overthecounter (otc) catalog - wellcare

2020

OvertheCounter (OTC) Catalog

Medicare Advantage Plan

If you’d like to place an order please give us a call at 18448545571 (TTY: 711) Monday–Saturday� from 8 a.m. to 8 p.m., and Sunday from 10 a.m. to 7 p.m., and our friendly customer service representatives�

will take your order. You can also visit us at www.WellCareOTCStore.com.�

Y0070_WCM_38634E_M CMS Accepted 09152019 ©WellCare 2019 NA0WCMOTC38634E_MOTC

https://www.WellCareOTCStore.com

Welcome to WellCare’s OTC Benefit Dear Member,

By enrolling in one of our WellCare plans, you receive a benefit allowance to spend on Over-The-Counter (OTC) products that are exclusively available from this catalog. Your OTC Benefit allows you to select items such as cold and cough medicines, incontinence products, vitamins, dental care, and much more. Items ordered from this catalog will be shipped directly to you.

Each plan offers different OTC benefit amounts. Check your Evidence of Coverage or Summary of Benefits to find the specific amount for your plan. Your benefit and items are only for your use. Be sure to use your benefit!

What is covered with your OTC Benefit? Eligible items include OTC remedies or medicines to alleviate or treat illness or injury, dental care items, eye and ear care items, and incontinence supplies (adult diapers). These items do not require a prescription from a healthcare provider.

Dual Purpose items are items that may serve more than one purpose. These items are sometimes used to alleviate or treat a medical condition or they may be used to promote general health and well-being. These items do not require a prescription from your provider to purchase. However, WellCare strongly recommends that you discuss these items with your provider prior to ordering or using. For your convenience, we have identified the dual purpose categories throughout the catalog.

In certain situations, items may be covered under Medicare Part B or D. When an item is covered by Part B or D, you should not use your OTC benefit card to buy it, because it is covered by Medicare and is not part of your supplemental OTC benefit. For example, gauze may be covered under Part B when it is being used, by prescription, to perform surgical wound dressing changes. In these situations, you should present your prescription and your WellCare member ID card at the pharmacy counter. For your convenience, we’ve marked these items with a (**).

Your benefit can be used anytime during the benefit period to order OTC items from this catalog. You are limited to one shipment per month, so be sure to order all of the items you need at the same time. Each plan offers different OTC benefit amounts and periods. Check your Evidence of Coverage or Summary of Benefits to find the specific amount for your plan and the length of your benefit period. Your benefit and items are only for your use. Be sure to use your benefit!

You can spend out-of-pocket beyond your Benefit allowance and any unused Benefit is forfeited at the end of each benefit period. Any out-of-pocket OTC items purchased by you will not be eligible for reimbursement from the Benefit Plan or Fieldtex Products, Inc. Only items purchased with your Benefit will be eligible for reimbursement. For information about member reimbursement, please contact Customer Service at 1-877-902-6784, TTY: 711.

Some items, under certain circumstances, may be covered under either Part B or Part D. Items covered by Part B or Part D are Medicare-covered, and are not part of the supplemental OTC benefit.

If you are mailing your order, be sure to allow 7 days for your order to reach us.

*Please keep this catalog for your entire 2020 benefit year*

How To Order There are three easy ways you can place your order: by mail, phone, or online. Whatever way you choose to place your order, be sure to have your Member ID number and date of birth available in order to access your benefit.

• By mail: Fill out the attached mail order form, place it in an envelope, include postage and mail to: Fieldtex Products Inc. WellCare Plan Order Dept. 2921 Brighton Henrietta Town Line Rd, Rochester, NY 14623. Be sure to give the order 7 days to reach us. The order will be processed during the benefit period that it is received, unless otherwise specified. A new mail order form is sent with each of your shipments.

• By phone: Call us at 1-844-854-5571 (TTY: 711) Monday – Saturday from 8 a.m. to 8 p.m. and Sunday from 10 a.m. to 7 p.m., and our friendly customer service representatives will take your order.

• Online: Visit us at www.WellcareOTCStore.com and login to place your order. Online you will be able to shop in the privacy of your home while keeping track of what you have ordered, check status of orders, and check benefit allowance.

Ordering Process 1. Each benefit period, choose the items you would like and write the number on your order form. Have

the filled out form available when you call or go online for faster and easy ordering.

2. Total all the items. Be sure to stay within your available allowance. If you go over your Available Benefit Amount, you will need a credit card for any extra order out-of-pocket expense.

3. Be sure to have your Member ID number (found on the front of your ID card). You will need to provide your Member ID number and your date of birth to access your account online or over the phone. If you are ordering online, your username is your Member ID, and your password is your date of birth in the format of “MMDDYY”. Example: June 6, 1940 would be entered as 060640

Important Information • The OTC Supplier cannot give you Medical advice. If you have a question about a product, please talk

to your medical health provider or your doctor.

• If you receive a damaged product, please contact Fieldtex Products, Inc. at 1-800-353-7763 (TTY:711) Monday – Friday from 8 a.m. to 8 p.m. immediately and ask for the OTC Department, and we will replace it at no cost to you.

• Please expect 7–10 business days for shipments, call 1-800-353-7763 (TTY:711) if an order does not arrive.

https://www.WellCareOTCStore.com

Ordering Over-The-Counter (OTC) products is convenient and easy!

By enrolling in one of our WellCare plans, you receive a benefit allowance to spend on OTC products. Items in the catalog include:

Pain Relief Medications First Aid Supplies Cold & Allergy

Vitamins & Supplements Dental Care Items and more!

Commonly Available Items Arthritis Pain Relief APAP 650mg Caplets 24/Ct** 922-90601 $4.50

Category: Pain Relief

Benadryl Allergy 24/Ct** 922-10874 $6.25

Category: Allergy

Bengay Greaseless Cream 2 oz. 922-10323 $6.75

Category: Ointments and Topicals - Analgesics

Centrum Women Multigummies 70/Ct922-00832 $12.00

Category: Vitamins and Minerals

Cotton Swabs 300/Ct 922-90891 $2.75

Category: First Aid - Dressing and Gauze

Crest Regular Toothpaste 4.6 oz. 922-90615 $3.50

Category: Dental Care - Toothpaste

Fish Oil Cholesterol Free 1000mg 120/Ct 922-90964 $7.25

Category: Vitamins and Minerals

Gas-X Extra Strength Softgels 10/Ct 922-91052 $4.25

Category: Stomach and Laxatives

Gentle Stool Softener 25/Ct 922-90590 $3.00


Ibuprofen IB Caplets 200mg 100/Ct** 922-90600N $3.00


Icy Hot Cream 1.25 oz. 922-10053 $5.00

Category: Ointments and Topicals - Analgesics

J and J 140 Piece First Aid Kit 922-90564 $22.00

Category: First Aid Kits

J and J Flexible XL Bandages 1 3/4 in. x 4 in. 10/Ct 922-10320 $5.00

Category: First Aid - Bandages

Luden’s Wild Cherry Throat Drops 30/Ct 922-11584 $3.00

Category: Cough Drops

Mint Flossers with Picks 50/Ct 922-90613 $2.00

Category: Dental Care

MiraLAX 7 Dose4.1 oz. 922-90883 $11.00


Neosporin Ointment 922-00835 $8.00

Category: Ointments and Topicals

Pepto Bismol 4 oz. 922-90923 $5.00


Prevail Adult Washcloths 48/Ct 922-11089 $4.50

Category: Incontinence

Prevail Bladder Control Pads Ultra Thin 30/Ct 922-99163 $8.00

Category: Incontinence

Thermacare Lower Back and Hip Heatwraps 2/Ct 922-90885 $11.50

Category: Hot and Cold Therapy

Tussin DM 4 oz. 922-90446 $3.00

Category: Cold and Flu

Commonly Available Items

Tylenol Extra Strength Caplets 500mg 100/Ct** 922-99059 $18.50


Vicks Vapor Rub 3.53 oz.922-11625 $13.00

Category: Cold and Flu

Visine Advanced Lubricant/ Redness and Irritation Relief .28 oz. 922-99063 $3.00

Category: Eye Care

Your Complete List of Available Over-the-Counter Products Item Item Number Price Limit Allergy Alka Seltzer Plus Severe Sinus Congestion LiquiGels 20/Ct 922-99038 $10.00

All Day Allergy Tablets 30/Ct - Cetirizene** 922-90584 $13.50

Allegra 12 Hour 60mg Tablets 12/Ct** 922-91071 $17.50

Allegra 24 Hour 180mg Tablets 30/Ct** 922-90980 $33.00 2 per month

Allergy / Sinus Headache Caplets 20/Ct** 922-90580 $4.00

Allergy 10mg Tablets 30/Ct - Loratidine** 922-90582 $4.00

Allergy Relief Capsules 24/Ct** 922-90581 $2.75

Benadryl Allergy Tablets 24/Ct** 922-10874 $6.25

Claritin Reditabs 10/Ct** 922-11580 $17.75

Complete Allergy Medicine Tablets 100/Ct** 922-11569N $2.00

Fexofenadine Tablets 30/Ct - Generic Allegra** 922-00301 $18.00

Flonase Nasal Spray For Allergies 60/Spray** 922-99046 $24.00

Nasacort Allergy 24 Hour 60/Spray** 922-10222 $23.50

Zyrtec 10mg Tablets 14/Ct** 922-91073 $22.00

Zyrtec 10mg Tablets 30/Ct** 922-00203 $31.00 2 per month

Cold and Flu Airborne Original Orange Tablets 10/Ct 922-90553 $10.50

Alka Seltzer Plus Cold and Cough LiquiGels 20/Ct 922-99912 $10.00

Alka Seltzer Plus Severe Cough, Mucus and Congestion Day/Night LiquiGels 20/Ct 922-99037 $10.00

Breathe Right Nasal Strips Large 30/Ct 922-10875 $19.50

Breathe Right Strips Small / Medium 30/Ct 922-90895 $19.50

Careall Medicated Chest Rub 3.53 oz. 922-99093 $2.25

Coricidin HPB Liqui-Gels 20/Ct 922-11575 $9.25

Cough / Cold High Blood Pressure Tablets 16/Ct 922-90090 $3.00

Delsym Cough Suppressant 6 fl. oz. 922-10013 $18.50

Effervescent Cold Relief Tablets 20/Ct 922-90579 $5.00

Mentholatum Ointment 1 oz. Jar 922-90444 $4.00

Mucinex DM Tablets 20/Ct** 922-11561 $21.00

Mucinex Fast-Max Cold, Flu and Sore Throat 9 fl. oz.** 922-99113 $24.00

Mucus Relief DM Tablets 30/Ct** 922-90576 $8.50

Nasal Decongestant Spray -Afrin- 1 oz.** 922-90897 $3.25

Nasal Spray Extra Moisture 1 oz.** 922-90898 $3.00

Nitetime Cold-Flu Relief SoftGels 16/Ct 922-90639 $4.50

Item Item Number Price Limit Cold and Flu (continued) Robitussin Cough and Chest Sugar Free 4 oz. 922-90516 $11.50

Saline Nasal Spray 1.5 oz. 922-90640 $2.00

Tussin DM 4 oz. 922-90446 $3.00

Tussin DM Sugar Free 4 oz. 922-90578 $4.25

Tylenol Cold / Flu Severe Caplets 24/Ct** 922-99065 $10.50

Tylenol Cold and Flu 8 fl. oz.** 922-99118 $10.50

Tylenol Sinus Severe Caplets 24/Ct** 922-99066 $10.50

Vicks DayQuil LiquiCaps 8/Ct 922-91076 $9.75

Vicks DayQuil Cold and Flu LiquiCaps 24/Ct 922-11952 $15.00

Vicks Vapor Rub 3.53 oz. 922-11625 $13.00

Cough Drops Black Cherry Sugar Free Cough Drops 25/Ct 922-90643 $2.25

Chloraseptic Lozenges - Citrus 18/Ct 922-11562 $5.00

Honey Lemon Cough Drops 30/Ct 922-99054 $1.25

Halls Honey Lemon Cough Drops 30/Ct 922-11601 $3.50

Halls Defense Asst Sugar Free Citrus 25/Ct 922-90912 $3.50

Halls Defense Citrus 30/Ct 922-90913 $3.50

Halls Menthol-Lyptus Cough Drops 30/Ct 922-11703 $3.50

Luden's Sugar Free Wild Cherry Cough Drop 25/Ct 922-99083 $3.00

Luden's Wild Cherry Throat Drops 30/Ct 922-11584 $3.00

Ricola Cherry Honey Cough Drops 24/Ct 922-99114 $3.25

Ricola Cough Drops 21/Ct 922-11571 $3.25

Ricola Sugar Free Lemon Cough Drops 19/Ct 922-90447 $3.25

Sucrets Sore Throat Cherry Lozenges 18/Ct 922-11591 $4.50

Vitamin C Drops 30/Ct 922-90914 $3.00

Dental Care Anbesol Maximum Strength .33 oz. 922-10221 $9.75

Dentek Instant Oral Pain Relief 50/Applications 922-00303 $8.00

Floss Waxed Unflavored 100 Yds 922-90652 $2.25

Freshmint Wax Mint Dental Floss 100 Yds 922-90612N $1.75

GUM Soft Picks 60/Ct 922-10227 $7.25

Gum Soft Picks Wider Spaces 50/Ct 922-00662 $4.00

J and J Waxed Mint Reach Floss 55 Yds 922-90077 $2.00

Mint Flosser with Pick 50/Ct 922-90613 $2.00

Orajel Medicated Mouth Sore Swabs 12/Ct 922-90080 $8.50

Tongue Cleaner 1/Ct 922-90954 $2.75

Item Item Number Price Limit Dental Care - Denture Denture Brush 922-90909 $0.50

Denture Cleaner Tablets 40/Ct 922-90906 $2.50

Fixodent Adhesive Neutral Zinc Free 2.4 oz. 922-99107 $8.50

Fixodent Free Cream 2.4 oz. 922-99109 $9.00

Fixodent Original 1.4 oz. 922-90128 $5.50

Fixodent Plus Scope Adhesive 2 oz. 922-99110 $9.00

Freshmint Denture Adhesive 2.4 oz. 922-90908 $3.00

Freshmint Denture Cleaning Tablets 90/Ct 922-90655N $5.00

Oral B Denture Brush Twin Head 922-90126 $4.00

Polident 3-Minute Tablets 40/Ct 922-99049 $5.50

Polident Overnight Tablets 40/Ct 922-91079 $5.50

Polident Overnight Tablets 84/Ct 922-90486 $10.50

Polident Tablets for Smokers 40/Ct 922-99050 $5.75

Poligrip Extra Care 2.2 oz. 922-90490 $9.00

Poligrip SPG Free 1.4 oz. 922-99051 $6.00

Poligrip SPG Free 2.4 oz. 922-99047 $9.00

Poligrip Super Original 2.4 oz. 922-90491 $9.00

Dental Care - Toothbrush Colgate Medium Toothbrush 922-99181 $2.50

Colgate Plus Soft Toothbrush 922-90156A $3.00 Elite Angle Full Head Medium Toothbrush 922-90654 $2.50 Elite Angle Full Head Soft Toothbrush 922-90653 $2.50

Freshmint Nylon Toothbrush 922-90910 $0.50

Interplak Rechargable Cordless Toothbrush 922-00352 $49.00 2 per year

Interplak Toothbrush Replacement Heads 2/Ct 922-00370 $23.75

Oral B 3D White Soft Toothbrush 922-90988 $5.00

Oral B Precision Clean Battery Powered Toothbrush 922-99149 $21.00 1 per quarter

Oral B Precision Replacement Brush Head 2/Ct 922-99911 $25.00

Dental Care - Toothpaste Aquafresh Cavity Protection Toothpaste 5.6 oz. 922-99044 $3.50

Biotene Fresh Mint Toothpaste 4.3 oz. 922-99045 $9.50

Colgate Total Clean Mint Toothpaste 4.8 oz. 922-90157 $5.75

Crest Regular Toothpaste 4.6 oz. 922-90615 $3.50

Crest Baking Soda and Peroxide Toothpaste 6.4 oz. 922-99148 $4.00

Freshmint Anticavity Toothpaste 4.6 oz. 922-90911 $1.50

Listerine Essential Care Original Gel Toothpaste 4.2 oz. 922-99147 $7.50

Item Item Number Price Limit Dental Care - Toothpaste (continued) Parodontax Extra Fresh Toothpaste 3.4 oz. 922-00305 $9.50

Pepsodent Complete Care Toothpaste 5.5 oz. 922-90617 $2.00

Sensodyne Deep Clean Toothpaste 4.0 oz. 922-90485 $9.50

Diabetic Supplies Cotton Diabetic Socks Small/Medium 1 pair 922-00158 $10.00

Cotton Diabetic Socks Large/XL 1 pair 922-00159 $10.00

Diabetic Health Pack 30/Ct 922-00353 $25.00

Glucose 4 gram tablets - Orange Flavor - 50/Ct 922-00296 $7.00

Glucose 4 gram tablets - Orange Flavor - 10/Ct 922-00295 $3.00

Gold Bond Diabetic Foot Cream 3.4 oz. 922-10223 $10.00

McKesson Brand Test Strips 50/Ct** 922-00356 $30.00

McKesson True Metrix Blood Glucose System** 922-00355 $30.00

Polyester Diabetic Socks Small/Medium 1 pair 922-00173 $10.00

Polyester Diabetic Socks Large/XL 1 pair 922-00174 $10.00

Diagnostic Equipment - Blood Pressure Monitors Healthmate Cuff Digital Blood Pressure Monitor Cuff Circumference 9 in. - 13 in. 922-90327 $48.00 1 per year

Omron Upper Arm Blood Pressure Monitor Cuff Circumference 9 in. - 17 in. 922-00358 $73.00 1 per year

Perfect Measure Blood Pressure Monitor Cuff Circumference 9.4 in. - 13.4 in. 922-00374 $64.00 1 per year

Diagnostic Equipment - Scales Health-O-Meter Scale 922-01078 $80.00 1 per year

Platform Scale 922-01070 $36.00 1 per year

Stainless Steel Digital Scale 922-01072 $55.00 1 per year

Diagnostic Equipment - Thermometers

Advocate Non-Contact Infrared Thermometer Speaks English/Spanish 922-99159 $55.00 1 per year

Digital Ear Thermometer 922-90956 $32.00 1 per year

Infrared Forehead Thermometer One Second Read 922-99170 $52.00 1 per year

Hand Held Digital Temple Touch Infrared Probe Thermometer 922-99169 $21.00 1 per quarter

Ear Care Debrox Earwax Removal Drops 1/2 fl. oz. 922-11848 $8.75

Ear Wax Removal Kit 0.5 fl. oz. 922-90641 $5.00

Lipo-Flavonoid Ear Ringing Relief Caplets 72/Ct 922-00319 $27.00

Item Item Number Price Limit Ear Care (continued) Murine Ear Wax Removal System 0.5. fl. oz. 922-99082 $9.50 Swim-Ear Ear Drops 1 fl. oz. 922-11655 $6.00

Eye Care Blink Contacts Lubricant Eye Drop 10mL 922-90917 $10.50

Clear Eyes Itchy Eye Relief .5 oz. 922-91080 $5.75

Clear Eyes Triple Action Relief .5 oz. 922-91045 $6.50 Eye Care Kit 911-55009 $15.00

Eye Drops Original .5 oz. 922-90453N $2.75

Naphcon A Eye Drops 922-00371 $17.00

Sterile Irritation Eye Drops .5 oz. 922-90588 $3.00

Stye Eye Ointment 0.125 oz. 922-11668 $10.50

Visine A.C. Seasonal Itching .5 oz. 922-91047 $5.50

Visine Advanced Lubricant/Redness .28 oz. 922-99063 $3.00

Visine Eye Allergy Relief Eye Drops .5 oz. 922-99064 $9.50 Feminine and UTI Monistat 7 Day 922-91092 $17.00

Monistat Chafing Relief Powder Gel 1.5 oz. 922-91101 $10.00

Uristat Ultra with Cranberry UTI Pain Relief Tablets 30/Ct 922-00226 $10.00

Fiber Supplements Benefiber 38 Servings 922-00830 $15.00

Best Fiber Powder Sugar Free 62 Servings 922-90575 $11.00

Fiber Gummies 120/Ct 922-00264 $18.00

Benefiber Assorted Fruit Chewables 100/Ct 922-99021 $22.00

Fiber-Con Caplets 36/Ct 922-11839 $10.00

Fiber-Tabs 90/Ct 922-90880 $10.00

Metamucil Capsules 0.52 gram 100/Ct 922-00359 $25.00 First Aid - Bandages All-In-One Finger Dressing - 3 Sterile Dressings 922-91060 $4.75

Antibacterial Sheer Band Aid Assorted 20/Ct 922-90876 $2.50

Curad Sensitive Comfort Bandages 3/4 in. x 3 in. 30/Ct 922-10494 $2.00 Curad Sooth and Cool Assorted Bandages 8/Ct 922-00375 $6.00

Curad Truly Ouchless XL Bandages 8/Ct 922-00377 $6.25

Elastic Bandage 2 in. x 5 Yds 922-00011 $1.75



J and J Flexible Fabric Assorted Bandages 30/Ct 922-10317 $5.00

J and J Flexible 3/4 in. x 3 in. Bandages 30/Ct 922-10319 $5.00

Item Item Number Price Limit First Aid - Bandages (continued) J and J Flexible XL 1 3/4 in. x 4 in. Bandages 10/Ct 922-10320 $5.00

J and J Plastic Bandages 3/4 in. x 3 in. 60/Ct 922-10866 $4.00

New Skin Liquid Bandage 50 Applications 922-10322 $6.00

Sheer Spot 7/8 in. Bandage 100/Ct 922-10135BX100 $3.00 First Aid - Dressings and Gauze Cohesive Elastic Bandage 3 in. x 5 Yds 922-00010 $3.00

Cotton Balls 100% Cotton 300/Ct 922-90773 $2.25

Cotton Swabs 300/Ct 922-90891 $2.75

J and J Gauze Pads 4 in. x 4 in. 10/Ct** 922-10907 $4.75

Krimptex Bandage Roll 4.5 in x 4.1 Yds 922-07104 $2.25 First Aid - Gloves Vinyl Gloves - Size Extra Large - 100/Ct 922-10011 $6.50

Vinyl Gloves - Size Large - 100/Ct 922-10010 $6.50

Vinyl Gloves - Size Medium - 100/Ct 922-10009 $6.50

Vinyl Gloves - Size Small - 100/Ct 922-10008 $6.50

First Aid - Tape Waterproof Tape 1 in. x 10 Yds 922-00101 $3.25

Covered Tape 1/2 in. x 5 Yds 922-00035 $2.00

Waterproof Tri-cut Tape 2 in. x 5 Yds 922-10039 $3.25

First Aid Kits Burn Care Kit 911-90050 $6.50

J and J 140 Piece First Aid Kit 922-90564 $22.00

Mini First Aid Kit 922-90457 $3.00

Personal Soft Sided First Aid Kit 911-93901-10999 $6.50

Curad First Aid Kit 922-99079 $14.00

Foot Care Arm and Hammer Odor Control Foot Powder 7 oz. 922-99158 $9.00

Clotrimazole Cream Usp 1% - 1 oz. 922-90610 $2.00

Compound W Plantar Pads 20/Ct 922-99078 $12.00

Corn and Callus Remover .3 fl. oz. 922-90608 $4.00

Corn Cushions 9/Ct 922-90609 $2.00

Foot Care Kit 911-90061 $7.50

Freeze Off Original Spray 8/Applications 922-99081 $22.00

Liquid Wart Remover .31 fl. oz. 922-90605 $5.00

Lotrimin Spray 4.6 oz. 922-90943 $11.50

Medicated Corn Remover Pads 9/Ct 922-11950 $2.00 Medicated Foot Powder 4 oz. 922-90607 $5.00

Item Item Number Price Limit

Foot Care (continued) Moleskin Plus 4/Sheets 922-90604 $2.75

Toe Separators - 2 small; 2 medium; 2 large 922-90636 $6.00

Tolnaftate Antifungal Cream .5 oz. 922-90905 $2.00

Zeasorb Athletes Foot Powder 2.5 oz. 922-00324 $9.75

Hemorrhoid Hemorrhoid Relief Ointment 2 oz. 922-90139 $5.00

Medicated Pads 100/Ct 922-90651 $6.00 Preparation H Cooling Gel 0.9 oz. 922-99157 $12.00 Preparation H Suppositories 24/Ct 922-99145 $24.00 Preparation H Totable Wipes 10/Ct 922-99152 $5.75 Suppositories 12/Ct 922-90154 $4.00 Tucks Medicated Pads 40/Ct 922-90940 $7.50

Home Testing Early Result Pregnancy Test 1/Ct 922-00246 $6.00 One Step Pregnancy Test 1/Ct 922-00245 $6.00

Hot and Cold Therapy Advocate Heating Pad Classic 12 in. x 15 in. 922-90890 $20.00 Cooling Eye Reusable Cold Pack 2.5 in. x 5 in. 922-10103 $2.00 Instant Heat Pack 5 in. x 9 in. 922-00067 $1.00 Maximum Strength Cold and Hot Pain Relief Liquid Roll On 2.5 fl. oz.

922-90122 $6.00

Extra Strength Cold and Hot Therapy Patch 5/Ct 922-90459 $5.00 Reusable Ice Bag Medium 9 in. 922-10089 $7.00

Salonpas Deep Relieving Gel 2.75 oz. 922-91030 $12.00

Salonpas Hot-Gel Patch 6/Ct 922-90889 $12.00

Select Heat Heating Pad 12 in. x 14 in. 922-00357 $55.00 1 per month

Thermacare Lower Back and Hip Heatwraps 2/Ct 922-90885 $11.50

Thermacare Muscle and Joint Heatwrap 1/Ct 922-91031 $5.00

Thermacare Neck To Arm Heatwraps 3/Ct 922-90887 $11.50

Therma-Kool Reusable Cold / Hot Pack 6 in. x 9 in. 922-00471 $3.00

Incontinence A & D Original Ointment 1.5 oz. 922-11640 $5.00

Balmex Adult Cream 3 oz. 922-91043 $6.50

Balmex Zinc Oxide Cream 2 oz. 922-91088 $5.00

Flushable Adult Wipes 48/Ct 922-10012 $4.00

Maxi Care 30 in. x 30 in. Absorbent Pads 10/Ct 922-90057 $8.00

Prevail Bladder Control Pads Maximum 48/Ct 922-99161 $15.50


Incontinence (continued) Prevail Bladder Control Pads Moderate 20/Ct 922-99162 $6.00 Prevail Bladder Control Pads Ultra Thin 30/Ct 922-99163 $8.00 Prevail Breezers 360 Briefs Medium with Flexible Stretch Fasteners Waist 26 in. - 48 in. White 16/Ct

922-10495 $16.50

Prevail Breezers 360 Briefs Large with Flexible Stretch Fasteners Waist 45 in. - 62 in. Blue 18/Ct

922-10496 $16.50

Prevail Breezers 360 Briefs XLarge with Flexible Stretch Fasteners Waist 58 in. - 70 in. Beige 15/Ct

922-10497 $16.50

Prevail Male Guard 14/Ct 922-99164 $6.00 Prevail Per-Fit Protective Underwear Women XLarge 14/Ct 922-99160 $14.00 Prevail Per-Fit Protective Underwear Women/Medium 20/Ct 922-99167 $15.00 Prevail Per-Fit Underwear Women/Large 18/Ct 922-99168 $15.00 Prevail Adult Washcloths 48/Ct 922-11089 $4.50 Reusable Bed Pad 34 in. x 36 in. 922-91068 $18.00 Surecare Shield Light-Moderate 25/Ct 922-11090 $8.00 Surecare Underwear Large 45 in. - 54 in. 18/Ct 922-90055 $15.00 Surecare Underwear Medium 34 in. - 46 in. 20/Ct 922-90056 $15.00 Surecare Underwear XL 48 in. - 66 in. 14/Ct 922-90054 $15.00 Vitamin A & D Ointment 4 oz. 922-99094 $2.50

Lactose Dairy Aid Original Strength Caplets 60/Ct 922-11872 $10.00 Dairy Digestive Fast Acting Caplets 60/Ct 922-99052 $15.00 Lactaid Fast Acting Caplets 32/Ct 922-90145 $14.00

Schiff Digestive Advantage Defense Caplets 32/Ct 922-99146 $15.50

Lice Complete Lice Treatment Kit - Includes: Lice Killing Shampoo, Nit Combing Gel and Bedding Spray 922-00247 $20.00

Motion Sickness Medication Acu-Strap Morning and Motion Sickness Band 922-90198 $5.00

Dramamine Tablets 12/Ct 922-90201 $7.00

Motion Sickness Tablets 12/Ct 922-90650 $2.00

Ointments and Topicals Antifungal Cream 1 oz. 922-10752 $4.00

Aveeno Anti-Itch Lotion 4 oz. 922-99056 $9.50

Bacitracin 1 oz. 922-00065 $2.50

Benadryl Extra Itch Cooling Spray 2 oz. 922-99058 $8.50

Calamine Lotion 6 fl. oz. 922-90933 $3.50


Ointments and Topicals (continued) Hydrocortisone 1% Anti-Itch Maximum Strength 922-90935 $3.00

Hydrocortisone Cream 1% 1 oz. 922-10057 $2.25

Itch Relief Cream Extra Soothing 1 oz. 922-90095 $3.75

Neosporin Ointment .5 oz. 922-00835 $8.00

Safetec First Aid Burn Gel 4 oz. 922-90471 $4.25

Triple Antibiotic Ointment Tube 1 oz. 922-00049 $2.50

Triple Antibiotic -Generic Neosporin- Plus 1 oz. 922-90932 $7.00

Ointments and Topicals - Analgesics Aspercreme 1.25 oz. 922-10050 $6.50

Aspercreme Lidocaine No Mess Liquid Roll On 2.5 oz. 922-00328 $10.50

Bengay Greaseless Topical Analgesic Cream 2 oz. 922-10323 $6.75

Cortizone-10 Cream 2 oz. 922-99100 $11.00

Flex-All Ultra Plus 2 oz. 922-91082 $8.00

Icy Hot Cream 1.25 oz. 922-10053 $5.00

Muscle Rub Ultra Strength Pain Relieving Cream 3 oz. 922-90900 $2.75

Muscle and Joint Vanishing Scent Gel 3 oz. 922-90901 $3.00

Ointments and Topicals - Cleaners Alcohol Wipes 200/Ct** 922-00050F $3.00

Bactine Maximum Pain Relieving Spray 5 oz. 922-00329 $9.00

Decolorized Iodine 2 oz. 922-91091 $5.00

J and J Hurt Free Antiseptic Wash 6 oz. 922-10321 $5.50

Pain Relief Acetaminophen Extra Strength Caplets 500mg APAP 100/Ct** 922-90599N $4.00

Acetaminophen Regular Strength Tablets 325mg 100/Ct** 922-90903 $3.00

Advil Coated Tablets 100/Ct** 922-90658 $19.00

Advil Coated Caplets 50/Ct** 922-91077 $11.00

Advil Liqui-Gels 80/Ct** 922-99097 $20.00

Advil Liqui-Gels 20/Ct** 922-91059 $7.00

Advil Migraine Liqui-Gels 20/Ct** 922-99098 $7.00

Advil PM Coated Caplets 40/Ct** 922-91065 $13.00

Advil PM Liqui-Gels 20/Ct** 922-99099 $10.00

Aleve Arthritis Caplets 100/Ct** 922-99116 $20.00

Aleve Easy Open Cap 220mg Gelcaps 40/Ct** 922-11704 $12.00

Aleve Liquid Gels 80/Ct** 922-99117 $25.00

Aleve PM Caplets 20/Ct** 922-99023 $9.25


Pain Relief (continued) Arthritis Pain Relief Tablets APAP 650mg 24/Ct** 922-90601 $4.50

Aspirin 81mg Chewable Tablets Orange 36/Ct** 922-90598 $2.50

Bayer Aspirin Low Dose Tablets 81mg 120/Ct** 922-99026 $13.00

Bayer Aspirin Tablets 325mg 100/Ct** 922-99027 $13.50

Bayer Chewable Aspirin Tablets 81mg Cherry 36/Ct** 922-90662 $5.00

Chewable Aspirin 81mg Tablets Orange 36/Ct** 922-90902 $1.50

Ecotrin Tablets 325mg 125/Ct** 922-00372 $12.50

Excedrin Extra Strength Caplets 100/Ct** 922-99101 $20.00

Excedrin Migraine Caplets 24/Ct** 922-99102 $7.00

Ibuprofen IB Caplets 200mg 100/Ct** 922-90600N $3.00

Icy Hot Smart Relief Tens Kit** 922-99111 $50.00 1 per year

Low Dose Aspirin Tablets 81mg 120/Ct** 922-11876N $2.00

Motrin IB Caplets 100/Ct** 922-90659 $16.00

Motrin IB Caplets 50/Ct** 922-91074 $10.00

Motrin IB Liquid Gels 20/Ct** 922-99103 $7.00

Motrin PM Caplets 20/Ct** 922-99104 $7.00

Naproxen -Generic Aleve- Caplets 220mg 100/Ct** 922-90602N $7.00

Non Aspirin Acetaminophen PM Caplets 500mg 50/Ct** 922-90904 $2.00

Norwich Aspirin Tablets 100/Ct** 922-10880 $3.75

Headache Relief Extra Strength Tablets 50/Ct** 922-99106 $4.00

St. Joseph Low Dose Aspirin Micro Tablets 81mg 120/Ct** 922-91058 $9.00

St. Joseph Low Dose Chewable Aspirin 81mg 36/Ct** 922-91057 $3.00

Tens OTC Accu Dual Channel 3000 Unit 922-99115 $60.00 1 per year



Tylenol PM Caplets 24/Ct** 922-99061 $7.50

Tylenol Regular Strength Tablets 100/Ct** 922-99062 $13.50

Skin Care Abreva Oral Care Pump 2.0 Gram 922-99043 $30.00

Aloe Vera 16 oz. 922-90950 $8.00

Aloe With Lidocaine Gel 8 oz. 922-90951 $6.25

Campho-Phenique Cold Sore Treatment Gel .23 oz. 922-11633 $7.50

Dermarest Medicated Psoriasis Gel 4 fl. oz. 922-00330 $10.00

Gold Bond Eczema Relief Cream 5.5 oz 922-10220 $14.00

Medicated Body Powder 10 oz. 922-90934 $5.00

2nd Skin Scar Gel .52 oz. 922-90121 $12.00


Sleep Aid Melatonin 3mg Tablets 120/Ct 922-00331 $9.50 Melatonin 3mg Tablets 100/Ct 922-00316 $7.50 Sleep Aid -Generic Unisom- 16/Ct 922-90927 $4.50 Sleep Aid -Generic Sominex- 32/Ct 922-90925 $3.25 Unisom Sleep Gels 32/Ct 922-10225 $15.00

Smoking Cessation Nicotine Gum 2mg - 40/Ct 922-99913 $38.00 Nicotine Gum 4mg - 40/Ct 922-99914 $39.50 Nicotine Lozenges 4mg - 72/Ct 922-99916 $60.00 Nicotine Lozenges 2mg - 72/Ct 922-99915 $60.00 Nicotine Patch Step 1 - 21mg - 7/Ct 922-99918 $30.00 Nicotine Patch Step 2 - 14mg - 7/Ct 922-99917 $30.00 Nicotine Patch Step 3 - 7mg - 7/Ct 922-99919 $30.00

Stomach and Laxatives Anti-Diarrheal Tablets 2mg 24/Ct 922-90120 $4.75 Anti-Nausea Liquid Cherry 4 oz. 922-90596 $3.50 Beano Tablets 30/Ct 922-11824 $7.25 Enema Adult 4.5 oz. 922-90918 $2.50 Equalactin Chews 48/Ct 922-00333 $11.25 Ex-Lax Chocolate 24/Ct 922-91053 $7.50 Gas-X Extra Strength Softgels 10/Ct 922-91052 $4.25 Gas Relief And Prevention Caplets 20/Ct 922-91054 $6.00 Generic Tums 96/Ct 922-90919 $5.00 Gentle Stool Softener 25/Ct 922-90590 $3.00 Imodium AD Caplets 24/Ct 922-00836 $18.00

Imodium Liquid 4 oz. 922-90657 $9.75

Laxative Bisocodyl 25/Ct 922-90589 $3.00

Miralax OTC 7 Dose 4.1 oz. 922-90883 $11.00

Phillips Stool Softner 30/Ct 922-99035 $7.00

Senna Laxative Tablets 100/Ct 922-90644 $4.50

Stomach - Antacids and Acid Reducers Alka-Seltzer Original Foil Tablets 36/Ct 922-91048 $8.00

Alka-Seltzer Heartburn Relief Chews Assorted 36/Ct 922-99025 $8.25

Chewy Delights Cherry -Generic Tums- 32/Ct 922-00335 $5.00

Famotidine Acid Reducer Tablets 10mg -Generic Pepcid- 30/Ct** 922-90648 $7.00

Lansoprazole -Generic Prevacid- 15mg Tablets 14/Ct** 922-90984 $16.50


Stomach - Antacids and Acid Reducers (continued)Omeprazole 20mg Tablets -Generic Prilosec- 14/Ct** 922-91070 $16.75

Omeprazole 20mg Tablets -Generic Prilosec- 28/Ct** 922-90982 $31.00

Pepcid Complete Cool Mint Chewable Tablets 25/Ct 922-00206 $17.00

Pepto Bismol 4 fl. oz. 922-90923 $5.00

Prelief Dietary Supplement Caplets 120/Ct 922-00334 $15.00

Prevacid 24 Hour 15mg OTC Tablets 14/Ct** 922-90978 $22.00

Prilosec 20mg OTC Tablets 14/Ct** 922-91075 $20.00

Prilosec 20mg OTC Tablets 28/Ct** 922-99105 $36.00 2 per month

Ranitidine 75mg Tablets 30/Ct 922-90594 $7.00

Rolaids Ultra Antacid Chewable Tablets Fruit 72/Ct 922-99156 $8.00

Rolaids Advanced Antacid Plus Anti-Gas Chewable Tablets 60/Ct 922-99154 $7.25

Rolaids Softchews Antacid -Flavors Vary- 12/Ct 922-99155 $4.00

Tums 96/Ct Flavors Vary 922-90466 $9.00

Tums Chewy Delights Cherry 32/Ct 922-00336 $8.00

Ultra Strength Antacid Calcium Chewable Tablets -Flavors Vary- 72/Ct 922-99144 $4.50

Zantac 150 Maximum Strength Tablets 24/Ct** 922-00172 $16.50

Sunscreen Coppertone Sunscreen SPF 30 - 8 oz. 922-90058 $15.00

Sunscreen SPF 50 - 8 oz. 922-90063 $7.50

Support - Ankle (Dual Purpose)Adjustable Ankle Support 922-10007 $12.00

Procare Elastic Ankle Support Large 922-90618 $6.00

Procare Elastic Ankle Support Medium 922-90619 $6.00

Procare Elastic Ankle Support Small 922-90620 $6.00

Procare Elastic Ankle Support XL 922-90621 $6.00

Procare Elastic Ankle Support XXL 922-90629 $6.00

Support - Back (Dual Purpose)Back Stabilizer Large 39 in. - 50 in. 922-90208 $48.00 1 per quarter

Futuro Back Support Small / Medium 29 in. - 39 in. 922-90449 $45.00 1 per quarter

Mueller Back Brace Adjustable 28 in. - 50 in. 922-90209 $27.00

Mueller Back Brace Lumbar Universal Fits 28 in. - 50 in. Waist 922-90210 $38.00 1 per quarter

Support - Elbow (Dual Purpose)Neoprene Elbow Support - One Size Fits All 922-10790 $18.00

Procare Elbow Support Large 10 in. - 11.5 in. 922-90626 $6.50


Support - Elbow (continued) (Dual Purpose)Procare Elastic Elbow Support Small 8 in. - 9 in. 922-90627 $6.50

Procare Elbow Support XL 11.5 in. - 13 in. 922-90628 $7.00

Tera-Prene Tennis Elbow Sleeve XL 12 in. - 14 in. 922-99089 $24.00 1 per quarter

Support - Knee (Dual Purpose)DJ Orthopedics Reddie Brace 2XL 19 in. 922-99084 $58.00 1 per quarter

DJ Orthopedics Reddie Brace XL 17 in. - 19 in. 922-99923 $57.00 1 per quarter

DJ Orthopedics Reddie Brace Large 15 in. -17 in. 922-99922 $57.00 1 per quarter

DJ Orthopedics Reddie Brace Medium 14 in. - 15 in. 922-99921 $57.00 1 per quarter

DJ Orthopedics Reddie Brace Small 13 in. - 14 in. 922-99920 $57.00 1 per quarter

Extra Large Scott Specialties Tera-Prene Knee Support 21.75 in 922-99088 $37.00 1 per quarter

Procare Support - Knee Large 20.5 in. - 23 in. 922-90622 $6.00

Procare Support - Knee Medium 18 in. - 20.5 in. 922-90623 $6.00

Procare Support - Knee Small 15.5 in. - 18 in. 922-90624 $6.00

Procare Support - Knee X-Large 23 in. - 25.5 in. 922-90625 $6.00

Support - Stockings (Dual Purpose)Mens Black Light Support - Extra Large 15-20 mmHg 922-00369 $30.00

Mens Black Light Support - Large 15-20 mmHg 922-00368 $30.00

Mens Black Light Support - Medium 15-20 mmHg 922-00367 $30.00

Mens Black Light Support - Small 15-20 mmHg 922-00366 $30.00

Unisex Beige Firm Support - Extra Large 30-40 mmHg 922-00389 $32.00

Unisex Beige Firm Support - Large 30-40 mmHg 922-00388 $32.00

Unisex Beige Firm Support - Medium 30-40 mmHg 922-00387 $32.00

Unisex Beige Firm Support - Small 30-40 mmHg 922-00386 $32.00

Unisex Beige Medium Support - Extra Large 20-30 mmHg 922-00385 $30.00

Unisex Beige Medium Support - Large 20-30 mmHg 922-00384 $30.00

Unisex Beige Medium Support - Medium 20-30 mmHg 922-00383 $30.00

Unisex Beige Medium Support - Small 20-30 mmHg 922-00382 $30.00

Womens Beige Light Support - Extra Large 15-20 mmHg 922-00365 $30.00

Womens Beige Light Support - Large 15-20 mmHg 922-00364 $30.00

Womens Beige Light Support - Medium 15-20 mmHg 922-00363 $30.00

Womens Beige Light Support - Small 15-20 mmHg 922-00362 $30.00

Supports - Wrist (Dual Purpose)Adjustable Wrist Support Unisize 922-91095 $9.00

Quick-Fit Wrist Support Left Unisize 922-91096 $27.00 1 per quarter

Quick-Fit Wrist Support Right Unisize 922-99119 $27.00 1 per quarter


Supports - Wrist (continued) (Dual Purpose)Wristlet 922-91097 $4.00

Vitamins, Minerals and Supplements (Dual Purpose)Vitamin B-6 50mg Tablets 100/Ct 922-90577 $4.00

B-12 1000mcg Melts 100/Ct 922-00294 $9.50

Vitamin B-12 250mcg Tablets 100/Ct 922-11864 $5.50

Vitamin B-12 500mcg Tablets 100/Ct 922-91083 $11.00

B-Complex Softgels 100/Ct *DOES NOT CONTAIN B-12 922-90298 $8.00

Sustain Release B-Complex Tablets 60/Ct 922-11863 $8.50

Vitamin C Chewables Wafers 500mg 60/Ct 922-00350 $12.00

Vitamin C-500 Tablets 100/Ct 922-11861 $5.00

Vitamin C 1000mg Tablets 100/Ct 922-00349 $17.00

Calcium 500mg + D Tablets 130/Ct 922-00339 $12.00

Calcium 600mg + D 200 IU Tablets 60/Ct 922-90230 $3.00

Chocolate Calcium Chews 60/Ct 922-90966 $6.25

Oyster Shell 500mg Plus D Tablets 150/Ct 922-90237 $6.00

Vitamin D 5000 IU Softgels 100/Ct 922-99073 $23.00

Vitamin D 400 IU Tablets 100/Ct 922-90309 $3.00

Vitamin E 100 IU Dl-Alpha Softgels 100/Ct 922-90316 $4.00

Windmill Vitamin E-400 IU Dl-Alpha Softgels 90/Ct 922-11862 $9.50

Folic Acid 400mcg Tablets 250/Ct 922-00343 $7.00

Ferosul 5 Iron Tablets 100/Ct 922-90245 $3.00

Iron 65mg Tablets 180/Ct 922-00346 $10.25

K 100mcg Tablets 100/Ct 922-99069 $4.50

Magnesium Citrate 250mg Softgels 60/Ct 922-00347 $15.00

Centrum Men MultiGummies 70/Ct 922-00833 $12.00

Centrum Women MultiGummies 70/Ct 922-00832 $12.00

Daily Men/Women Maximum Vitamin Pak 30/Ct 922-00361 $23.00

Daily One Multivitamin For Women 100/Ct 922-90961 $10.00

Generic Centrum Silver 125/Ct 922-00345 $8.00

Multi-Vitamin with Iron 100/Ct 922-90257 $5.00

One A Day Men's 50plus Advantage 65/Ct 922-90664 $14.00

One A Day Proactive 65plus For Men And Women 150/Ct 922-99033 $14.00

One A Day Women's 50plus Advantage 65/Ct 922-90663 $14.00

Potassium Gluconate 595mg Tablets 100/Ct 922-99076 $7.00

Airborne Gummies Berry/Citrus 21/Ct

Co Q10 100mg Softgels 40/Ct

922-00837 $10.50

922-00360 $30.00


Vitamins, Minerals and Supplements (continued) (Dual Purpose)Co Q10 50mg Gummies 60/Ct 922-00341 $22.00

Fish Oil Cholesterol Free 1000mg Softgels 120/Ct 922-90964 $7.25

Glucoflex Glucosamine and Chondroitin Caplets 60/Ct 922-11869 $16.25

Zinc Lozenges with Vitamin C 50/Ct 922-00248 $7.00

Weight Loss - Kitchen Scales Digital Kitchen Scale 922-01080 $25.00 2 per year

Digital Stainless Steel Food Scale 922-01081 $28.00 1 per year

WellCare OTC Mail Order Form For Benefit period

Member Name: _____________________________________________________________________________Member ID:_________________________________________Date of Birth: ____________________________

Ship To: ___________________________________________________________________________________Address: __________________________________________________________________________________Apt./Room #:__________________City:________________________State:________Zip: _________________Phone: ( ____ ) _____________________________________________________________________________Alternate Contact: __________________________________________________________________________Phone: ( ____ ) _____________________________________________________________________________

Item # Description Qty Price Total

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Total:

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Cut H

ere

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 (TTY: 711).�

ظوحلم رفاوتت ةيوغللا ةدعاسملا تامدخ نإف ،ةغللا ركذا ثدحتت تنك اذإ :ةقرب لصتا .ناجملاب كل م4056-374-877-1.(711 :مكبلاو مصلا فتاه مقر)

ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 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).�

UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-877-374-4056 (TTY: 711).�

ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 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。 ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-877-374-4056 (TTY: 711).�

Y0070_WCM_35764M_CInternalApproved06182019

©WellCare2019NA0WCMINS36994E_CMBO

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 (TTY: 711).

مقرب لصتا .ناجملاب كل رفاوتت ةيوغللا ةدعاسملا تامدخ نإف ،ةغللا ركذا ثدحتت تنك اذإ :ةظوحلم.(711 :مكبلاو مصلا فتاه مقر) 1-877-374-4056

ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele 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).

UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer 1-877-374-4056 (TTY: 711).

ATENÇÃO: Se fala português, encontram-se disponíveis serviços linguísticos, grátis. Ligue para 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。ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-877-374-4056 (TTY: 711).

NA0WCMINS41542K_CMBOY0070_WCM_35764M_C Internal Approved 05292019©WellCare 2019

گیار تروصب ینابز تالیهست ،دینک یم وگتفگ یسراف نابز هب رگا :هجوتنا اب .دشاب یم مهارف امش یارب(TTY: 711) 4056-374-877-1.دیریگب سامت

धयान द: यदि आप हिदी बोलत ह तो आपक लिए मफत म भाषा सहायता सवाए उपलबध ह। 1-877-374-4056 (TTY:711) पर कॉल कर।

ՈՒՇԱԴՐՈՒԹՅՈՒՆ՝ Եթե խոսում եք հայերեն, ապա ձեզ անվճար կարող են տրամադրվել լեզվական աջակցության ծառայություններ: Զանգահարեք 1-877-374-4056 (TTY (հեռատիպ)՝ 711).

સચના: જો તમ ગજરાતી બોલતા હો, તો નિ:શલક ભાષા સહાય સવાઓ તમારા માટ ઉપલબધ છ. ફોન કરો 1-877-374-4056 (TTY: 711).�

LUS CEEV: Yog tias koj hais lus Hmoob, cov kev pab txog lus, muaj kev pab dawb rau koj. Hu rau 1-877-374-4056 (TTY: 711).�

4056-374-877-1ں ریکال ک۔ ںیہاب یتدسں یمتفمات دمخیکدد میکان زبو کآپ وتں، یہےتولباردو آپ راگردار: بخ(TTY: 711).

បរយតន៖ បើសនជាអនកនយាយ ភាសាខមររ, សរវាជនយផនរកភាសា ដោយមនគតឈនល គអាចមានសរាបបរើអនក។ ចរ ទរសពទ 1-877-374-4056 (TTY: 711)។

ਧਿਆਨ ਦਿਓ: ਜ ਤਸੀ ਪਜਾਬੀ ਬਲਦ ਹ, ਤਾ ਭਾਸਾ ਵਿਚ ਸਹਾਇਤਾ ਸਵਾ ਤਹਾਡ ਲਈ ਮਫਤ ਉਪਲਬਧ ਹ। 1-877-374-4056 (TTY: 711) ‘ਤ ਕਾਲ ਕਰ।. লকষয করনঃ যদি আপনি বাংলা, কথা বলতে পারেন, তাহলে নিঃখরচায ভাষা সহাযতা পরিষেবা উপলবধ আছে। ফোন করন ১-877-374-4056 (TTY: 711)।

טפור .לאצפא ןופ יירפ סעסיוורעס ףליה ךארפש ךייא ראפ ןאהראפ ןענעז ,שידיא טדער ריא ביוא :םאזקרעמפיוא1-877-374-4056 (TTY: 711).�

MO LOU SILAFIA: Afai e te tautala Gagana fa’a Sāmoa, o loo iai auaunaga fesoasoan, e fai fua e leai se totogi, mo oe, Telefoni mai: 1-877-374-4056 (TTY: 711).�

ማስታወሻ: የሚናገሩት ቋንቋ ኣማርኛ ከሆነ የትርጉም እርዳታ ድርጅቶች፣ በነጻ ሊያግዝዎት ተዘጋጀተዋል፡ ወደ ሚከተለው ቁጥር ይደውሉ 1-877-374-4056 (መስማት ለተሳናቸው: 711).

เรยน: ถาคณพดภาษาไทยคณสามารถใชบรการชวยเหลอทางภาษาไดฟร โทร 1-877-374-4056 (TTY: 711).�

XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa 1-877-374-4056 (TTY: 711).�

Wann du [Deitsch (Pennsylvania German / Dutch)] schwetzscht, kannscht du mitaus Koschte ebber gricke, ass dihr helft mit die englisch Schprooch. Ruf selli Nummer uff: Call 1-877-374-4056 (TTY: 711).�

ATENSIÓN: Yanggen un tungó [I linguahén Chamoru], i setbision linguahé gaige para hagu dibatde ha. Agang I 1-877-374-4056 (TTY: 711).�

ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε 1-877-374-4056 (TTY: 711).�

PAKDAAR: Nu saritaem ti Ilocano, ti serbisyo para ti baddang ti lengguahe nga awanan bayadna, ket sidadaan para kenyam. Awagan ti 1-877-374-4056 (TTY: 711).

ໂປດຊາບ: ຖາວາ ທານເວາພາສາ ລາວ, ການບລການຊວຍເຫອດານພາສາ, ໂດຍບເສຽຄາ, ແມນມພອມໃຫທານ. ໂທຣ 1-877-374-4056 (TTY: 711).

D&& BAA AK) N&N&ZIN: D77 Din4 bizaad bee y1n7[ti’go, saad bee 1k1’1nida’1wo’d66’, t’11 jiik’eh, n1 h0l=. Koj8’ h0d77lnih 1-877-374-4056 (TTY: 711).

KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në 1-877-374-4056 (TTY: 711).

OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite 1-877-374-4056 (TTY-Telefon za osobe sa oštećenim govorom ili sluhom: 711).

УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної служби мовної підтримки. Телефонуйте за номером 1-877-374-4056 (телетайп: 711).

ܐܢܫܒܠܐܪܬܝܕܗܐ ܬܠܡܚܢܬܘܒܠܝܕܩܢܬܘܨܝܡܐ،ܝܪܬܘܐܐܢܫܠܢܬܘܡܝܡܙܗܐܟܢܘܚܬܐܢܐܐ:ܪܗܙܘ).711 (TTY: 4056-374-877-1ܐ ܢܢܝܡܠܥܢܪܘܩܬ.ܐܝܢܓܡ

Ige nti: O buru na asu Ibo asusu, enyemaka diri gi site na call 1-877-374-4056 (TTY: 711).

धयान दिनहोस: तपारइल नपाली बोलनहनछ भन तपारइको निमति भाषा सहायता सवाहर निःशलक रपमा उपलबध छ । फोन गरनहोस 1-877-374-4056 (टिटिवाइ: 711) ।

AANDACHT: Als u nederlands spreekt, kunt u gratis gebruikmaken van de taalkundige diensten. Bel 1-877-374-4056 (TTY: 711).

ymol.ymo;= erh>uwdRAunD AusdmtCd<AerRM>Ausdmtw>rRpXRvXAwvXmbl.vXmphRAeDwrHRb.ohM. vDRIAud; 1-877-374-4056 (TTY: 711).

LALE: Ñe kwōj kōnono Kajin Ṃajōḷ, kwomaroñ bōk jerbal in jipañ ilo kajin ṇe aṃ ejjeḷọk wōṇāān. Kaalọk 1-877-374-4056 (TTY: 711).

သတျပရန - အကယ၍ သငသည ျမနမာစကား က ေျပာပါက၊ ဘာသာစကား အကအည၊ အခမ၊ သငအတြက စစဥေဆာငရြကေပးပါမည။ ဖနးနပါတ 1-877-374-4056 (TTY: 711) သ႔ ေခၚဆပါ။.

ATENȚIE: Dacă vorbiți limba română, vă stau la dispoziție servicii de asistență lingvistică, gratuit. Sunați la 1-877-374-4056 (TTY: 711).

MEI AUCHEA: Ika iei foosun fonuomw: Foosun Chuuk, iwe en mei tongeni omw kopwe angei aninisin chiakku, ese kamo. Kori 1-877-374-4056 (TTY: 711).

E NĀNĀ MAI: Inā hoʻopuka ʻoe i ka ʻōlelo [hoʻokomo ʻōlelo], loaʻa ke kōkua manuahi iā ʻoe. E kelepona iā 1-877-374-4056 (TTY: 711).

FAKATOKANGA’I: Kapau ‘oku ke Lea-Fakatonga, ko e kau tokoni fakatonu lea ‘oku nau fai atu ha tokoni ta’etotongi, pea teke lava ‘o ma’u ia. Telefoni mai 1-877-374-4056 (TTY: 711).

PAKDAAR: Nu saritaem ti Ilocano, ti serbisyo para ti baddang ti lengguahe nga awanan bayadna, ket sidadaan para kenyam. Awagan ti 1-877-374-4056 (TTY: 711).

ໂປດຊາບ: ຖາວາ ທານເວາພາສາ ລາວ, ການບລການຊວຍເຫອດານພາສາ, ໂດຍບເສຽຄາ, ແມນມພອມໃຫທານ. ໂທຣ 1-877-374-4056 (TTY: 711).

D&& BAA AK) N&N&ZIN: D77 Din4 bizaad bee y1n7[ti’go, saad bee 1k1’1nida’1wo’d66’, t’11 jiik’eh, n1 h0l=. Koj8’ h0d77lnih 1-877-374-4056 (TTY: 711).

KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në 1-877-374-4056 (TTY: 711).

OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite 1-877-374-4056 (TTY-Telefon za osobe sa oštećenim govorom ili sluhom: 711).

УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до безкоштовної служби мовної підтримки. Телефонуйте за номером 1-877-374-4056(телетайп: 711).

ܒܠܫܢܐ ܐܚܠܡܬܐ ܕܗܝܪܬ ܡܨܝܬܘܢ ܕܩܒܠܝܬܘܢ ܝܐ،

ܐܬܘܪ ܠܫܢܐ ܗܡܙܡܝܬܘܢ ܟܐ ܐܚܬܘܢ ܐܢ ܐ:

ܙܘܗܪ

1-877-374-4056 ܡܢܝܢܐ ܥܠ ܩܪܘܢ .(TTY: 711) ܡܓܢܐܝܬ.

Ige nti: O buru na asu Ibo asusu, enyemaka diri gi site na call 1-877-374-4056 (TTY: 711).

धयान दिनहोस: तपारइल नपाली बोलनहनछ भन तपारइको निमति भाषा सहायता सवाहर निःशलक रपमा उपलबध छ । फोन गरनहोस 1-877-374-4056 (टिटिवाइ: 711) ।

AANDACHT: Als u nederlands spreekt, kunt u gratis gebruikmaken van de taalkundige diensten. Bel 1-877-374-4056 (TTY: 711).

ymol.ymo;= erh>uwdRAunD AusdmtCd<AerRM>Ausdmtw>rRpXRvXAwvXmbl.vXmphRAeDwrHRb.ohM. vDRIAud;

1-877-374-4056 (TTY: 711).

LALE: Ñe kwōj kōnono Kajin Ṃajōḷ, kwomaroñ bōk jerbal in jipañ ilo kajin ṇe aṃ ejjeḷọk wōṇāān. Kaalọk 1-877-374-4056 (TTY: 711).

သတျပရန - အကယ၍ သငသည ျမနမာစကား က ေျပာပါက၊ ဘာသာစကား အကအည၊ အခမ၊ သငအတြက စစဥေဆာငရြကေပးပါမည။ ဖနးနပါတ 1-877-374-4056 (TTY: 711) သ႔ ေခၚဆပါ။.

ATENȚIE: Dacă vorbiți limba română, vă stau la dispoziție servicii de asistențălingvistică, gratuit. Sunați la 1-877-374-4056 (TTY: 711).

MEI AUCHEA: Ika iei foosun fonuomw: Foosun Chuuk, iwe en mei tongeni omw kopwe angei aninisin chiakku, ese kamo. Kori 1-877-374-4056 (TTY: 711).

E NĀNĀ MAI: Inā hoʻopuka ʻoe i ka ʻōlelo [hoʻokomo ʻōlelo], loaʻa ke kōkua manuahi iā ʻoe. E kelepona iā 1-877-374-4056 (TTY: 711).

FAKATOKANGA’I: Kapau ‘oku ke Lea-Fakatonga, ko e kau tokoni fakatonu lea ‘oku naufai atu ha tokoni ta’etotongi, pea teke lava ‘o ma’u ia. Telefoni mai 1-877-374-4056 (TTY: 711).

Ni songen mwohmw ohte, komw pahn sohte anahne kawehwe mesen nting me koatoantoal kan ahpw wasa me ntingie [Lokaiahn Pohnpei] komw kalangan oh ntingidieng ni lokaiahn Pohnpei. Call 1-877-374-4056 (TTY: 711).

ICITONDERWA: Nimba uvuga Ikirundi, uzohabwa serivisi zo gufasha mu ndimi, ku buntu. Woterefona 1-877-374-4056 (TTY: 711).

ATENSYON: Kung nagsulti ka og Cebuano, aduna kay magamit nga mga serbisyo sa tabang sa lengguwahe, nga walay bayad. Tawag sa 1-877-374-4056 (TTY: 711).

ANOMPA PA PISAH: [Chahta] makilla ish anompoli hokma, kvna hosh Nahollo Anompa ya pipilla hosh chi tosholahinla. Atoko, hattak yvmma im anompoli chi bvnnakmvt, holhtina pa payah: 1-877-374-4056 (TTY: 711).

KUMBUKA: Ikiwa unazungumza Kiswahili, unaweza kupata, huduma za lugha, bila malipo. Piga simu 1-877-374-4056 (TTY: 711).

Hagsesda: iyuhno hyiwoniha [tsalagi gawonihisdi]. Call 1-877-374-4056 (TTY: 711).

PERHATIAN: Jika Anda berbicara dalam Bahasa Indonesia, layanan bantuan bahasa akan tersedia secara gratis. Hubungi 1-877-374-4056 (TTY: 711).

DİKKAT: Eğer Türkçe konuşuyor iseniz, dil yardımı hizmetlerinden ücretsiz olarak yararlanabilirsiniz. 1-877-374-4056 (TTY: 711) irtibat numaralarını arayın.

ای یناکەیرازوگتەمزخ ،تیەکەد ەسەق یدروک ینامز ەب رەگەئ :یراداگائ،نامز یتەمر ەب یدنەویەپ .ەتسەدرەب ۆت ۆب ،ییاڕۆخەب TTY (1-877-374-4056)711.ەکب

ICITONDERWA: Nimba uvuga Ikirundi, uzohabwa serivisi zo gufasha mu ndimi, ku buntu. Woterefona 1-877-374-4056 (TTY: 711).

శరదధ పటటండ: ఒకవళ మరు తలుగు భష మటలడుతుననటలయత, మ కరకు తలుగు భష సహయక సవలు ఉచతంగ లభసతయ. 1-877-374-4056 (TTY: 711) కు కల చయండ.

PIŊ KENE: Na ye jam në Thuɔŋjaŋ, ke kuɔny yenë kɔc waar thook atɔ kuka lëu yök abac ke cïn wënh cuatë piny. Yuɔpë 1-877-374-4056 (TTY: 711).

MERK: Hvis du snakker norsk, er gratis språkassistansetjenester tilgjengelige for deg. Ring 1-877-374-4056 (TTY: 711).

ATENCIÓ: Si parleu Català, teniu disponible un servei d”ajuda lingüística sense cap càrrec. Truqueu al 1-877-374-4056 (TTY o teletip: 711).

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_15342E ©WellCare2018 NJ9WCMINS15342E_0000Y0070_WCM_40136E_C©WellCare2019

NA0WCMINS36994E_CMBO

mailto:[email protected]

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf

http://www.hhs.gov/ocr/office/file/index.html

WellCare Health Plans, Inc., is an HMO plan with a Medicare contract. Enrollment in our plans depends on contract renewal. Please contact your plan for details.

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