
ic (H
MO
)
C
OVE
RE
D M
ED
ICA
L A
ND
HO
SPIT
AL
BEN
EFI
TS
1 S
ervi
ces m
ay re
quire
prio
r aut
horiz
atio
n 2 S
ervi
ces m
ay re
quire
a re
ferra
l fro
m y
our d
octo
r $1
50 co
-pay
per
day
for D
ays 1
-10
$0 co
-pay
per
day
for D
ays 1
1-90
N
o ad
ditio
nal h
ospi
tal d
ays.
Inpa
tient
Hos
pita
l Cov
erag
e1
2
O
utpa
tient
Hos
pita
l Cov
erag
e, S
urge
ry, a
nd S
ervi
ces
12
$100
Co-
pay
Am
bulat
ory
Surg
ical C
ente
r $1
75 C
o-pa
y fo
r non
-sur
gica
l ser
vice
s O
utpa
tient
Hos
pita
l $2
00 C
o-pa
y fo
r sur
gica
l ser
vice
s W
hat Y
ou S
houl
d K
now:
C
over
ed se
rvice
s inc
lude
surg
ery,
hea
rt ca
thet
eriz
atio
ns, o
ncol
ogy
relat
ed
serv
ices,
resp
irato
ry se
rvice
s, wo
und
care
, inf
usio
n th
erap
ies a
nd o
ther
th
erap
eutic
pro
cedu
res d
one i
n an
out
patie
nt se
tting
.
4
Wel
lCar
e Tex
anPl
us C
lass
ic (H
MO
)
D
octo
r Visi
ts1
2
$0 C
o-pa
y Pr
imar
y C
are P
hysic
ian
$35
Co-
pay
Spec
ialis
t $0
Co-
pay f
or ea
ch in
-net
work
visit
to o
ther
hea
lth ca
re p
rofe
ssio
nals,
such
as
a Ph
ysici
an’s
Ass
istan
t or N
urse
Pra
ctiti
oner
, in
a PC
P of
fice f
or
Med
icare
-cov
ered
serv
ices.
Oth
er H
ealth
Car
e Pro
fess
iona
ls
$35
Co-
pay
for e
ach
in-n
etwo
rk vi
sit to
oth
er h
ealth
care
pro
fess
iona
ls,
such
as a
Phys
ician
’s A
ssist
ant o
r Nur
se P
ract
ition
er, i
n a S
pecia
list’s
offi
ce
for M
edica
re-c
over
ed se
rvice
s. $3
0 C
o-pa
y fo
r eac
h in
-net
work
visit
to o
ther
hea
lth ca
re p
rofe
ssio
nals
in
a clin
ic or
pha
rmac
y se
tting
for M
edica
re-c
over
ed se
rvice
s. W
hat Y
ou S
houl
d K
now:
Yo
ur p
rimar
y ca
re p
hysic
ian
is th
e doc
tor w
ho w
ill h
andl
e mos
t of y
our
healt
h ca
re se
rvice
s. T
hey
will
refe
r you
to sp
ecia
lists
when
nee
ded.
5
Wel
lCar
e Tex
anPl
us C
lass
ic (H
MO
)
$0 C
o-pa
y Pr
even
tive C
are
A
bdom
inal
aorti
c ane
urys
m sc
reen
ing;
Alco
hol m
isuse
coun
selin
g; B
one
mas
s mea
sure
men
t; Br
east
canc
er sc
reen
ing (
mam
mog
ram
); C
ardi
ovas
cular
di
seas
e (be
havio
ral t
hera
py);
Car
diov
ascu
lar sc
reen
ings
; Cer
vical
and
vagi
nal
canc
er sc
reen
ing;
Col
orec
tal c
ance
r scr
eeni
ngs (
colo
nosc
opy,
feca
l occ
ult
bloo
d te
st, fl
exib
le sig
moi
dosc
opy)
; Dep
ress
ion
scre
enin
g; D
iabe
tes
scre
enin
gs; H
IV sc
reen
ing;
Med
ical n
utrit
ion
ther
apy
serv
ices;
Obe
sity
sc
reen
ing
and
coun
selin
g; P
rosta
te ca
ncer
scre
enin
gs (P
SA);
Sexu
ally
tra
nsm
itted
infe
ctio
ns sc
reen
ing
and
coun
selin
g; T
obac
co u
se ce
ssat
ion
co
unse
ling
(cou
nseli
ng fo
r peo
ple w
ith n
o sig
n of
toba
cco-
relat
ed d
iseas
e);
Vac
cines
, inc
ludi
ng F
lu sh
ots,
Hep
atiti
s B sh
ots,
Pneu
moc
occa
l sho
ts;
"Welc
ome t
o M
edica
re" p
reve
ntiv
e visi
t (on
e-tim
e); A
nnua
l Well
ness
visit
.
Wha
t You
Sho
uld
Kno
w:
Dur
ing
a col
onos
copy
that
is b
eing
com
plet
ed as
a pr
even
tive s
cree
ning
, ab
norm
al tis
sue a
nd/o
r pol
yp re
mov
al wi
ll be
cove
red
at a
$0 co
-pay
men
t. A
ny ad
ditio
nal p
reve
ntive
serv
ices a
ppro
ved
by M
edica
re d
urin
g the
cont
ract
ye
ar w
ill b
e cov
ered
.
Em
erge
ncy C
are
$90
Co-
pay
Em
erge
ncy
Visi
t W
hat Y
ou S
houl
d K
now:
If
you
are a
dmitt
ed to
the h
ospi
tal w
ithin
24
hour
s, yo
u do
not
hav
e to
pay
your
shar
e of t
he co
st fo
r em
erge
ncy
serv
ices.
6
Wel
lCar
e Tex
anPl
us C
lass
ic (H
MO
)
$30
Co-
pay
Urg
ently
Nee
ded
Serv
ices
W
hat Y
ou S
houl
d K
now:
If
you
are a
dmitt
ed to
the h
ospi
tal w
ithin
24
hour
s, yo
u do
not
hav
e to
pay
your
shar
e of t
he co
st fo
r urg
ently
nee
ded
serv
ices.
D
iagn
ostic
Ser
vice
s/La
bs/ I
mag
ing
12
$75
Co-
pay
when
per
form
ed at
a sp
ecia
list's
offi
ce o
r fre
e sta
ndin
g fa
cility
D
iagn
ostic
Rad
iolo
gy (M
RIs
, CT
Sca
ns)
$175
Co-
pay
when
serv
ices a
re p
erfo
rmed
in an
out
patie
nt se
tting
$3
0 C
o-pa
y fo
r bas
ic di
agno
stic t
ests
and
proc
edur
es
Dia
gnos
tic T
ests
and
Proc
edur
es
$100
Co-
pay f
or ad
vanc
ed d
iagn
ostic
tests
and
proc
edur
es su
ch as
a ca
rdia
c str
ess t
est
$0 C
o-pa
y La
b Se
rvice
s (M
edica
re ap
prov
ed la
b wo
rk)
$0 C
o-pa
y O
utpa
tient
X-R
ays
$35
Co-
pay w
hen
perfo
rmed
at a
Spec
ialis
t’s o
ffice
or f
ree-
stand
ing
facil
ity
and
20%
of t
he co
st wh
en p
erfo
rmed
in an
out
patie
nt se
tting
T
hera
peut
ic R
adio
logy
Ser
vice
s (e.g
., ra
diat
ion
treat
men
t for
canc
er)
20%
of t
he co
st R
elate
d M
edica
l Sup
plie
s
Hea
ring
Serv
ices
12
H
earin
g E
xam
$3
5 C
o-pa
y M
edica
re C
over
ed
$0 C
o-pa
y R
outin
e Hea
ring
Exa
m
1
Eve
ry ye
ar
7
Wel
lCar
e Tex
anPl
us C
lass
ic (H
MO
)
Ann
ual H
earin
g A
id A
llowa
nce
Thi
s ben
efit
cove
rs $3
50 p
er ea
r eve
ry ye
ar, c
over
ing 2
ears
with
a m
axim
um
of $
700
towa
rds t
he p
urch
ase o
f 2 h
earin
g ai
ds.
$0 C
o-pa
y H
earin
g A
id F
ittin
gs/E
valu
atio
n
1 E
very
year
W
hat Y
ou S
houl
d K
now:
M
edica
re co
vers
dia
gnos
tic h
earin
g an
d ba
lance
exam
s if y
our d
octo
r or
othe
r hea
lthca
re p
rovi
der o
rder
s the
se te
sts to
see i
f you
nee
d m
edica
l tre
atm
ent.
Dia
gnos
tic h
earin
g an
d ba
lance
evalu
atio
ns p
erfo
rmed
by
your
pro
vide
r to
de
term
ine i
f you
nee
d m
edica
l tre
atm
ent a
re co
vere
d as
outp
atien
t car
e whe
n
furn
ished
by
a phy
sicia
n, au
diol
ogist
, or o
ther
qua
lifie
d pr
ovid
er.
Thi
s plan
cove
rs 1
rout
ine h
earin
g sc
reen
ing
per y
ear.
The
hea
ring
bene
fit o
n th
is pl
an in
clude
s a ro
utin
e hea
ring
exam
. In
ad
ditio
n, o
ur p
lan p
ays u
p to
$70
0 ev
ery
year
towa
rds t
he p
urch
ase
of 2
hea
ring
aids
($35
0 pe
r ear
).
8
Wel
lCar
e Tex
anPl
us C
lass
ic (H
MO
)
You
pay
noth
ing
for t
he fo
llowi
ng p
reve
ntiv
e den
tal s
ervi
ces:
Den
tal S
ervi
ces
12
Clea
ning
(for
up
to 1
ever
y six
mon
ths)
Den
tal x
-ray
(s) (f
or u
p to
1 ev
ery
12 to
36
mon
ths)
Ora
l exa
m (f
or u
p to
1 ev
ery
six m
onth
s) Fl
uorid
e tre
atm
ent (
for u
p to
1 ev
ery
year
) O
ur p
lan p
ays u
p to
$50
0 ev
ery
year
for m
ost d
enta
l ser
vice
s. A
dditi
onal
co
mpr
ehen
sive d
enta
l ser
vice
s you
will
pay
not
hing
for i
nclu
de o
ne
perio
dont
ics p
roce
dure
ever
y 6
to 3
6 m
onth
s or o
ne ex
tract
ion
per y
ear a
s we
ll as
1 o
ral m
axill
ofac
ial p
roce
dure
ever
y 60
mon
ths.
The
den
tal b
enef
its o
n th
is pl
an in
clude
cove
rage
of p
reve
ntiv
e and
co
mpr
ehen
sive s
ervi
ces u
p to
$50
0, in
cludi
ng b
ut n
ot li
mite
d to
clea
ning
s,
x-ra
y(s),
ora
l exa
ms,
fluor
ide t
reat
men
t and
filli
ngs.
Vi
sion
Serv
ices
12
E
ye E
xam
s $0
for M
edica
re-c
over
ed d
iabe
tes r
etin
opat
hy sc
reen
ing
and
a $35
Co-
pay
for a
ll ot
her M
edica
re-c
over
ed ey
e exa
ms
Med
icare
Cov
ered
$0 C
o-pa
y R
outin
e Eye
Exa
ms (
1 ev
ery
year
)
Eye
wear
$0
Co-
pay
Med
icare
Cov
ered
T
he vi
sion
bene
fit o
n th
is pl
an in
clude
s a ro
utin
e eye
exam
. In
addi
tion,
ou
r plan
pay
s up
to $
100
ever
y ye
ar fo
r up
to 1
pai
r of c
onta
ct le
nses
, ey
eglas
ses (
fram
es an
d len
ses),
eyeg
lass f
ram
es o
r eye
glas
s len
ses.
Con
tact
Len
ses,
Eye
Glas
s Fra
mes
and
Lens
es, E
ye G
lass L
ense
s, E
ye
Glas
s Fra
mes
Wha
t You
Sho
uld
Kno
w:
Yo
u pa
y no
thin
g fo
r Med
icare
-cov
ered
Glau
com
a scr
eeni
ngs.
The
se
scre
enin
gs ar
e im
porta
nt fo
r ear
ly d
etec
tion
and
prev
entio
n of
Glau
com
a. Yo
u pa
y no
thin
g fo
r eye
glas
ses o
r con
tact
lens
es af
ter c
atar
act s
urge
ry.
9
Wel
lCar
e Tex
anPl
us C
lass
ic (H
MO
)
M
enta
l Hea
lth S
ervi
ces
12
$237
co-p
ay p
er d
ay fo
r Day
s 1-7
$0
co-p
ay p
er d
ay fo
r Day
s 8-9
0 In
patie
nt H
ospi
tal V
isit
$20
Co-
pay
Out
patie
nt In
divi
dual
The
rapy
$2
0 C
o-pa
y O
utpa
tient
Gro
up T
hera
py
$55
Co-
pay
Parti
al H
ospi
taliz
atio
n $0
co-p
ay p
er d
ay fo
r Day
s 1-2
0 $1
72.0
0 co
-pay
per
day
for D
ays 2
1-10
0 Sk
illed
Nur
sing
Faci
lity (
SNF)
12
Wha
t You
Sho
uld
Kno
w:
Our
plan
cove
rs u
p to
100
day
s per
ben
efit
perio
d in
a SN
F. A
Ben
efit
Pe
riod
begi
ns th
e firs
t day
you
go in
to a
facil
ity (a
cute
inpa
tient
, lon
g te
rm
care
acut
e or S
NF)
and
ends
whe
n yo
u ha
ven’
t rec
eived
any i
npat
ient f
acili
ty
care
for 6
0 co
nsec
utiv
e day
s. T
here
is n
o lim
it to
the n
umbe
r of b
enef
it
perio
ds y
ou m
ay h
ave.
Ph
ysic
al T
hera
py1
2
$35
Co-
pay
Occ
upat
iona
l The
rapy
Visi
t $1
0 C
o-pa
y Ph
ysica
l, Sp
eech
, Lan
guag
e The
rapy
$2
50 C
o-pa
y A
mbu
lanc
e1
Wha
t You
Sho
uld
Kno
w:
The
cost
shar
e is n
ot w
aive
d if
you
are a
dmitt
ed fo
r inp
atie
nt h
ospi
tal c
are.
10
Wel
lCar
e Tex
anPl
us C
lass
ic (H
MO
)
$0 C
o-pa
y fo
r 24
One
-way
trip
s eve
ry ye
ar
Tra
nspo
rtat
ion
1
Wha
t You
Sho
uld
Kno
w:
The
firs
t ste
p to
stay
ing
healt
hy is
get
ting
to y
our d
octo
r. T
hat’s
why
we
cove
r the
se sh
ared
trip
s to
plan
appr
oved
hea
lth ca
re p
rovi
ders
. We w
ant
to m
ake s
ure y
ou g
et th
e car
e you
nee
d, w
hen
you
need
it. C
all C
usto
mer
Se
rvice
72
hour
s in
adva
nce t
o re
serv
e a ri
de fo
r you
r app
oint
men
t.
Med
icar
e Par
t B D
rugs
1
20%
of t
he co
st C
hem
othe
rapy
dru
gs
10%
of t
he co
st O
ther
Par
t B d
rugs
11
Wel
lCar
e Tex
anPl
us C
lass
ic (H
MO
) PR
ESC
RIP
TIO
N D
RU
G B
EN
EFI
TS
$250
per
yea
r on
Tie
rs 2
to 5
Pa
rt D
Ded
uctib
le
Afte
r you
pay
your
ded
uctib
le, Y
ou p
ay th
ese c
o-pa
ys o
r coi
nsur
ance
amou
nts u
ntil
your
tota
l yea
rly d
rug
cost
reac
hes $
3,82
0.
Tot
al ye
arly
dru
g co
sts ar
e the
tota
l dru
g co
sts p
aid
by b
oth
you
and
our P
art D
plan
. In
itial
Cov
erag
e Sta
ge
Thr
ee-M
onth
O
ne-M
onth
St
anda
rd R
etai
l and
M
ail C
ost-
Shar
e (In
N
etwo
rk)
$0.0
0 $0
.00
Tie
r 1: P
refe
rred
G
ener
ic D
rugs
$1
2.50
$5
.00
Tie
r 2: G
ener
ic D
rugs
$87.
50
$35.
00
Tier
3: P
refe
rred
Bran
d
Dru
gs
$187
.50
$75.
00
Tie
r 4: N
on-P
refe
rred
D
rugs
Not
Ava
ilabl
e 28
%
Tie
r 5: S
pecia
lty T
ier
Dru
gs
Wha
t You
Sho
uld
Kno
w:
You
may
get
you
r dru
gs at
net
work
reta
il ph
arm
acie
s and
mai
l ord
er p
harm
acie
s. If
you
resid
e in
a lon
g-te
rm ca
re fa
cility
, yo
u pa
y the
sam
e as a
t a re
tail
phar
mac
y. Yo
u m
ay ge
t dru
gs fr
om an
out-
of-n
etwo
rk p
harm
acy a
t the
sam
e cos
t as a
n in
-net
work
Stan
dard
Ret
ail a
nd
Mai
l con
t'd
phar
mac
y. Y
ou w
ill b
e rei
mbu
rsed
up
to th
e plan
’s co
st of
the d
rug
min
us th
e co-
pay
or co
-insu
ranc
e for
dru
gs p
urch
ased
ou
t-of
-net
work
unt
il to
tal y
early
dru
g co
sts re
ach
$3,8
20. Y
ou w
ill li
kely
hav
e to
pay t
he p
harm
acy’s
full
char
ge fo
r the
dru
gs
and
subm
it do
cum
enta
tion
to re
ceiv
e rei
mbu
rsem
ent.
Cos
t-sh
arin
g m
ay ch
ange
dep
endi
ng o
n th
e pha
rmac
y yo
u us
e and
wh
en yo
u m
ove f
rom
one
pha
se o
f the
Par
t D b
enef
it to
anot
her,
your
cost-
shar
ing
may
chan
ge as
well
. For
mor
e inf
orm
atio
n
on th
e add
ition
al ph
arm
acy s
pecif
ic co
st-sh
arin
g and
the p
hase
s of t
he b
enef
it, p
lease
call
us o
r acc
ess o
ur E
vide
nce o
f Cov
erag
e on
line.
12
Wel
lCar
e Tex
anPl
us C
lass
ic (H
MO
)
Thr
ee-M
onth
O
ne-M
onth
Pr
efer
red
Mai
l C
ost-
Shar
e (In
N
etwo
rk)
$0.0
0 $0
.00
Tie
r 1: P
refe
rred
G
ener
ic D
rugs
$0
.00
$5.0
0 T
ier 2
: Gen
eric
Dru
gs
$70.
00
$35.
00
Tier
3: P
refe
rred
Bran
d
Dru
gs
$150
.00
$75.
00
Tie
r 4: N
on-P
refe
rred
D
rugs
Not
Ava
ilabl
e 28
%
Tie
r 5: S
pecia
lty T
ier
Dru
gs
Wha
t You
Sho
uld
Kno
w:
90-d
ay su
pply
of T
ier 1
and
Tie
r 2 p
resc
riptio
n dr
ugs f
or a
$0 co
-pay
; 90-
day
supp
ly o
f Tie
r 3 an
d T
ier 4
pre
scrip
tion
drug
s fo
r two
30-
day c
o-pa
ys. A
vaila
ble o
nly f
rom
a pr
efer
red
mai
l ser
vice
pha
rmac
y and
fille
d du
ring
the i
nitia
l cov
erag
e sta
ge. S
ee
the F
orm
ular
y an
d E
vide
nce o
f Cov
erag
e (E
OC
) for
avai
labili
ty an
d co
-pay
s.
Pref
erre
d M
ail c
ont'd
Afte
r you
ente
r the
cove
rage
gap
, you
pay
25%
of t
he p
lan’s
cost
for c
over
ed b
rand
nam
e dru
gs an
d 37
% o
f the
plan
’s co
st fo
r co
vere
d ge
neric
dru
gs u
ntil
your
out
-of-
pock
et co
sts to
tal $
5,10
0, w
hich
is th
e end
of t
he co
vera
ge g
ap. N
ot ev
eryo
ne w
ill
ente
r the
cove
rage
gap
.
Cov
erag
e Gap
Sta
ge
Afte
r you
r yea
rly o
ut-o
f-po
cket
dru
g co
sts (i
nclu
ding
dru
gs p
urch
ased
thro
ugh
your
reta
il ph
arm
acy a
nd th
roug
h m
ail o
rder
) re
ach
$5,
100,
you
pay
the g
reat
er o
f: C
atas
trop
hic C
over
age
5% o
f the
cost;
or
$3.4
0 co
-pay
for g
ener
ics (i
nclu
ding
bra
nd d
rugs
trea
ted
as g
ener
ic) o
r $8
.50
co-p
aym
ent f
or al
l oth
er d
rugs
.
13
Wel
lCar
e Tex
anPl
us C
lass
ic (H
MO
)
A
dditi
onal
Cov
ered
Ben
efits
$9
0 C
o-pa
y W
orld
wide
Cov
erag
e (fo
r Em
erge
ncy a
nd U
rgen
t Car
e)
Wha
t You
Sho
uld
Kno
w:
Wor
ldwi
de C
over
age i
s sub
ject t
o a $2
5,00
0 max
imum
plan
cove
rage
. The
re
is no
cove
rage
for m
edica
tion
purc
hase
s whi
le ou
tside
of t
he U
nite
d St
ates
.
Reh
abili
tatio
n Se
rvic
es1
2
$35
Co-
pay
Car
diac
(Hea
rt) R
ehab
ilita
tion
Serv
ices
$30
Co-
pay
Pulm
onar
y R
ehab
ilita
tion
Fo
ot C
are (
Podi
atry
Ser
vice
s)1
2
$35
Co-
pay
Med
icare
Cov
ered
Med
ical
Equ
ipm
ent/
Supp
lies
1
20%
of t
he co
st D
urab
le M
edica
l Equ
ipm
ent (
e.g.,
whee
lchai
rs, o
xyge
n)
20%
of t
he co
st Pr
osth
etics
(e.g
., b
race
s, ar
tifici
al lim
bs)
$0 C
o-pa
y D
iabe
tes M
onito
ring
Supp
lies
20%
of t
he co
st D
iabe
tic T
hera
peut
ic Sh
oes o
r Ins
erts
$0 C
o-pa
y D
iabe
tic S
elf-M
anag
emen
t Tra
inin
g W
hat Y
ou S
houl
d K
now:
C
over
ed d
iabe
tes s
uppl
ies i
nclu
de: b
lood
glu
cose
mon
itor,
bloo
d gl
ucos
e te
st str
ips,
lance
t dev
ices a
nd la
ncet
s, an
d gl
ucos
e-co
ntro
l sol
utio
ns.
14
Wel
lCar
e Tex
anPl
us C
lass
ic (H
MO
)
W
elln
ess P
rogr
ams
$0 C
o-pa
y Fi
tnes
s $0
Co-
pay
Add
ition
al R
outin
e Ann
ual P
hysic
al $0
Co-
pay
24-H
our N
urse
Adv
ice L
ine
$0 C
o-pa
y E
nhan
ced
Dise
ase M
anag
emen
t W
hat Y
ou S
houl
d K
now:
The
ben
efit
on th
is pl
an co
vers
an an
nual
mem
bers
hip
at a
parti
cipat
ing
he
alth
club
or fi
tnes
s cen
ter.
For m
embe
rs w
ho d
o no
t liv
e nea
r a
parti
cipat
ing
fitne
ss ce
nter
and/
or p
refe
r to
exer
cise a
t hom
e, m
embe
rs ca
n
choo
se fr
om av
ailab
le ex
ercis
e pro
gram
s to
be sh
ippe
d to
them
at n
o co
st.
The
Ann
ual P
hysic
al E
xam
is a
com
preh
ensiv
e phy
sical
exam
inat
ion
and
ev
aluat
ion
of th
e sta
tus o
f chr
onic
dise
ases
. It i
nvol
ves a
n ac
tual
phys
ical
exam
and
coul
d in
clude
som
e tes
ting a
nd h
ealth
hist
ory.
Well
ness
pro
gram
s ar
e a g
reat
way
to m
aint
ain
your
hea
lth. W
heth
er it
's an
extra
chec
kup
du
ring
the y
ear o
r you
just
have
a sim
ple h
ealth
que
stion
, we a
re h
ere a
s yo
ur p
artn
er in
hea
lth.
C
hiro
prac
tic C
are
12
$20
Co-
pay
Med
icare
Cov
ered
15
Wel
lCar
e Tex
anPl
us C
lass
ic (H
MO
)
$0 C
o-pa
y H
ome H
ealth
Car
e1
2
Wha
t You
Sho
uld
Kno
w:
Cov
ered
serv
ices i
nclu
de p
art-
time o
r int
erm
itten
t Ski
lled
Nur
sing
and
ho
me h
ealth
-aid
e ser
vice
s inc
ludi
ng p
hysic
al th
erap
y, oc
cupa
tiona
l the
rapy
, an
d sp
eech
ther
apy,
med
ical a
nd so
cial s
ervi
ces,
med
ical e
quip
men
t &
supp
lies.
Wha
t You
Sho
uld
Kno
w:
Hos
pice
Yo
u pa
y no
thin
g fo
r hos
pice
care
from
a M
edica
re-c
ertif
ied
hosp
ice. Y
ou
may
hav
e to p
ay p
art o
f the
cost
for d
rugs
and
resp
ite ca
re. H
ospi
ce is
cove
red
ou
tside
of o
ur p
lan. P
lease
cont
act u
s for
mor
e det
ails.
Out
patie
nt S
ubst
ance
Abu
se1
2
20%
of t
he co
st In
divi
dual
The
rapy
20
% o
f the
cost
Gro
up T
hera
py
20%
of t
he co
st R
enal
Dia
lysis
12
Our
plan
will
pay
up
to $
40 ev
ery q
uart
er fo
r the
pur
chas
e of c
over
ed
over
-the
-cou
nter
item
s. O
ver-
The
-Cou
nter
(OT
C) H
ealth
Item
s
Plea
se vi
sit o
ur w
ebsit
e to
see o
ur li
st of
cove
red
over
-the
-cou
nter
item
s.
Mea
ls1
2
$0 C
o-pa
y for
pos
t-ac
ute m
eals
imm
ediat
ely fo
llowi
ng an
Inpa
tient
hos
pita
l sta
y to
aid in
reco
very
with
a m
ax o
f 10
mea
ls wi
thin
14
day b
enef
it du
ratio
n.
Post-
Acu
te M
eals
$0 C
o-pa
y fo
r chr
onic
mea
ls as
par
t of a
supe
rvise
d pr
ogra
m d
esig
ned
to
trans
ition
mem
bers
with
chro
nic c
ondi
tions
with
a m
ax o
f 84
mea
ls pe
r ye
ar, b
ut n
ot li
mite
d to
num
ber o
f day
s.
Chr
onic
Mea
ls
16
Well
Car
e Hea
lth P
lans,
Inc.,
is an
HM
O, P
PO, P
DP,
PFF
S pl
an w
ith a
Med
icare
cont
ract
. Enr
ollm
ent i
n W
ellC
are T
exan
Plus
Clas
sic (H
MO
) dep
ends
on
cont
ract
rene
wal.
Thi
s inf
orm
atio
n is
not a
com
plet
e des
crip
tion
of b
enef
its. C
all 1
-866
-687
-887
8 / T
TY
711
for m
ore i
nfor
mat
ion.
Li
mita
tions
, co-
paym
ents
and
restr
ictio
ns m
ay ap
ply.
Ben
efits
, pre
miu
ms a
nd/o
r co-
paym
ents/
coin
sura
nce m
ay ch
ange
on
Janu
ary
1 of
each
yea
r. T
he
form
ular
y, p
harm
acy
netw
ork
and/
or p
rovi
der n
etwo
rk m
ay ch
ange
at an
y tim
e. Yo
u wi
ll re
ceiv
e not
ice w
hen
nece
ssar
y. Y
ou m
ust c
ontin
ue to
pay
you
r Pa
rt B
prem
ium
. Our
plan
s use
a fo
rmul
ary.
You
hav
e the
choi
ce to
sign
up
for a
utom
ated
mai
l ser
vice
deli
very
. You
can
get p
resc
riptio
n dr
ugs s
hipp
ed to
yo
ur h
ome t
hrou
gh o
ur n
etwo
rk m
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17
Multi-Language Insert Multi-language Interpreter Services
ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call 1-877-374-4056 (TTY: 711).
ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-877-374-4056 (TTY: 711).
注意:如果您使用繁體中文,您可以免費獲得語言援助服務。請致電 1-877-374-4056 (TTY: 711) 。
CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-877-374-4056 (TTY: 711).
주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-877-374-4056 (TTY: 711)번으로 전화해 주십시오.
PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-877-374-4056 (TTY: 711).
ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-877-374-4056 (телетайп: 711).
ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-877-374-4056 (TTY: 711).
Multi-Language InsertMulti-Language Interpreter Services
ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call 1-877-374-4056 (TTY: 711).
ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-877-374-4056 (TTY: 711).
WCM_14436Z Internal Approved 06132018 ©WellCare 2018 NA9WCMINS14436Z_0000
UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-877-374-4056 (TTY: 711).
ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-877-374-4056 (TTY: 711).
ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-877-374-4056 (TTY: 711).
注意事項:日本語を話される場合、無料の言語支援をご利用いただけます。1-877-374-4056 (TTY: 711) まで、お電話にてご連絡ください。
ՈՒՇԱԴՐՈՒԹՅՈՒՆ՝ Եթե խոսում եք հայերեն, ապա ձեզ անվճար կարող են տրամադրվել լեզվական աջակցության ծառայություններ: Զանգահարեք 1-877-374-4056 (TTY (հեռատիպ)՝ 711):
Multi-Language InsertMulti-Language Interpreter Services
ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call 1-877-374-4056 (TTY: 711).
ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-877-374-4056 (TTY: 711).
WCM_14436Z Internal Approved 06132018 ©WellCare 2018 NA9WCMINS14436Z_0000
ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-877-374-4056 (TTY: 711).
WCM_14436Z Internal Approved 06132018 NA7WCMINS02310E_0000 ©WellCare 2018
Discrimination is Against the Law WellCare Health Plans, Inc., complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. WellCare Health Plans does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. WellCare Health Plans, Inc.:
Provides free aids and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats)
Provides free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages
If you need these services, contact WellCare Customer Service for help or you can ask Customer Service to put you in touch with a Civil Rights Coordinator who works for WellCare. If you believe that WellCare Health Plans, Inc., has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: WellCare Health Plans, Inc. Grievance Department P.O. Box 31384 Tampa, FL 33631-3384 Telephone: 1-866-530-9491 TTY: 711 Fax: 1-866-388-1769 Email: [email protected] You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, a WellCare Civil Rights Coordinator is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue SW. Room 509F, HHH Building Washington, DC 20201 1-800-368-1019, 800-537-7697 (TDD) Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. * This Nondiscrimination Notice also applies to all subsidiaries of WellCare Health Plans, Inc.
WCM_14439E NA9WCMINS14857E_0000 ©WellCare 2018
Pre-Enrollment Checklist Before making an enrollment decision, it is important that you fully understand our benefits and rules. If you have any questions, you can call and speak to a customer service representative at 1-866-527-0056 (TTY 711).
Understanding the Benefits
Review the full list of benefits found in the Evidence of Coverage (EOC), especially for those services that you routinely see a doctor. Visit www.wellcare.com/medicare or www.ohanahealthplan.com/medicare or call 1-866-527-0056 to view a copy of the EOC.
Review the provider directory (or ask your doctor) to make sure the doctors you see now are in the network. If they are not listed, it means you will likely have to select a new doctor.
Review the pharmacy directory to make sure the pharmacy you use for any prescription medicines is in the network. If the pharmacy is not listed, you will likely have to select a new pharmacy for your prescriptions.
Understanding Important Rules
In addition to your monthly plan premium, you must continue to pay your Medicare Part B premium. This premium is normally taken out of your Social Security check each month.
Benefits, premiums and/or copayments/co-insurance may change on January 1, 2020.
Except in emergency or urgent situations, we do not cover services by out-of-network providers (doctors who are not listed in the provider directory).
Y0070_WCM_20902E_C Internal Approved 08102018 ©WellCare 2018 NA9WCMINS20902E_0000
Contact Us
For more information, please call us at the phone number below or visit us at www.wellcare.com/medicare.
Not yet a member? Please call us toll-free at 1-866-527-0056 (TTY 711). Your call may be answered by a licensed agent. Already a member? Please call us toll-free at 1-866-687-8878 (TTY 711).
Hours of Operation Between October 1 and March 31, representatives are available Monday–Sunday, 8 a.m. to 8 p.m. Between April 1 and September 30, representatives are available Monday–Friday, 8 a.m. to 8 p.m.
Formularies and Directories You can see our plan's Provider/Pharmacy Directory and our complete plan formulary (list of Part D prescription drugs) at our website: www.wellcare.com/medicare. Or, call us and we'll send you a copy. We're with our members every step of the way.