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

ail s

ervi

ce d

elive

ry p

rogr

am.

You

shou

ld ex

pect

to re

ceiv

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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: 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 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.