2018 Summary of Benefits Medicare Advantage Plans

California

Los Angeles, Orange

H5087 | Plan 005 1/1/2018–12/31/18

Easy Choice Best Plan (HMO)

H5087_WCM_02969E ©WellCare 2017 CA8RMRSOB02969E_0005

Summary of Benefits January 1, 2018– December 31, 2018

All Easy Choice Best Plan (HMO) members can be sure of one thing: the quality of their healthcare is our top priority. Like all Medicare health plans, we cover everything that Original Medicare covers. On top of that, we add some other benefits to help you stay healthy. For instance, when you have urgent health care needs, you can talk to our nurses on call. If you become a member of our plan, our Nurse Advice Line is open 24 hours every day. We’re here to help our members with every health question or concern they may have. This booklet gives you a brief overview of how we put members first. It highlights the services we cover and what you as a member can expect to pay. Please keep in mind, however, that it doesn't list every service we cover or every limitation or exclusion. To get a complete list of services we cover, give us a call and ask for this plan’s "Evidence of Coverage." You can also find a copy on our website at www.wellcare.com/medicare. You can compare the coverage and costs in this booklet with the coverage and costs offered by Original Medicare by looking in your current Medicare & You handbook. You can view it online at www.medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week. TTY users may call 1-877-486-2048. To join Easy Choice Best Plan (HMO), you must be entitled to Medicare Part A, enrolled in Medicare Part B and live in our service area. Our service area includes the following counties in California: Los Angeles, Orange. Contact information and hours

1 If you are not a member of this plan, call toll-free 1-866-999-3945 (TTY 711). We’d love to talk to you!

1 If you are a member of this plan, call toll-free 1-866-999-3945 (TTY 711). 1 From October 1 to February 14, we're here for you 7 days per week, 8 a.m. to 8 p.m. 1 From February 15 to September 30, you can call us Monday–Friday, 8 a.m. to 8 p.m. 1 Our website: www.wellcare.com/medicare

Which doctors, hospitals and pharmacies can I use? Easy Choice Best Plan (HMO) has a network of doctors, hospitals and other providers. You can save money by using providers in the plan's network. If you use providers that are not in our network, the plan may not pay for these services. We also have a network of pharmacies and you must generally use these pharmacies to fill your prescription for covered Part D drugs. 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.

Summary of Benefits | 1

This booklet is also available in different formats, including Braille, large print and audio compact disc (CD). This document may be available in a non-English language. For additional information, call us at 1-877-374-4056, (TTY 711).

Summary of Benefits | 2

Sum

ma

ry o

f Ben

efit

s Ja

nuar

y 1,

201

8– D

ecem

ber 3

1, 2

018

NO

TE

: 1

SE

RVI

CE

S W

ITH

A1 M

AY

RE

QU

IRE

PR

IOR

AU

TH

OR

IZA

TIO

N.

1

SER

VIC

ES

WIT

H A

2 MA

Y R

EQ

UIR

E A

RE

FER

RA

L FR

OM

YO

UR

DO

CT

OR

.

Thi

ngs t

o kn

ow

Eas

y Cho

ice B

est P

lan

(HM

O)

Prem

ium

s and

Ben

efits

Ove

rvie

w

You

mus

t con

tinue

to p

ay yo

ur M

edica

re

Part

B pr

emiu

m.

You

pay

$0.0

0 M

onth

ly P

lan

Prem

ium

The

ded

uctib

le is

the a

mou

nt y

ou m

ust

pay

out o

f poc

ket f

or m

edica

l ser

vice

s be

fore

our

plan

beg

ins t

o pa

y its

shar

e.

No

Ded

uctib

le D

educ

tible

$3

,400

annu

ally

Max

imum

Out

-of-

Pock

et

Res

pons

ibili

ty (d

oes n

ot in

clud

e pr

escr

iptio

n dr

ugs)

T

he m

ost y

ou p

ay fo

r co-

pays

, co

insu

ranc

e and

oth

er co

sts fo

r M

edica

re-c

over

ed P

art A

and

B se

rvice

s fo

r the

yea

r. If

you

reac

h th

is lim

it on

ou

t-of

-poc

ket c

osts,

you

kee

p ge

tting

co

vere

d fo

r hos

pita

l and

med

ical s

ervi

ces

while

we p

ay th

e ful

l cos

t for

the r

est o

f th

e yea

r. Sum

mar

y of

Ben

efits

| 3

Thi

ngs t

o kn

ow

Eas

y Cho

ice B

est P

lan

(HM

O)

If yo

u ha

ppen

to h

ave a

n in

patie

nt

hosp

ital s

tay,

talk

to o

ne o

f our

care

Fo

r inp

atie

nt ac

ute h

ospi

tal y

ou p

ay

$0 co

-pay

per

day

for D

ays 1

-90

$0 co

-pay

per

day

for D

ays 9

1-21

0

Inpa

tient

Hos

pita

l Cov

erag

e1,2

man

ager

s afte

r you

are d

ischa

rged

. Our

ca

re m

anag

ers c

an h

elp

mak

e sur

e you

st

ay h

ealth

y and

out

of t

he h

ospi

tal.

$0 co

-pay

for 1

20 ad

ditio

nal h

ospi

tal

days

.

Yo

u pa

y $2

0 co

-pay

at an

ambu

lator

y

surg

ical c

ente

r O

utpa

tient

Sur

gery

1,2

1

T

his i

nclu

des t

he fo

llowi

ng:

You

pay

$0 co

-pay

for n

on-s

urgi

cal

serv

ices a

nd $

50 co

-pay

for s

urgi

cal

serv

ices

4 A

mbu

lator

y su

rgica

l cen

ter

4 O

utpa

tient

hos

pita

l

Your

prim

ary c

are p

hysic

ian

is th

e do

ctor

who

will

han

dle m

ost o

f you

r Yo

u pa

y $0

co-p

ay fo

r eac

h pr

imar

y car

e vi

sit

Doc

tor V

isits

1,2

he

alth

care

serv

ices

. The

y will

refe

r you

to

spec

ialis

ts w

hen

need

ed.

You

pay $

0 co

-pay

for e

ach

spec

ialist

visit

1

T

his i

nclu

des v

isits

to yo

ur p

rimar

y ca

re p

hysic

ian

and

spec

ialis

ts $5

co-p

ay fo

r eac

h vi

sit to

oth

er h

ealth

ca

re p

rofe

ssio

nals

in a

clini

c or p

harm

acy

setti

ng fo

r Med

icare

-cov

ered

serv

ices.

Stay

hea

lthy b

y get

ting

your

annu

al

welln

ess v

isit.

A w

elln

ess v

isit i

s a go

od

You

pay

noth

ing

for t

he fo

llowi

ng:

Prev

entiv

e Car

e

1

1

Abd

omin

al ao

rtic a

neur

ysm

sc

reen

ing

The

se se

rvice

s are

pro

vide

d to

help

sc

reen

for a

nd p

reve

nt o

r dia

gnos

e a h

ealth

pro

blem

st

ep to

take

for y

our h

ealth

. Dur

ing t

hat

visit

, you

can

work

with

your

PC

P to

get

all y

our p

reve

ntiv

e scr

eeni

ngs a

nd ca

re.

1 A

lcoho

l misu

se co

unse

ling

1 Bo

ne m

ass m

easu

rem

ent

Sum

mar

y of

Ben

efits

| 4

Thi

ngs t

o kn

ow

Eas

y Cho

ice B

est P

lan

(HM

O)

Any

addi

tiona

l pre

vent

ive s

ervi

ces

appr

oved

by

Med

icare

dur

ing

the

cont

ract

yea

r will

be c

over

ed.

1 Br

east

canc

er sc

reen

ing

(m

amm

ogra

m)

1 C

ardi

ovas

cular

dise

ase (

beha

vior

al

ther

apy)

1

C

ardi

ovas

cular

scre

enin

gs

1 C

ervi

cal a

nd va

gina

l can

cer

scre

enin

g 1

C

olor

ecta

l can

cer s

cree

ning

s (C

olon

osco

py, F

ecal

occu

lt bl

ood

te

st, F

lexib

le sig

moi

dosc

opy)

1

D

epre

ssio

n sc

reen

ing

1 D

iabe

tes s

cree

ning

s 1

H

IV sc

reen

ing

1 M

edica

l nut

ritio

n th

erap

y se

rvice

s 1

O

besit

y sc

reen

ing

and

coun

selin

g 1

Pr

osta

te ca

ncer

scre

enin

gs (P

SA)

1 Se

xuall

y tra

nsm

itted

infe

ctio

ns

scre

enin

g an

d co

unse

ling

1 T

obac

co u

se ce

ssat

ion

coun

selin

g

(cou

nseli

ng fo

r peo

ple w

ith n

o sig

n

of to

bacc

o-re

lated

dise

ase)

1

V

accin

es, i

nclu

ding

Flu

shot

s,

Hep

atiti

s B sh

ots,

Pneu

moc

occa

l sh

ots

1 "W

elcom

e to M

edica

re" p

reve

ntiv

e vi

sit (o

ne-t

ime)

1

Ye

arly

"Well

ness

" visi

t

Sum

mar

y of

Ben

efits

| 5

Thi

ngs t

o kn

ow

Eas

y Cho

ice B

est P

lan

(HM

O)

If yo

u ar

e adm

itted

to th

e hos

pita

l with

in

24 h

ours

, you

do

not h

ave t

o pa

y yo

ur

shar

e of t

he co

st fo

r em

erge

ncy

care

.

You

pay

$80

co-p

ay p

er vi

sit

Em

erge

ncy C

are

If yo

u ar

e adm

itted

to th

e hos

pita

l with

in

24 h

ours

, you

do

not h

ave t

o pa

y yo

ur

You

pay

$5 co

-pay

per

visit

U

rgen

tly N

eede

d Se

rvic

es

shar

e of t

he co

st fo

r urg

ently

nee

ded

se

rvice

s.

Yo

u pa

y $0

co-p

ay w

hen

diag

nosti

c ra

diol

ogy

serv

ices a

re p

erfo

rmed

at a

Dia

gnos

tic S

ervi

ces/

Labs

/ Im

agin

g1,2

1

T

his i

nclu

des t

he fo

llowi

ng:

spec

ialis

t's o

ffice

or f

ree s

tand

ing

facil

ity

and

$0 co

-pay

whe

n di

agno

stic r

adio

logy

4

D

iagn

ostic

radi

olog

y se

rvice

(e

.g., M

RI,

CT sc

an)

serv

ices a

re p

erfo

rmed

in an

out

patie

nt

setti

ng

4 La

b se

rvice

s Yo

u pa

y $0

co-p

ay fo

r lab

serv

ices

4 D

iagn

ostic

tests

and

pr

oced

ures

Yo

u pa

y $0

co-p

ay fo

r bas

ic di

agno

stic

tests

and

proc

edur

es an

d $0

co-p

ay fo

r 4

O

utpa

tient

x-r

ays

4 T

hera

peut

ic ra

diol

ogy s

ervic

es

(e.g.

, rad

iatio

n tre

atm

ent f

or

canc

er)

adva

nced

diag

nosti

c tes

ts an

d pr

oced

ures

su

ch as

a ca

rdia

c stre

ss te

st Yo

u pa

y $0

co-p

ay fo

r X-r

ays

You

pay

20%

of t

he co

st fo

r the

rape

utic

ra

diol

ogy

serv

ices

Yo

u pa

y $0

for a

hea

ring

exam

to

diag

nose

and

treat

hea

ring

and

balan

ce

issue

s

Hea

ring

Serv

ices

1,2

1 T

his i

nclu

des i

nfor

mat

ion

on

cove

rage

of h

earin

g ex

ams a

nd ai

ds

Sum

mar

y of

Ben

efits

| 6

Thi

ngs t

o kn

ow

Eas

y Cho

ice B

est P

lan

(HM

O)

You

pay

$0 fo

r a ro

utin

e hea

ring

exam

(1

per

yea

r) H

earin

g ai

d co

vere

d wi

th an

annu

al

allow

ance

of $

1000

towa

rds t

he p

urch

ase

of a

hear

ing

aid

You

pay

$0 fo

r hea

ring

aid

fittin

g/

evalu

atio

ns (f

or u

p to

1 ev

ery

year

)

Yo

u pa

y no

thin

g fo

r the

follo

wing

pr

even

tive d

enta

l ser

vice

s: D

enta

l Ser

vice

s1,2

1 C

leani

ng (f

or u

p to

1 ev

ery

six

mon

ths)

): $1

0-$5

5 co

-pay

, de

pend

ing

on th

e ser

vice

1

D

enta

l x-r

ay(s)

(for

up

to 1

ever

y

12 to

36

mon

ths)

: $0-

$30

co-p

ay,

depe

ndin

g on

the s

ervi

ce

1 O

ral e

xam

(for

up

to 1

ever

y six

m

onth

s) : $

0-$4

0 co

-pay

, de

pend

ing

on th

e ser

vice

1

Fl

uorid

e tre

atm

ent (

for u

p to

1

ever

y six

mon

ths)

: $9-

$20

co-p

ay,

depe

ndin

g on

the s

ervi

ce

Our

plan

pay

s up

to $

2000

ever

y yea

r for

m

ost d

enta

l ser

vice

s. A

dditi

onal

co

mpr

ehen

sive d

enta

l ser

vice

s inc

lude

on

e of t

he fo

llowi

ng: o

ne E

ndod

ontic

pr

oced

ure p

er y

ear,

one P

erio

dont

ics

proc

edur

e eve

ry 6

to 3

6 m

onth

s or o

ne

Sum

mar

y of

Ben

efits

| 7

Thi

ngs t

o kn

ow

Eas

y Cho

ice B

est P

lan

(HM

O)

Ext

ract

ion

per y

ear.

Also

inclu

ded

is on

e Pr

osth

odon

tic p

roce

dure

ever

y 12

to 6

0

mon

ths,

one O

ral M

axill

ofac

ial pr

oced

ure

ever

y 60

mon

ths o

r oth

er se

rvice

s eve

ry

24 to

36 m

onth

s. O

ne D

iagn

ostic

serv

ice

is als

o in

clude

d as

well

as o

ne R

esto

rativ

e se

rvice

ever

y tw

o ye

ars.

Cos

t sha

res m

ay

vary

by

serv

ice.

The

den

tal b

enef

its o

n th

is pl

an in

clude

co

vera

ge fo

r a d

eep

clean

ing,

filli

ng,

dent

ures

or a

brid

ge or

a cr

own

and

a roo

t ca

nal.

You

pay n

othi

ng fo

r Med

icar

e-co

vere

d

Gla

ucom

a scr

eeni

ngs.

The

se sc

reen

ings

Yo

u pa

y $0

for M

edica

re-c

over

ed

diab

etes

retin

opat

hy sc

reen

ing

and

you

Visio

n Se

rvic

es1,

2

1

T

his i

nclu

des i

nfor

mat

ion

on

cove

rage

of v

ision

exam

s and

ey

ewea

r

are i

mpo

rtan

t for

early

det

ectio

n an

d

prev

entio

n of

Gla

ucom

a.

You

pay n

othi

ng fo

r eye

glas

ses o

r con

tact

len

ses a

fter c

atar

act s

urge

ry.

pay $

0 for

all o

ther

Med

icare

-cov

ered

eye

exam

s Yo

u pa

y $0

co-p

ay fo

r rou

tine v

ision

ex

am (1

per

yea

r) O

ur p

lan p

ays u

p to

$20

0 ev

ery

year

for

up to

1 p

air o

f con

tact

lens

es, e

yegl

asse

s (fr

ames

and

lense

s), ey

eglas

s fra

mes

or

eyeg

lass l

ense

s.

Fo

r inp

atie

nt m

enta

l hea

lth se

rvice

s you

pa

y $0

co-p

ay p

er d

ay fo

r Day

s 1-9

0 M

enta

l Hea

lth S

ervi

ces1,

2

1

T

his i

nclu

des t

he fo

llowi

ng

You

pay

$40

co-p

ay p

er o

utpa

tient

th

erap

y vi

sit

4 In

patie

nt v

isits

Sum

mar

y of

Ben

efits

| 8

Thi

ngs t

o kn

ow

Eas

y Cho

ice B

est P

lan

(HM

O)

4 O

utpa

tient

gro

up o

r in

divi

dual

ther

apy

visit

s

Our

plan

cove

rs u

p to

100 d

ays i

n a S

NF.

Yo

u pa

y no

thin

g pe

r day

for d

ays 1

th

roug

h 20

Sk

illed

Nur

sing

Faci

lity (

SNF)

1,2

$50.

00 co

-pay

per

day

for d

ays 2

1

thro

ugh

100

Yo

u pa

y $0

co-p

ay fo

r phy

sical

and

sp

eech

lang

uage

ther

apy

Phys

ical

ther

apy a

nd sp

eech

and

la

ngua

ge th

erap

y visi

t1,2

Yo

u pa

y $5

0 co

-pay

A

mbu

lanc

e1

The

firs

t ste

p to

stay

ing

heal

thy i

s ge

tting

to yo

ur d

octo

r. T

hat's

why

we

You

pay

noth

ing

for 3

2 O

ne-w

ay tr

ips

ever

y yea

r. T

hese

are s

hare

d tri

ps to

plan

T

rans

port

atio

n1

prov

ide r

ides

to p

lan

appr

oved

hea

lth

appr

oved

loca

tions

. Call

Cus

tom

er

care

pro

vide

rs. W

e wan

t to

mak

e sur

e Se

rvice

48

hour

s in

adva

nce t

o re

serv

e a

ride f

or y

our a

ppoi

ntm

ent.

you

get t

he ca

re yo

u ne

ed, w

hen

you

ne

ed it

.

Yo

u pa

y 20

% o

f the

cost

for

chem

othe

rapy

dru

gs

Med

icar

e Par

t B D

rugs

1

1

T

his i

nclu

des t

he fo

llowi

ng:

You

pay 2

0% o

f the

cost

for o

ther

Par

t B

drug

s 4

C

hem

othe

rapy

dru

gs

4 Pa

rt B

drug

s

Sum

mar

y of

Ben

efits

| 9

Eas

y C

hoice

Bes

t Plan

(HM

O)

Thi

ngs t

o kn

ow

Part

D C

ost S

hare

s Pa

rt D

Info

T

his p

lan d

oes n

ot h

ave a

ded

uctib

le Pa

rt D

ded

uctib

le

Yo

u pa

y the

follo

wing

unt

il yo

ur to

tal y

early

dru

g co

sts re

ach

$3,7

50. T

otal

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

In

itial

Cov

erag

e

plan

. You

may

get

your

dru

gs at

net

work

reta

il ph

arm

acie

s and

mai

l ser

vice

ph

arm

acie

s.

Pr

efer

red

Mai

l for

T

hree

Mon

th S

uppl

y St

anda

rd R

etai

l and

M

ail f

or T

hree

Mon

th

Supp

ly

Stan

dard

Ret

ail,

Mai

l an

d Pr

efer

red

Mai

l for

O

ne M

onth

Sup

ply

Initi

al C

over

age (

Afte

r yo

u pa

y yo

ur

dedu

ctib

le, if

ap

plica

ble)

Cos

t-sh

arin

g m

ay

chan

ge d

epen

ding

on

You

pay

$0.0

0 Yo

u pa

y $0

.00

You

pay

$0.0

0 T

ier 1

: Pre

ferr

ed

Gen

eric

Dru

gs

the p

harm

acy

you

You

pay

$25.

00

You

pay

$30.

00

You

pay

$10.

00

Tie

r 2: G

ener

ic D

rugs

ch

oose

, if y

ou re

side i

n

a lon

g te

rm ca

re (L

TC

) Yo

u pa

y $1

17.5

0 Yo

u pa

y $1

41.0

0 Yo

u pa

y $4

7.00

T

ier 3

: Pre

ferr

ed

Bran

d D

rugs

fa

cility

or i

f you

get

yo

ur m

edica

tion

at a

You

pay

$247

.50

You

pay

$297

.00

You

pay

$99.

00

Tie

r 4: N

on-P

refe

rred

D

rugs

re

tail

loca

tion

or

thro

ugh

mai

l ser

vice

. W

hen

you

mov

e fro

m

one p

hase

of t

he P

art D

N

/A

N/A

Yo

u pa

y 33

%

Tie

r 5: S

peci

alty

Dru

gs

bene

fit to

anot

her,

your

co

st-sh

arin

g m

ay

chan

ge as

well

. For

m

ore i

nfor

mat

ion

on

the a

dditi

onal

phar

mac

y

Sum

mar

y of

Ben

efits

| 10

Eas

y C

hoice

Bes

t Plan

(HM

O)

spec

ific c

ost-

shar

ing

an

d th

e pha

ses o

f the

be

nefit

, plea

se ca

ll us

or

acce

ss o

ur E

vide

nce o

f C

over

age o

nlin

e.

Mos

t Med

icare

dru

g plan

s hav

e a co

vera

ge ga

p (a

lso ca

lled

the "

donu

t hol

e").

Thi

s mea

ns th

at th

ere's

a t

empo

rary

chan

ge in

wha

t you

will

pay

for y

our d

rugs

. The

cove

rage

gap

begi

ns af

ter t

he to

tal y

early

dr

ug co

st (in

cludi

ng w

hat o

ur p

lan h

as p

aid

and

what

you

hav

e pai

d) re

ache

s $3,

750.

Cov

erag

e Gap

On

this

plan

, whe

n yo

u ar

e in

the c

over

age g

ap st

age,

the p

lan p

rovi

des s

ome c

over

age.

For d

rugs

on

T

ier 1

, you

pay

a $0

.00

co-p

aym

ent.

For d

rugs

on

Tie

rs 2

-5, y

ou p

ay 3

5% o

f the

plan

's co

st fo

r co

vere

d br

and

nam

e dru

gs an

d 44

% o

f the

plan

's co

st fo

r cov

ered

gen

eric

drug

s unt

il yo

ur co

sts to

tal

$5,0

00 w

hich

is th

e end

of t

he co

vera

ge g

ap.

Afte

r you

r yea

rly o

ut-o

f-po

cket

dru

g cos

ts (n

ot in

cludi

ng w

hat t

he p

lan h

as p

aid,

but

inclu

ding

dru

gs

you

purc

hase

d th

roug

h yo

ur re

tail

phar

mac

y an

d th

roug

h m

ail o

rder

) rea

ch $

5,00

0, y

ou p

ay th

e gr

eate

r of:

Cat

astro

phic

Cov

erag

e

1

5% o

f the

cost,

or

1

$3.3

5 co

-pay

for g

ener

ic (in

cludi

ng b

rand

dru

gs tr

eate

d as

gen

eric)

and

a $8.

35 co

-pay

men

t for

all

oth

er d

rugs

.

Sum

mar

y of

Ben

efits

| 11

Thi

ngs t

o kn

ow

Eas

y Cho

ice B

est P

lan

(HM

O)

Prem

ium

s and

Ben

efits

Ove

rvie

w

Yo

u pa

y $0

co-p

ay fo

r car

diac

reha

b

serv

ices

Reh

abili

tatio

n Se

rvic

es1,

2

1

T

his i

nclu

des t

he fo

llowi

ng:

You

pay

$0 co

-pay

for o

ccup

atio

nal

ther

apy

4 C

ardi

ac (h

eart)

reha

b se

rvice

s 4

O

ccup

atio

nal t

hera

py vi

sit

Yo

u pa

y $0

co-p

ay fo

r Med

icare

cove

red

po

diat

ry

Foot

Car

e (po

diat

ry se

rvic

es)1,

2

1

T

his i

nclu

des i

nfor

mat

ion

on

cove

rage

of f

oot e

xam

s, tre

atm

ent

and

care

Yo

u pa

y $0

co-p

ay fo

r 1 vi

sit ev

ery

6

mon

ths a

dditi

onal

rout

ine p

odia

try

serv

ices

Yo

u pa

y 20

% o

f the

cost

for d

urab

le

med

ical e

quip

men

t M

edic

al E

quip

men

t/Su

pplie

s1

1

T

his i

nclu

des t

he fo

llowi

ng:

You

pay

20%

of t

he co

st fo

r pro

sthet

ics

4 D

urab

le m

edica

l equ

ipm

ent

(e.g

., w

heelc

hairs

, oxy

gen)

Yo

u pa

y no

thin

g fo

r dia

betic

supp

lies

4 Pr

osth

etics

(e.g

., b

race

s,

artif

icial

limbs

) Yo

u pa

y 20

% o

f the

cost

for d

iabe

tic

ther

apeu

tic sh

oes a

nd in

serts

4

D

iabe

tes s

uppl

ies

4 D

iabet

ic th

erap

eutic

shoe

s and

in

serts

The

se p

rogr

ams a

re w

ays t

o st

ay

heal

thy.

Whe

ther

it’s

an ex

tra c

heck

up

You

pay

noth

ing

for f

itnes

s. T

his i

s a

basic

fitn

ess m

embe

rshi

p at

no

cost

to

you.

Wel

lnes

s Pro

gram

s1

1

T

his i

nclu

des t

he fo

llowi

ng:

Sum

mar

y of

Ben

efits

| 12

Thi

ngs t

o kn

ow

Eas

y Cho

ice B

est P

lan

(HM

O)

durin

g the

year

or yo

u ju

st h

ave a

sim

ple

heal

th q

uest

ion,

we a

re h

ere a

s you

r pa

rtne

r in

heal

th.

You p

ay n

othi

ng fo

r an

addi

tiona

l rou

tine

annu

al ph

ysica

l Yo

u pa

y no

thin

g fo

r our

Nur

se A

dvice

Li

ne

4 Fi

tnes

s 4

A

dditi

onal

rout

ine a

nnua

l ph

ysica

l 4

N

urse

Adv

ice L

ine –

24 h

ours

Yo

u pa

y $0

co-p

ay fo

r med

ical

chiro

prac

tic se

rvice

s C

hiro

prac

tic C

are2

1

T

his i

nclu

des t

he fo

llowi

ng:

4

M

edica

l chi

ropr

actic

se

rvice

s N

ot co

vere

d 4

R

outin

e chi

ropr

actic

serv

ices

Yo

u pa

y $0

for 1

2 vi

sits e

very

yea

r. A

cupu

nctu

re2

O

ur p

lan w

ill p

ay u

p to

$23

ever

y mon

th

for t

he p

urch

ase o

f cov

ered

ov

er-t

he-c

ount

er it

ems.

Ove

r the

Cou

nter

item

s

Plea

se vi

sit o

ur w

ebsit

e to

see o

ur li

st of

co

vere

d ov

er-t

he-c

ount

er it

ems.

Sum

mar

y of

Ben

efits

| 13

Multi-Language Insert Multi-language Interpreter Services

ATTENTION: If you speak English, language assistance services, free of charge, are available to you. Call 1-866-999-3945 (TTY: 711).

ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-866-999-3945 (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 1-866-999-3945 (TTY: 711) 。

CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-866-999-3945 (TTY: 711).

주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-866-999-3945 (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 1-866-999-3945 (TTY: 711).

ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-866-999-3945 (телетайп: 711).

ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم 1-866-999-3945(رقم هاتف الصم والبكم: 711).

ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 1-866-999-3945 (TTY: 711).

ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-866-999-3945 (TTY: 711).

UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-866-999-3945 (TTY: 711).

ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 1-866-999-3945 (TTY: 711).

ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-866-999-3945 (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。1-866-999-3945 (TTY: 711) まで、お電話にてご連絡ください。

ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-866-999-3945 (TTY: 711).

توجه: اگر به زبان فارسی گفتگو می کنید، تسهیلات زبانی بصورت رایگان برای شما فراهم می باشد. با(TTY: 711) 3945-999-866-1 تماس بگیرید.

H5087_WCM_00962Z CMS ACCEPTED 06262017©WellCare 2017

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.:

1 Provides free aids and services to people with disabilities to communicate effectively with us, such as:

4 Qualified sign language interpreters 4 Written information in other formats (large print, audio, accessible electronic formats,

other formats) 1 Provides free language services to people whose primary language is not English, such as:

4 Qualified interpreters 4 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 number - 1-877-247-6272; Fax: 1-866-388-1769; OperationalGrievance@wellcare.com. 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 ‘Ohana Health Plan, a plan offered by WellCare Health Insurance of Arizona, Inc., and Easy Choice Health Plan, a WellCare company.

NA035233_WCM_INS_ENG

Easy Choice Health Plan (HMO), a WellCare company, is a Medicare Advantage organization with a Medicare contract. Enrollment in Easy Choice (HMO) depends on contract renewal. We Cover Part D drugs. In addition, we cover Part B drugs such as chemotherapy and some drugs administered by your provider. You must continue to pay your Medicare Part B premium. Easy Choice uses a formulary. The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. This information is not a complete description of benefits. Contact the plan for more information. Limitations, co-payments and restrictions may apply. Benefits, premiums and/or co- payments/coinsurance may change on January 1 of each year. You have the choice to sign up for automated mail service delivery. You can get prescription drugs shipped to your home through our network mail service delivery program. You should expect to receive your prescription drugs within 10–14 calendar days from the time that the mail service pharmacy receives the order. If you do not receive your prescription drugs within this time, please contact us at 1-866-892-9006 (TTY 1-866-507-6135), 24 hours a day, seven days a week, or visit mailrx.wellcare.com