2019 Summary of Benefits - WellCare
24
2019 Summary of Benefits Medicare Advantage Plans Texas Austin, Brazoria, Chambers, Fort Bend, Galveston (partial county), Hardin, Harris, Jefferson, Liberty, Montgomery, Orange, Waller H4506 | Plan 003 WellCare TexanPlus Classic (HMO) H4506_WCM_16324E_M ©WellCare 2018 TX9UARSOB16324E_0003
Transcript of 2019 Summary of Benefits - WellCare
2019 Summary of Benefits Medicare Advantage Plans
Texas
Austin, Brazoria, Chambers, Fort Bend, Galveston (partial county), Hardin, Harris, Jefferson, Liberty, Montgomery, Orange, Waller
H4506 | Plan 003
WellCare TexanPlus Classic (HMO)
H4506_WCM_16324E_M ©WellCare 2018 TX9UARSOB16324E_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: In
itial
Cov
erag
e, C
over
age
Gap
, and
Cat
astro
phic
Cov
erag
e. Yo
u ca
n se
e our
plan
's pr
ovid
er an
d ph
arm
acy
dire
ctor
y an
d ou
r co
mpl
ete p
lan fo
rmul
ary
(list
of P
art D
pre
scrip
tion
drug
s) at
our
we
bsite
: www
.wel
lcar
e.co
m/m
edic
are.
Or c
all u
s and
we'l
l sen
d yo
u
a cop
y. W
e’re h
ere w
ith o
ur m
embe
rs ev
ery
step
of th
e way
.
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: A
ustin
, Br
azor
ia, C
ham
bers
, For
t Ben
d, G
alves
ton
(par
tial c
ount
y), H
ardi
n,
Har
ris, J
effe
rson
, Lib
erty
, Mon
tgom
ery,
Ora
nge,
Wall
er.
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.
$3
,400
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 $2
50 co
-pay
per
stay
$0
co-p
ay fo
r 60
addi
tiona
l hos
pita
l day
s. In
patie
nt H
ospi
tal C
over
age
12
O
utpa
tient
Hos
pita
l Cov
erag
e, S
urge
ry, a
nd S
ervi
ces
12
$50
Co-
pay
Am
bulat
ory
Surg
ical C
ente
r $1
50 C
o-pa
y fo
r non
-sur
gica
l ser
vice
s O
utpa
tient
Hos
pita
l $1
50 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
for e
ach
in-n
etwo
rk vi
sit to
oth
er h
ealth
care
pro
fess
iona
ls in
a
PCP,
Spe
cialis
t, cli
nic o
r pha
rmac
y se
tting
for M
edica
re-c
over
ed se
rvice
s. O
ther
Hea
lth C
are P
rofe
ssio
nals
$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. $2
5 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
$120
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
)
$25
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
10%
of t
he co
st wh
en p
erfo
rmed
at a
spec
ialis
t's o
ffice
or f
ree s
tand
ing
fa
cility
D
iagn
ostic
Rad
iolo
gy (M
RIs
, CT
Sca
ns)
10%
of t
he co
st wh
en se
rvice
s are
per
form
ed in
an o
utpa
tient
setti
ng
$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
$25
Co-
pay
for a
dvan
ced
diag
nosti
c tes
ts an
d pr
oced
ures
such
as a
card
iac
stres
s tes
t $0
Co-
pay
Lab
Serv
ices (
Med
icare
appr
oved
lab
work
) $0
Co-
pay
Out
patie
nt X
-Ray
s 10
% o
f the
cost
The
rape
utic
Rad
iolo
gy S
ervi
ces (
e.g.,
radi
atio
n tre
atm
ent f
or ca
ncer
) 20
% o
f the
cost
Rela
ted
Med
ical S
uppl
ies
Wha
t You
Sho
uld
Kno
w:
Prio
r aut
horiz
atio
n is
requ
ired
to b
e cov
ered
exce
pt fo
r x-r
ays a
nd so
me l
ab
proc
edur
es, w
hen
done
in fr
ee-s
tand
ing
facil
ities
.
Hea
ring
Serv
ices
12
H
earin
g E
xam
$3
5 C
o-pa
y M
edica
re C
over
ed
7
Wel
lCar
e Tex
anPl
us C
lass
ic (H
MO
)
Rou
tine H
earin
g E
xam
$0
Co-
pay
1 E
very
year
$7
50 to
ward
s the
pur
chas
e of o
ne h
earin
g ai
d A
nnua
l Hea
ring
Aid
Allo
wanc
e $0
Co-
pay
Hea
ring
Aid
Fitt
ings
/Eva
luat
ion
1
Eve
ry ye
ar
Wha
t You
Sho
uld
Kno
w:
Med
icare
cove
rs d
iagn
ostic
hea
ring
and
balan
ce ex
ams i
f you
r doc
tor o
r ot
her h
ealth
care
pro
vide
r ord
ers t
hese
tests
to se
e if y
ou n
eed
med
ical
treat
men
t. D
iagn
ostic
hea
ring
and
balan
ce ev
aluat
ions
per
form
ed b
y yo
ur p
rovi
der t
o
dete
rmin
e if y
ou n
eed
med
ical t
reat
men
t are
cove
red
as ou
tpat
ient c
are w
hen
fu
rnish
ed b
y a p
hysic
ian,
audi
olog
ist, o
r oth
er q
ualif
ied
prov
ider
. T
his p
lan co
vers
1 ro
utin
e hea
ring
scre
enin
g pe
r yea
r. T
he h
earin
g be
nefit
on
this
plan
inclu
des a
rout
ine h
earin
g ex
am. I
n
addi
tion,
our
plan
pay
s up
to $
750
ever
y ye
ar to
ward
s the
pur
chas
e of
1 h
earin
g ai
d.
8
Wel
lCar
e Tex
anPl
us C
lass
ic (H
MO
)
You
pay
a $5
co-p
ay fo
r the
follo
wing
pre
vent
ive d
enta
l ser
vice
s: D
enta
l Ser
vice
s1
2
Clea
ning
s D
enta
l x-r
ay(s)
O
ral e
xam
s Fl
uorid
e tre
atm
ents
Our
plan
pay
s up
to $
1000
ever
y ye
ar fo
r mos
t den
tal s
ervi
ces.
Add
ition
al
com
preh
ensiv
e den
tal s
ervic
es yo
u wi
ll pa
y not
hing
for i
nclu
de th
e fol
lowi
ng:
perio
dont
ics, p
rosth
odon
tic, o
ral m
axill
ofac
ial p
roce
dure
and
som
e oth
er
serv
ices.
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
$10
00, i
nclu
ding
but
not
lim
ited
to cl
eani
ngs,
x-
ray(
s), o
ral e
xam
s, flu
orid
e tre
atm
ent,
perio
dont
al sc
aling
and
fillin
gs.
Vi
sion
Serv
ices
12
E
ye E
xam
s $0
Co-
pay
Med
icare
Cov
ered
$0
Co-
pay
Rou
tine E
ye E
xam
s (R
efra
ctio
n)
$0 C
o-pa
y G
lauco
ma S
cree
ning
s
Eye
wear
$0
Co-
pay
Med
icare
Cov
ered
$0
Co-
pay
(cov
ered
up
to $
100
Eve
ry ye
ar)
Con
tact
Len
ses,
Eye
Glas
ses,
Eye
Glas
s Len
ses,
Eye
Glas
s Fra
mes
W
hat Y
ou S
houl
d K
now:
O
ur p
lan co
vers
up
to 1
rout
ine e
ye ex
am (r
efra
ctio
n) E
very
year
. E
nhan
ced
bene
fits f
or ey
ewea
r to
inclu
de co
vera
ge fo
r con
tact
lens
es, e
ye
glas
ses (
lense
s and
fram
es),
eye g
lass l
ense
s and
eye g
lass f
ram
es u
p to
a
max
imum
ben
efit
of $
100
Eve
ry ye
ar, n
ot re
lated
to p
ost c
atar
act s
urge
ry.
9
Wel
lCar
e Tex
anPl
us C
lass
ic (H
MO
)
Med
icare
cove
red
eyew
ear i
s lim
ited
to o
ne p
air o
f glas
ses o
r con
tact
s afte
r ca
tara
ct su
rger
y.
M
enta
l Hea
lth S
ervi
ces
12
$325
co-p
ay p
er st
ay
Inpa
tient
Hos
pita
l Visi
t $2
0 C
o-pa
y O
utpa
tient
Indi
vidu
al T
hera
py
$20
Co-
pay
Out
patie
nt G
roup
The
rapy
$3
5 C
o-pa
y Pa
rtial
Hos
pita
lizat
ion
Wha
t You
Sho
uld
Kno
w:
Our
plan
cove
rs u
p to
190
day
s in
a life
time f
or in
patie
nt m
enta
l hea
lth ca
re
in a
psyc
hiat
ric h
ospi
tal.
The
inpa
tient
hos
pita
l car
e lim
it do
es n
ot ap
ply t
o
inpa
tient
men
tal s
ervi
ces p
rovi
ded
in a
gene
ral h
ospi
tal.
$0 co
-pay
per
day
for D
ays 1
-20
$100
.00
co-p
ay p
er d
ay fo
r Day
s 21-
100
Skill
ed N
ursin
g Fa
cilit
y (SN
F)1
2
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.
10
Wel
lCar
e Tex
anPl
us C
lass
ic (H
MO
)
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.
$0 C
o-pa
y fo
r 48
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
10%
of t
he co
st C
hem
othe
rapy
dru
gs
10%
of t
he co
st W
hat Y
ou S
houl
d K
now:
In
-Net
work
: $0
Cos
t sha
re fo
r res
pira
tory
com
poun
d m
edica
tions
ad
min
ister
ed th
roug
h a n
ebul
izer
pro
vide
d by
a pr
efer
red
vend
or. 1
0% fo
r all
oth
er M
edica
re P
art B
dru
gs.
Oth
er P
art B
dru
gs
11
12
Wel
lCar
e Tex
anPl
us C
lass
ic (H
MO
) PR
ESC
RIP
TIO
N D
RU
G B
EN
EFI
TS
$0.0
0 Pa
rt D
Ded
uctib
le
You
pay t
hese
co-p
ays o
r coi
nsur
ance
amou
nts u
ntil
your
tota
l yea
rly d
rug
cost
reac
hes $
3,82
0. T
otal
year
ly d
rug
costs
are t
he
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
$100
.00
$40.
00
Tier
3: P
refe
rred
Bran
d
Dru
gs
$200
.00
$80.
00
Tie
r 4: N
on-P
refe
rred
D
rugs
Not
Ava
ilabl
e 33
%
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.
13
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
$80.
00
$40.
00
Tier
3: P
refe
rred
Bran
d
Dru
gs
$160
.00
$80.
00
Tie
r 4: N
on-P
refe
rred
D
rugs
Not
Ava
ilabl
e 33
%
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
Und
er th
is pl
an, y
ou m
ay p
ay ev
en le
ss fo
r the
gen
eric
drug
s on
the f
orm
ular
y. Y
our c
ost v
arie
s by
tier.
You
will
need
to u
se
your
form
ular
y to
loca
te y
our d
rug’s
tier
. The
char
t belo
w sh
ows h
ow m
uch
it wi
ll co
st yo
u.
3 M
onth
Ret
ail
1 M
onth
Ret
ail
$0
$0
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
.
14
Wel
lCar
e Tex
anPl
us C
lass
ic (H
MO
)
A
dditi
onal
Cov
ered
Ben
efits
$1
20 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 $
25,0
00 m
axim
um p
lan co
vera
ge. O
r 60
day
s of c
are,
which
ever
is re
ache
d fir
st. T
here
is n
o co
vera
ge fo
r 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
15
Wel
lCar
e Tex
anPl
us C
lass
ic (H
MO
)
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
10%
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 fro
m a
pref
erre
d su
pplie
r D
iabe
tes M
onito
ring
Supp
lies
$0 C
o-pa
y fro
m a
non-
pref
erre
d su
pplie
r 20
% o
f the
cost
Dia
betic
The
rape
utic
Shoe
s or I
nser
ts $0
Co-
pay
Dia
betic
Self
-Man
agem
ent T
rain
ing
Wha
t You
Sho
uld
Kno
w:
Cov
ered
dia
bete
s sup
plie
s inc
lude
: blo
od g
luco
se m
onito
r, bl
ood
gluc
ose
test
strip
s, lan
cet d
evice
s and
lanc
ets,
and
gluc
ose-
cont
rol s
olut
ions
.
16
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
W
hat Y
ou S
houl
d K
now:
Our
plan
onl
y co
vers
man
ipul
atio
n of
the s
pine
to co
rrect
a su
blux
atio
n
(whe
n 1
or m
ore o
f the
bon
es o
f you
r spi
ne m
ove o
ut o
f pos
ition
.)
17
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
Co-
pay
Indi
vidu
al T
hera
py
$20
Co-
pay
Gro
up T
hera
py
20%
of t
he co
st R
enal
Dia
lysis
12
Our
plan
will
pay
up
to $
30 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
18
Well
Car
e Tex
anPl
us, i
s 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
co
ntra
ct re
newa
l. T
his i
nfor
mat
ion
is no
t a co
mpl
ete d
escr
iptio
n of
ben
efits
. Call
1-8
66-2
30-2
513
/ TT
Y 71
1 fo
r mor
e inf
orm
atio
n.
Lim
itatio
ns, c
o-pa
ymen
ts an
d re
strict
ions
may
appl
y. B
enef
its, p
rem
ium
s and
/or c
o-pa
ymen
ts/co
insu
ranc
e may
chan
ge o
n Ja
nuar
y 1
of ea
ch y
ear.
The
fo
rmul
ary,
pha
rmac
y ne
twor
k an
d/or
pro
vide
r net
work
may
chan
ge at
any
time.
You
will
rece
ive n
otice
whe
n ne
cess
ary.
You
mus
t con
tinue
to p
ay y
our
Part
B pr
emiu
m. O
ur p
lans u
se a
form
ular
y. Y
ou h
ave t
he ch
oice
to si
gn u
p fo
r aut
omat
ed m
ail s
ervi
ce d
elive
ry. Y
ou ca
n ge
t pre
scrip
tion
drug
s shi
pped
to
your
hom
e thr
ough
our
net
work
mai
l ser
vice
deli
very
pro
gram
. Yo
u sh
ould
expe
ct to
rece
ive y
our p
resc
riptio
n dr
ugs w
ithin
10–
14 ca
lenda
r day
s fro
m th
e tim
e tha
t the
mai
l ser
vice
pha
rmac
y rec
eive
s the
ord
er. I
f you
do
no
t rec
eive
you
r pre
scrip
tion
drug
s with
in th
is tim
e, pl
ease
cont
act u
s at 1
-866
-892
-900
6 (T
TY
1-86
6-50
7-61
35),
24 h
ours
a da
y, se
ven
days
a we
ek, o
r vi
sit m
ailrx
.well
care
.com
. Plea
se co
ntac
t you
r plan
for d
etai
ls.
19
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 1-866-556-4607 (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 1-866-556-4607 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 1-866-556-4607 (TTY 711). Your call may be answered by a licensed agent. Already a member? Please call us toll-free at 1-866-230-2513 (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.
