Summary of BenefitsMedicare Advantage Plans
IllinoisChampaign, Cook, Douglas, Kane, Kankakee, Knox, Madison, Monroe, Peoria, St. Clair, Tazewell,
Vermilion, Washington, Will
Harmony Health Plan of Illinois, Inc. | H1416
01/01/13 - 12/31/13
WellCare Value (HMO-POS)
009
H1416_IL019382_WCM_SOB_ENG CMS Accepted©WellCare 2012 IL_06_12
IL330SB46229E
Thank you for your interest in WellCare Value (HMO-POS). Our plan is offered by Harmony HealthPlan of Illinois, Inc./WellCare, a Medicare Advantage Health Maintenance Organization (HMO), witha point-of-service option (POS) that contracts with the Federal government. This Summary ofBenefits tells you some features of our plan. It doesn't list every service that we cover or list everylimitation or exclusion. To get a complete list of our benefits, please call WellCare Value (HMO-POS)and ask for the "Evidence of Coverage".
You have choices in your health care
As a Medicare beneficiary, you can choose from different Medicare options. One option is theOriginal (fee-for-service) Medicare Plan. Another option is a Medicare health plan, like WellCareValue (HMO-POS). You may have other options too. You make the choice. No matter what youdecide, you are still in the Medicare Program.
You may join or leave a plan only at certain times. Please call WellCare Value (HMO-POS) at thenumber listed at the end of this introduction or 1-800-MEDICARE (1-800-633-4227) for moreinformation. TTY/TDD users should call 1-877-486-2048. You can call this number 24 hours a day,7 days a week.
How can I compare my options?
You can compare WellCare Value (HMO-POS) and the Original Medicare Plan using this Summaryof Benefits. The charts in this booklet list some important health benefits. For each benefit, youcan see what our plan covers and what the Original Medicare Plan covers.
Our members receive all of the benefits that the Original Medicare Plan offers. We also offer morebenefits, which may change from year to year.
Where is WellCare Value (HMO-POS) available?
The service area for this plan includes: Champaign, Cook, Douglas, Kane, Kankakee, Knox, Madison,Monroe, Peoria, St. Clair, Tazewell, Vermilion, Washington, Will Counties, IL. You must live in oneof these areas to join the plan.
Who is eligible to join WellCare Value (HMO-POS)?
You can join WellCare Value (HMO-POS) if you are entitled to Medicare Part A and enrolled inMedicare Part B and live in the service area. However, individuals with End-Stage Renal Disease aregenerally not eligible to enroll in WellCare Value (HMO-POS) unless they are members of ourorganization and have been since their dialysis began.
Can I choose my doctors?
WellCare Value (HMO-POS) has formed a network of doctors, specialists, and hospitals. You canuse any doctor who is part of our network. In some cases, you may also go to doctors outside ofour network. The health providers in our network can change at any time.
Summary of Benefits | 1
Section I - Introduction to Summary of Benefits
You can ask for a current provider directory. For an updated list, visit us at www.wellcare.com. Ourcustomer service number is listed at the end of this introduction.
What happens if I go to a doctor who's not in your network?
Generally, you are restricted to a doctor who is part of your network. However, we will cover yourcare from any provider for emergency or urgently needed care. Also, our point of service benefitallows you to get care from providers not in your network under certain conditions. For moreinformation, please call the customer service number listed at the end of this introduction.
Where can I get my prescriptions if I join this plan?
WellCare Value (HMO-POS) has formed a network of pharmacies. You must use a network pharmacyto receive plan benefits. We may not pay for your prescriptions if you use an out-of-networkpharmacy, except in certain cases. The pharmacies in our network can change at any time. You canask for a pharmacy directory or visit us at www.wellcare.com. Our customer service number islisted at the end of this introduction.
WellCare Value (HMO-POS) has a list of preferred pharmacies. At these pharmacies, you may getyour drugs at a lower co-pay or coinsurance. You may go to a non-preferred pharmacy, but youmay have to pay more for your prescription drugs.
Does my plan cover Medicare Part B or Part D drugs?
WellCare Value (HMO-POS) does cover both Medicare Part B prescription drugs and Medicare PartD prescription drugs.
What is a prescription drug formulary?
WellCare Value (HMO-POS) uses a formulary. A formulary is a list of drugs covered by your planto meet patient needs. We may periodically add, remove, or make changes to coverage limitationson certain drugs or change how much you pay for a drug. If we make any formulary change thatlimits our members' ability to fill their prescriptions, we will notify the affected members beforethe change is made. We will send a formulary to you and you can see our complete formulary onour website at www.wellcare.com.
If you are currently taking a drug that is not on our formulary or subject to additional requirementsor limits, you may be able to get a temporary supply of the drug. You can contact us to requestan exception or switch to an alternative drug listed on our formulary with your physician's help.Call us to see if you can get a temporary supply of the drug or for more details about our drugtransition policy.
How can I get extra help with my prescription drug plan costs or get extrahelp with other Medicare costs?
You may be able to get extra help to pay for your prescription drug premiums and costs as wellas get help with other Medicare costs. To see if you qualify for getting extra help, call:
Summary of Benefits | 2
Section I - Introduction to Summary of Benefits
1 1-800-MEDICARE (1-800-633-4227). TTY/TDD users should call 1-877-486-2048, 24 hours a day/7days a week and see www.medicare.gov 'Programs for People with Limited Income and Resources'in the publication Medicare & You.1 The Social Security Administration at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through
Friday. TTY/TDD users should call 1-800-325-0778 or1 Your State Medicaid Office.
What are my protections in this plan?
All Medicare Advantage Plans agree to stay in the program for a full calendar year at a time. Planbenefits and cost-sharing may change from calendar year to calendar year. Each year, plans candecide whether to continue to participate with Medicare Advantage. A plan may continue in theirentire service area (geographic area where the plan accepts members) or choose to continue onlyin certain areas. Also, Medicare may decide to end a contract with a plan. Even if your MedicareAdvantage Plan leaves the program, you will not lose Medicare coverage. If a plan decides not tocontinue for an additional calendar year, it must send you a letter at least 90 days before yourcoverage will end. The letter will explain your options for Medicare coverage in your area.
As a member of WellCare Value (HMO-POS), you have the right to request an organizationdetermination, which includes the right to file an appeal if we deny coverage for an item or service,and the right to file a grievance. You have the right to request an organization determination ifyou want us to provide or pay for an item or service that you believe should be covered. If wedeny coverage for your requested item or service, you have the right to appeal and ask us to reviewour decision. You may ask us for an expedited (fast) coverage determination or appeal if you believethat waiting for a decision could seriously put your life or health at risk, or affect your ability toregain maximum function. If your doctor makes or supports the expedited request, we mustexpedite our decision. Finally, you have the right to file a grievance with us if you have any typeof problem with us or one of our network providers that does not involve coverage for an itemor service. If your problem involves quality of care, you also have the right to file a grievance withthe Quality Improvement Organization (QIO) for your state. Please refer to the Evidence of Coverage(EOC) for the QIO contact information.
As a member of WellCare Value (HMO-POS), you have the right to request a coverage determination,which includes the right to request an exception, the right to file an appeal if we deny coveragefor a prescription drug, and the right to file a grievance. You have the right to request a coveragedetermination if you want us to cover a Part D drug that you believe should be covered. Anexception is a type of coverage determination. You may ask us for an exception if you believe youneed a drug that is not on our list of covered drugs or believe you should get a non-preferred drugat a lower out-of-pocket cost. You can also ask for an exception to cost utilization rules, such asa limit on the quantity of a drug. If you think you need an exception, you should contact us beforeyou try to fill your prescription at a pharmacy. Your doctor must provide a statement to supportyour exception request. If we deny coverage for your prescription drug(s), you have the right toappeal and ask us to review our decision. Finally, you have the right to file a grievance if you haveany type of problem with us or one of our network pharmacies that does not involve coverage
Summary of Benefits | 3
Section I - Introduction to Summary of Benefits
for a prescription drug. If your problem involves quality of care, you also have the right to file agrievance with the Quality Improvement Organization (QIO) for your state. Please refer to theEvidence of Coverage (EOC) for the QIO contact information.
What is a Medication Therapy Management (MTM) program?
A Medication Therapy Management (MTM) Program is a free service we offer. You may be invitedto participate in a program designed for your specific health and pharmacy needs. You may decidenot to participate but it is recommended that you take full advantage of this covered service ifyou are selected. Contact WellCare Value (HMO-POS) for more details.
What types of drugs may be covered under Medicare Part B?
Some outpatient prescription drugs may be covered under Medicare Part B. These may include,but are not limited to, the following types of drugs. Contact WellCare Value (HMO-POS) for moredetails.
1 Some Antigens: If they are prepared by a doctor and administered by a properly instructedperson (who could be the patient) under doctor supervision.1 Osteoporosis Drugs: Injectable osteoporosis drugs for some women.1 Erythropoietin (Epoetin Alfa or Epogen®): By injection if you have end-stage renal disease
(permanent kidney failure requiring either dialysis or transplantation) and need this drug to treatanemia.1 Hemophilia Clotting Factors: Self-administered clotting factors if you have hemophilia.1 Injectable Drugs: Most injectable drugs administered incident to a physician's service.1 Immunosuppressive Drugs: Immunosuppressive drug therapy for transplant patients if the
transplant took place in a Medicare-certified facility and was paid for by Medicare or by a privateinsurance company that was the primary payer for Medicare Part A coverage.1 Some Oral Cancer Drugs: If the same drug is available in injectable form.1 Oral Anti-Nausea Drugs: If you are part of an anti-cancer chemotherapeutic regimen.1 Inhalation and Infusion Drugs administered through Durable Medical Equipment.
Where can I find information on plan ratings?
The Medicare program rates how well plans perform in different categories (for example, detectingand preventing illness, ratings from patients and customer service). If you have access to the web,you may use the Web tools on www.medicare.gov and select "Health and Drug Plans" then "CompareDrug and Health Plans" to compare the plan ratings for Medicare plans in your area. You can alsocall us directly to obtain a copy of the plan ratings for this plan. Our customer service number islisted below.
Summary of Benefits | 4
Section I - Introduction to Summary of Benefits
Please call WellCare for more information about WellCare Value (HMO-POS).
Visit us at www.wellcare.com or, call us:
Customer Service Hours for October 1 – February 14: Sunday, Monday, Tuesday,Wednesday, Thursday, Friday, Saturday, 8:00 a.m. - 9:00 p.m. EasternCustomer Service Hours for February 15 – September 30: Monday, Tuesday, Wednesday,Thursday, Friday, 8:00 a.m. – 9:00 p.m. Eastern
Current members should call toll-free and locally (866) 334-6876 for questions relatedto the Medicare Advantage program or Medicare Part D Prescription Drug program.(TTY/TDD (877) 247-6272)
Prospective members should call toll-free and locally (877) 817-5794 for questionsrelated to the Medicare Advantage program or Medicare Part D Prescription Drugprogram. (TTY/TDD (877) 247-6272)
For more information about Medicare, please call Medicare at 1-800-MEDICARE(1-800-633-4227). TTY users should call 1-877-486-2048. You can call 24 hours a day, 7 daysa week. Or, visit www.medicare.gov on the web.
This document may be available in other formats such as Braille, large print or other alternateformats. This document may be available in a non-English language. For additional information,call customer service at the phone number listed above.
Este documento puede estar disponible en un idioma diferente al inglés. Para informaciónadicional, llame a Servicio al Cliente al número de teléfono indicado más arriba.
Summary of Benefits | 5
Section I - Introduction to Summary of Benefits
WEL
LCA
RE V
ALU
E (H
MO
-PO
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INA
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EDIC
ARE
BEN
EFIT
Impo
rtan
t In
form
atio
n
Gen
eral
In 2
012
the
mon
thly
Par
t B
Prem
ium
was
$99
.90
and
may
chan
ge fo
r 201
3 an
d th
e an
nual
Part
B d
educ
tible
am
ount
was
$140
and
may
cha
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for 2
013.
1Pr
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nd O
ther
Impo
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form
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n$0
mon
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pla
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add
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to y
our m
onth
ly M
edic
are
Part
B p
rem
ium
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t pe
ople
will
pay
the
sta
ndar
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onth
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MA
pla
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owev
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ome
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caus
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for m
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abou
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Par
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pre
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base
don
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cal
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icar
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1-80
0-M
EDIC
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(1-8
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.TT
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sho
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6-20
48. Y
ou m
ay a
lso c
all S
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curit
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TY u
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eans
you
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mor
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a h
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ir
In-N
etw
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$3,9
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ut-o
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lim
it fo
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icar
e-co
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-of-
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inco
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(ove
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,000
$3,9
00 o
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edic
are-
cove
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.C
onta
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lan
for d
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der t
his
limit.
for s
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170,
000
for
mar
ried
coup
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. For
mor
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form
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out
Part
Bpr
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base
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inco
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call
Med
icar
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1-80
0-M
EDIC
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If yo
u ha
ve a
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ions
abo
ut t
his
plan
’s be
nefit
s or
cos
ts, p
leas
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ntac
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ellC
are
for d
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Sect
ion
II -
Sum
ma
ry o
f Ben
efit
sFo
r Con
trac
t H
1416
, Pla
n 00
9
Sum
ma
ry o
f Ben
efits
| 6
WEL
LCA
RE V
ALU
E (H
MO
-PO
S)O
RIG
INA
L M
EDIC
ARE
BEN
EFIT
Impo
rtan
t In
form
atio
n(1-
800-
633-
4227
). TT
Y u
sers
shou
ld c
all 1
-877
-486
-204
8. Y
oum
ay a
lso c
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ocia
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at
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shou
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all 1
-800
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In-N
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You
may
go
to a
ny d
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Med
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2D
octo
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Hos
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(For
mor
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form
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eeEm
erge
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Car
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#15
and
Urg
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Nee
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Car
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16.)
Refe
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requ
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for n
etw
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spec
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or c
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in b
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its).
Inpa
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Car
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In-N
etw
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In 2
012
the
amou
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for e
ach
bene
fit p
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ere:
3In
patie
nt H
ospi
tal C
are
(incl
udes
Sub
stan
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buse
and
Reha
bilit
atio
n Se
rvic
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No
limit
to t
he n
umbe
r of d
ays
cove
red
by t
he p
lan
each
hosp
ital s
tay.
1D
ays 1
- 60
: $115
6 de
duct
ible
1D
ays
61 -
90:
$28
9 pe
r day
For M
edic
are-
cove
red
hosp
ital s
tays
:1
Day
s 91
- 15
0: $
578
per
lifet
ime
rese
rve
day
1D
ays
1 - 7
: $20
0 co
-pay
per
day
1D
ays
8 -
90: $
0 co
-pay
per
day
Thes
e am
ount
s may
cha
nge
for
2013
.$0
co-
pay
for a
dditi
onal
hos
pita
l day
s
Exce
pt in
an
emer
genc
y, y
our d
octo
r mus
t tel
l the
pla
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at y
ouar
e go
ing
to b
e ad
mitt
ed t
o th
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spita
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all 1
-800
-MED
ICA
RE(1-
800-
633-
4227
) for
info
rmat
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abou
t lif
etim
ere
serv
e da
ys.
Life
time
rese
rve
days
can
onl
ybe
use
d on
ce.
1Pr
emiu
m a
nd O
ther
Impo
rtan
t In
form
atio
n
Sum
ma
ry o
f Ben
efits
| 7
WEL
LCA
RE V
ALU
E (H
MO
-PO
S)O
RIG
INA
L M
EDIC
ARE
BEN
EFIT
Inpa
tient
Car
eA
"ben
efit
perio
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tart
s th
eda
y yo
u go
into
a h
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tal o
rsk
illed
nur
sing
faci
lity.
It e
nds
whe
n yo
u go
for 6
0 da
ys in
aro
w w
ithou
t hos
pita
l or s
kille
dnu
rsin
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re. I
f you
go
into
the
hosp
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fter
one
ben
efit
perio
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s en
ded,
a n
ewbe
nefit
per
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begi
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oum
ust p
ay th
e in
patie
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dedu
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r eac
h be
nefit
perio
d. T
here
is n
o lim
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the
num
ber o
f ben
efit
perio
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ouca
n ha
ve.
In-N
etw
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In 2
012
the
amou
nts
for e
ach
bene
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4In
patie
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enta
l Hea
lth
Car
eYo
u ge
t up
to
190
days
of i
npat
ient
psy
chia
tric
hos
pita
l car
e in
a lif
etim
e. In
patie
nt p
sych
iatr
ic h
ospi
tal s
ervi
ces
coun
t to
war
dth
e 19
0-da
y lif
etim
e lim
itatio
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ly if
cer
tain
con
ditio
ns a
re m
et.
This
limita
tion
does
not
app
ly t
o in
patie
nt p
sych
iatr
ic s
ervi
ces
furn
ished
in a
gen
eral
hos
pita
l.
1D
ays 1
- 60
: $115
6 de
duct
ible
1D
ays
61 -
90:
$28
9 pe
r day
1D
ays
91 -
150:
$57
8 pe
rlif
etim
e re
serv
e da
y
Thes
e am
ount
s may
cha
nge
for
2013
.Fo
r Med
icar
e-co
vere
d ho
spita
l sta
ys:
1D
ays
1 - 7
: $20
0 co
-pay
per
day
You
get
up t
o 19
0 da
ys o
fin
patie
nt p
sych
iatr
ic h
ospi
tal
care
in a
life
time.
Inpa
tient
psyc
hiat
ric h
ospi
tal s
ervi
ces
coun
t to
war
d th
e 19
0-da
y
1D
ays
8 -
90: $
0 co
-pay
per
day
Exce
pt in
an
emer
genc
y, y
our d
octo
r mus
t tel
l the
pla
n th
at y
ouar
e go
ing
to b
e ad
mitt
ed t
o th
e ho
spita
l.
3In
patie
nt H
ospi
tal C
are
(incl
udes
Sub
stan
ce A
buse
and
Reha
bilit
atio
n Se
rvic
es)
Sum
ma
ry o
f Ben
efits
| 8
WEL
LCA
RE V
ALU
E (H
MO
-PO
S)O
RIG
INA
L M
EDIC
ARE
BEN
EFIT
Inpa
tient
Car
elif
etim
e lim
itatio
n on
ly if
cert
ain
cond
ition
s are
met
. Thi
slim
itatio
n do
es n
ot a
pply
to
inpa
tient
psy
chia
tric
ser
vice
sfu
rnish
ed in
a g
ener
al h
ospi
tal.
Gen
eral
In 2
012
the
amou
nts
for e
ach
bene
fit p
erio
d af
ter a
t le
ast
a3-
day
cove
red
hosp
ital s
tay
wer
e:
5Sk
illed
Nur
sing
Faci
lity
(SN
F)(in
a M
edic
are-
cert
ified
skill
ed n
ursin
g fa
cilit
y)A
utho
rizat
ion
rule
s m
ay a
pply
.
In-N
etw
ork
Plan
cov
ers
up t
o 10
0 da
ys e
ach
bene
fit p
erio
d1
Day
s 1 -
20:
$0
per d
ay
No
prio
r hos
pita
l sta
y is
requ
ired.
1D
ays 2
1 - 10
0: $
144.
50 p
er d
ay
Thes
e am
ount
s may
cha
nge
for
2013
.Fo
r SN
F st
ays:
1D
ays
1 - 2
0: $
0 co
-pay
per
day
100
days
for e
ach
bene
fitpe
riod.
1D
ays
21 -
100:
$15
0 co
-pay
per
day
A "b
enef
it pe
riod"
sta
rts
the
day
you
go in
to a
hos
pita
l or
SNF.
It e
nds
whe
n yo
u go
for
60 d
ays
in a
row
with
out
hosp
ital o
r ski
lled
nurs
ing
care
.If
you
go in
to th
e ho
spita
l aft
eron
e be
nefit
per
iod
has
ende
d,a
new
ben
efit
perio
d be
gins
.
4In
patie
nt M
enta
l Hea
lth
Car
e
Sum
ma
ry o
f Ben
efits
| 9
WEL
LCA
RE V
ALU
E (H
MO
-PO
S)O
RIG
INA
L M
EDIC
ARE
BEN
EFIT
Inpa
tient
Car
eYo
u m
ust
pay
the
inpa
tient
hosp
ital d
educ
tible
for e
ach
bene
fit p
erio
d. T
here
is n
o lim
itto
the
num
ber o
f ben
efit
perio
ds y
ou c
an h
ave.
Gen
eral
$0 c
o-pa
y.6
Hom
e H
ealt
h C
are
(incl
udes
med
ical
lyne
cess
ary
inte
rmitt
ent
skill
ed n
ursin
g ca
re, h
ome
heal
th a
ide
serv
ices
, and
reha
bilit
atio
n se
rvic
es, e
tc.)
Aut
horiz
atio
n ru
les
may
app
ly.
In-N
etw
ork
$0 c
o-pa
y fo
r eac
h M
edic
are-
cove
red
hom
e he
alth
visi
t
Gen
eral
You
pay
part
of t
he c
ost
for
outp
atie
nt d
rugs
and
inpa
tient
resp
ite c
are.
7H
ospi
ce
You
mus
t get
car
e fr
om a
Med
icar
e-ce
rtifi
ed h
ospi
ce. Y
our p
lan
will
pay
for a
con
sulta
tive
visit
bef
ore
you
sele
ct h
ospi
ce.
You
mus
t ge
t ca
re fr
om a
Med
icar
e-ce
rtifi
ed h
ospi
ce.
Out
patie
nt C
are
In-N
etw
ork
20%
coi
nsur
ance
8D
octo
r Off
ice
Visi
ts
$5 c
o-pa
y fo
r eac
h M
edic
are-
cove
red
prim
ary
care
doc
tor v
isit.
$35
co-p
ay fo
r eac
h M
edic
are-
cove
red
spec
ialis
t vi
sit.
5Sk
illed
Nur
sing
Faci
lity
(SN
F)(in
a M
edic
are-
cert
ified
skill
ed n
ursin
g fa
cilit
y)
Sum
ma
ry o
f Ben
efits
| 1
0
WEL
LCA
RE V
ALU
E (H
MO
-PO
S)O
RIG
INA
L M
EDIC
ARE
BEN
EFIT
Out
patie
nt C
are
In-N
etw
ork
Supp
lem
enta
l rou
tine
care
not
cove
red
9C
hiro
prac
tic S
ervi
ces
$20
co-p
ay fo
r eac
h M
edic
are-
cove
red
chiro
prac
tic v
isit
20%
coi
nsur
ance
for m
anua
lm
anip
ulat
ion
of t
he s
pine
to
corr
ect
subl
uxat
ion
(adi
spla
cem
ent
or m
isal
ignm
ent
of a
join
t or
bod
y pa
rt) i
f you
get
it fr
om a
chi
ropr
acto
r or
othe
r qua
lifie
d pr
ovid
ers.
Med
icar
e-co
vere
d ch
iropr
actic
visi
ts a
re fo
r man
ual m
anip
ulat
ion
of t
he s
pine
to
corr
ect
subl
uxat
ion
(a d
ispla
cem
ent
orm
isal
ignm
ent
of a
join
t or
bod
y pa
rt) i
f you
get
it fr
om a
chiro
prac
tor.
In-N
etw
ork
Supp
lem
enta
l rou
tine
care
not
cove
red.
10Po
diat
ry S
ervi
ces
$35
co-p
ay fo
r eac
h M
edic
are-
cove
red
podi
atry
visi
t20
% c
oins
uran
ce fo
r med
ical
lyne
cess
ary
foot
car
e, in
clud
ing
care
for m
edic
al c
ondi
tions
affe
ctin
g th
e lo
wer
lim
bs.
Med
icar
e-co
vere
d po
diat
ry v
isits
are
for m
edic
ally
-nec
essa
ryfo
ot c
are.
Gen
eral
35%
coi
nsur
ance
for m
ost
outp
atie
nt m
enta
l hea
lthse
rvic
es
11O
utpa
tient
Men
tal H
ealt
hC
are
Aut
horiz
atio
n ru
les
may
app
ly.
In-N
etw
ork
Spec
ified
co-
paym
ent
for
outp
atie
nt p
artia
lho
spita
lizat
ion
prog
ram
serv
ices
furn
ished
by
a ho
spita
lor
com
mun
ity m
enta
l hea
lthce
nter
(CM
HC
). C
o-pa
y ca
nnot
exce
ed t
he P
art
A in
patie
ntho
spita
l ded
uctib
le.
$35
co-p
ay fo
r eac
h M
edic
are-
cove
red
indi
vidu
al t
hera
py v
isit
$25
co-p
ay fo
r eac
h M
edic
are-
cove
red
grou
p th
erap
y vi
sit
$35
co-p
ay fo
r eac
h M
edic
are-
cove
red
indi
vidu
al t
hera
py v
isit
with
a p
sych
iatr
ist
$25
co-p
ay fo
r eac
h M
edic
are-
cove
red
grou
p th
erap
y vi
sit w
itha
psyc
hiat
rist
Sum
ma
ry o
f Ben
efits
| 1
1
WEL
LCA
RE V
ALU
E (H
MO
-PO
S)O
RIG
INA
L M
EDIC
ARE
BEN
EFIT
Out
patie
nt C
are
$110
co-
pay
for M
edic
are-
cove
red
part
ial h
ospi
taliz
atio
n pr
ogra
mse
rvic
es"P
artia
l hos
pita
lizat
ion
prog
ram
" is
a st
ruct
ured
prog
ram
of a
ctiv
e ou
tpat
ient
psyc
hiat
ric t
reat
men
t th
at is
mor
e in
tens
e th
an t
he c
are
rece
ived
in y
our d
octo
r's o
rth
erap
ist's
offic
e an
d is
anal
tern
ativ
e to
inpa
tient
hosp
italiz
atio
n.
Gen
eral
20%
coi
nsur
ance
12O
utpa
tient
Sub
stan
ceA
buse
Car
eA
utho
rizat
ion
rule
s m
ay a
pply
.
In-N
etw
ork
$35
co-p
ay fo
r Med
icar
e-co
vere
d in
divi
dual
sub
stan
ce a
buse
outp
atie
nt t
reat
men
t vi
sits
$25
co-p
ay fo
r Med
icar
e-co
vere
d gr
oup
subs
tanc
e ab
use
outp
atie
nt t
reat
men
t vi
sits
Gen
eral
20%
coi
nsur
ance
for t
hedo
ctor
's se
rvic
es13
Out
patie
nt S
ervi
ces
Aut
horiz
atio
n ru
les
may
app
ly.
Spec
ified
co-
paym
ent
for
outp
atie
nt h
ospi
tal f
acili
tyse
rvic
es. C
o-pa
y ca
nnot
exce
ed t
he P
art
A in
patie
ntho
spita
l ded
uctib
le.
In-N
etw
ork
$100
co-
pay
for e
ach
Med
icar
e-co
vere
d am
bula
tory
sur
gica
lce
nter
visi
t
$150
co-
pay
for e
ach
Med
icar
e-co
vere
d ou
tpat
ient
hos
pita
lfa
cilit
y vi
sit20
% c
oins
uran
ce fo
ram
bula
tory
sur
gica
l cen
ter
faci
lity
serv
ices
11O
utpa
tient
Men
tal H
ealt
hC
are
Sum
ma
ry o
f Ben
efits
| 1
2
WEL
LCA
RE V
ALU
E (H
MO
-PO
S)O
RIG
INA
L M
EDIC
ARE
BEN
EFIT
Out
patie
nt C
are
Gen
eral
20%
coi
nsur
ance
14A
mbu
lanc
e Se
rvic
es(m
edic
ally
nec
essa
ryam
bula
nce
serv
ices
)A
utho
rizat
ion
rule
s m
ay a
pply
.
In-N
etw
ork
$100
co-
pay
for M
edic
are-
cove
red
ambu
lanc
e be
nefit
s.
Gen
eral
20%
coi
nsur
ance
for t
hedo
ctor
's se
rvic
es15
Emer
genc
y C
are
(You
may
go
to a
nyem
erge
ncy
room
if y
oure
ason
ably
bel
ieve
you
nee
dem
erge
ncy
care
.)
$65
co-p
ay fo
r Med
icar
e-co
vere
d em
erge
ncy
room
visi
ts
Wor
ldw
ide
cove
rage
.
If yo
u ar
e ad
mitt
ed t
o th
e ho
spita
l with
in 2
4-ho
ur(s
) for
the
sam
e co
nditi
on, y
ou p
ay $
0 fo
r the
em
erge
ncy
room
visi
t.
Spec
ified
co-
paym
ent
for
outp
atie
nt h
ospi
tal f
acili
tyem
erge
ncy
serv
ices
.
Emer
genc
y se
rvic
es c
o-pa
yca
nnot
exc
eed
Part
A in
patie
ntho
spita
l ded
uctib
le fo
r eac
hse
rvic
e pr
ovid
ed b
y th
eho
spita
l.
You
don'
t ha
ve t
o pa
y th
eem
erge
ncy
room
co-
pay
if yo
uar
e ad
mitt
ed to
the
hosp
ital a
san
inpa
tient
for t
he s
ame
cond
ition
with
in 3
day
s of
the
emer
genc
y ro
om v
isit.
Not
cov
ered
out
side
the
U.S
.ex
cept
und
er li
mite
dci
rcum
stan
ces.
Sum
ma
ry o
f Ben
efits
| 1
3
WEL
LCA
RE V
ALU
E (H
MO
-PO
S)O
RIG
INA
L M
EDIC
ARE
BEN
EFIT
Out
patie
nt C
are
Gen
eral
20%
coi
nsur
ance
, or a
set
co-p
ay16
Urg
ently
Nee
ded
Car
e(T
his
is N
OT
emer
genc
yca
re, a
nd in
mos
t ca
ses,
isou
t of
the
ser
vice
are
a.)
$35
co-p
ay fo
r Med
icar
e-co
vere
d ur
gent
ly-n
eede
d-ca
re v
isits
If yo
u ar
e ad
mitt
ed t
o th
e ho
spita
l with
in 2
4-ho
ur(s
) for
the
sam
e co
nditi
on, y
ou p
ay $
0 fo
r the
urg
ently
-nee
ded-
care
visi
t.
NO
T co
vere
d ou
tsid
e th
e U
.S.
exce
pt u
nder
lim
ited
circ
umst
ance
s.
Gen
eral
20%
coi
nsur
ance
17O
utpa
tient
Reh
abili
tatio
nSe
rvic
es(O
ccup
atio
nal T
hera
py,
Phys
ical
The
rapy
, Spe
ech
and
Lang
uage
The
rapy
)
Aut
horiz
atio
n ru
les
may
app
ly.
In-N
etw
ork
$35
co-p
ay fo
r Med
icar
e-co
vere
d O
ccup
atio
nal T
hera
py v
isits
$35
co-p
ay fo
r Med
icar
e-co
vere
d Ph
ysic
al T
hera
py a
nd/o
rSp
eech
and
Lan
guag
e Pa
thol
ogy
visit
s
Out
patie
nt M
edic
al S
ervi
ces
and
Supp
lies
Gen
eral
20%
coi
nsur
ance
18D
urab
le M
edic
al E
quip
men
t(in
clud
es w
heel
chai
rs,
oxyg
en, e
tc.)
Aut
horiz
atio
n ru
les
may
app
ly.
In-N
etw
ork
20%
of t
he c
ost
for M
edic
are-
cove
red
dura
ble
med
ical
equi
pmen
t
Sum
ma
ry o
f Ben
efits
| 1
4
WEL
LCA
RE V
ALU
E (H
MO
-PO
S)O
RIG
INA
L M
EDIC
ARE
BEN
EFIT
Out
patie
nt M
edic
al S
ervi
ces
and
Supp
lies
Gen
eral
20%
coi
nsur
ance
19Pr
osth
etic
Dev
ices
(incl
udes
bra
ces,
artif
icia
llim
bs a
nd e
yes,
etc.
)A
utho
rizat
ion
rule
s m
ay a
pply
.
In-N
etw
ork
20%
of t
he c
ost
for M
edic
are-
cove
red
pros
thet
ic d
evic
es
Gen
eral
20%
coi
nsur
ance
for d
iabe
tes
self-
man
agem
ent
trai
ning
20D
iabe
tes
Prog
ram
s an
dSu
pplie
sA
utho
rizat
ion
rule
s m
ay a
pply
.20
% c
oins
uran
ce fo
r dia
bete
ssu
pplie
sIn
-Net
wor
k
$0 c
o-pa
y fo
r Med
icar
e-co
vere
d D
iabe
tes
self-
man
agem
ent
trai
ning
20%
coi
nsur
ance
for d
iabe
ticth
erap
eutic
sho
es o
r ins
erts
0% o
f the
cos
t fo
r Med
icar
e-co
vere
d D
iabe
tes
mon
itorin
gsu
pplie
s
Dia
betic
Sup
plie
s an
d Se
rvic
es a
re li
mite
d to
spe
cific
man
ufac
ture
rs, p
rodu
cts
and/
or b
rand
s. C
onta
ct t
he p
lan
for a
list
of c
over
ed s
uppl
ies.
20%
of t
he c
ost
for M
edic
are-
cove
red
Ther
apeu
tic s
hoes
or
inse
rts
Gen
eral
20%
coi
nsur
ance
for d
iagn
ostic
test
s an
d X
-ray
s21
Dia
gnos
tic T
ests
, X-R
ays,
Lab
Serv
ices
, and
Rad
iolo
gySe
rvic
esA
utho
rizat
ion
rule
s m
ay a
pply
.
In-N
etw
ork
$0 c
o-pa
y fo
rM
edic
are-
cove
red
lab
serv
ices$0
co-
pay
for M
edic
are-
cove
red
lab
serv
ices
Sum
ma
ry o
f Ben
efits
| 1
5
WEL
LCA
RE V
ALU
E (H
MO
-PO
S)O
RIG
INA
L M
EDIC
ARE
BEN
EFIT
Out
patie
nt M
edic
al S
ervi
ces
and
Supp
lies
Lab
Serv
ices
: Med
icar
e co
vers
med
ical
ly n
eces
sary
dia
gnos
ticla
b se
rvic
es t
hat
are
orde
red
by y
our t
reat
ing
doct
or w
hen
they
are
pro
vide
d by
a C
linic
al
$0 t
o $5
0 co
-pay
for M
edic
are-
cove
red
diag
nost
ic p
roce
dure
san
d te
sts
$0 c
o-pa
y fo
r Med
icar
e-co
vere
d X
-ray
s
$50
co-p
ay fo
r Med
icar
e-co
vere
d di
agno
stic
radi
olog
y se
rvic
es(n
ot in
clud
ing
X-r
ays)
Labo
rato
ry Im
prov
emen
t$3
5 co
-pay
for M
edic
are-
cove
red
ther
apeu
tic ra
diol
ogy
serv
ices
Am
endm
ents
(CLI
A) c
ertif
ied
labo
rato
ry t
hat
part
icip
ates
inM
edic
are.
Dia
gnos
tic la
bse
rvic
es a
re d
one
to h
elp
your
doct
or d
iagn
ose
or ru
le o
ut a
susp
ecte
d ill
ness
or c
ondi
tion.
Med
icar
e do
es n
ot c
over
mos
tsu
pple
men
tal r
outin
e sc
reen
ing
test
s, lik
e ch
ecki
ng y
our
chol
este
rol.
In-N
etw
ork
20%
coi
nsur
ance
for C
ardi
acRe
habi
litat
ion
serv
ices
22C
ardi
ac a
nd P
ulm
onar
yRe
habi
litat
ion
Serv
ices
$35
to $
150
co-p
ay fo
r Med
icar
e-co
vere
d C
ardi
ac R
ehab
ilita
tion
Serv
ices
20%
coi
nsur
ance
for P
ulm
onar
yRe
habi
litat
ion
serv
ices
$35
to $
150
co-p
ay fo
r Med
icar
e-co
vere
d In
tens
ive
Car
diac
Reha
bilit
atio
n Se
rvic
es20
% c
oins
uran
ce fo
r Int
ensiv
eC
ardi
ac R
ehab
ilita
tion
serv
ices$3
5 to
$15
0 co
-pay
for M
edic
are-
cove
red
Pulm
onar
yRe
habi
litat
ion
Serv
ices
This
appl
ies
to p
rogr
amse
rvic
es p
rovi
ded
in a
doc
tor's
offic
e. S
peci
fied
cost
sha
ring
for p
rogr
am s
ervi
ces
prov
ided
by h
ospi
tal o
utpa
tient
depa
rtm
ents
.
21D
iagn
ostic
Tes
ts, X
-Ray
s,La
b Se
rvic
es, a
nd R
adio
logy
Serv
ices
Sum
ma
ry o
f Ben
efits
| 1
6
WEL
LCA
RE V
ALU
E (H
MO
-PO
S)O
RIG
INA
L M
EDIC
ARE
BEN
EFIT
Prev
entiv
e Se
rvic
es, W
elln
ess/
Educ
atio
n A
nd O
ther
Sup
plem
enta
l Ben
efit
Prog
ram
s
Gen
eral
No
coin
sura
nce,
co-
paym
ent
or d
educ
tible
for t
he fo
llow
ing:
23Pr
even
tive
Serv
ices
,W
elln
ess/
Educ
atio
n an
dot
her S
uppl
emen
tal B
enef
itPr
ogra
ms
$0 c
o-pa
y fo
r all
prev
entiv
e se
rvic
es c
over
ed u
nder
Orig
inal
Med
icar
e at
zer
o co
st s
harin
g.
Any
add
ition
al p
reve
ntiv
e se
rvic
es a
ppro
ved
by M
edic
are
mid
-yea
r will
be
cove
red
by t
he p
lan
or b
y O
rigin
al M
edic
are.
1A
bdom
inal
Aor
tic A
neur
ysm
Scre
enin
g1
Bone
Mas
s M
easu
rem
ent.
Cov
ered
onc
e ev
ery
24m
onth
s (m
ore
ofte
n if
med
ical
ly n
eces
sary
) if y
oum
eet
cert
ain
med
ical
cond
ition
s.
In-N
etw
ork
The
plan
cov
ers t
he fo
llow
ing
supp
lem
enta
l edu
catio
n/w
elln
ess
prog
ram
s:1
Hea
lth C
lub
Mem
bers
hip/
Fitn
ess
Cla
sses
1C
ardi
ovas
cula
r Scr
eeni
ng1
Nur
sing
Hot
line
1C
ervi
cal a
nd V
agin
al C
ance
rSc
reen
ing.
Cov
ered
onc
eev
ery
2 ye
ars.
Cov
ered
onc
ea
year
for w
omen
with
Med
icar
e at
hig
h ris
k.
$0 c
o-pa
y fo
r Enh
ance
d D
iseas
e M
anag
emen
t.
Con
tact
pla
n fo
r det
ails
.
1C
olor
ecta
l Can
cer S
cree
ning
1D
iabe
tes
Scre
enin
g1
Influ
enza
Vac
cine
1H
epat
itis
B Va
ccin
e fo
rpe
ople
with
Med
icar
e w
hoar
e at
risk
Sum
ma
ry o
f Ben
efits
| 1
7
WEL
LCA
RE V
ALU
E (H
MO
-PO
S)O
RIG
INA
L M
EDIC
ARE
BEN
EFIT
Prev
entiv
e Se
rvic
es, W
elln
ess/
Educ
atio
n A
nd O
ther
Sup
plem
enta
l Ben
efit
Prog
ram
s1
HIV
Scr
eeni
ng. $
0 co
-pay
for
the
HIV
scr
eeni
ng, b
ut y
ouge
nera
lly p
ay 2
0% o
f the
Med
icar
e-ap
prov
ed a
mou
ntfo
r the
doc
tor's
visi
t. H
IVsc
reen
ing
is co
vere
d fo
rpe
ople
with
Med
icar
e w
hoar
e pr
egna
nt a
nd p
eopl
e at
incr
ease
d ris
k fo
r the
infe
ctio
n, in
clud
ing
anyo
new
ho a
sks
for t
he t
est.
Med
icar
e co
vers
thi
s te
ston
ce e
very
12 m
onth
s or
up
to t
hree
tim
es d
urin
g a
preg
nanc
y.1
Brea
st C
ance
r Scr
eeni
ng(M
amm
ogra
m).
Med
icar
eco
vers
scr
eeni
ngm
amm
ogra
ms o
nce
ever
y 12
mon
ths
for a
ll w
omen
with
Med
icar
e ag
e 40
and
old
er.
Med
icar
e co
vers
one
base
line
mam
mog
ram
for
wom
en b
etw
een
ages
35-
39.
23Pr
even
tive
Serv
ices
,W
elln
ess/
Educ
atio
n an
dot
her S
uppl
emen
tal B
enef
itPr
ogra
ms
Sum
ma
ry o
f Ben
efits
| 1
8
WEL
LCA
RE V
ALU
E (H
MO
-PO
S)O
RIG
INA
L M
EDIC
ARE
BEN
EFIT
Prev
entiv
e Se
rvic
es, W
elln
ess/
Educ
atio
n A
nd O
ther
Sup
plem
enta
l Ben
efit
Prog
ram
s1
Med
ical
Nut
ritio
n Th
erap
ySe
rvic
es. N
utrit
ion
ther
apy
is fo
r peo
ple
who
hav
edi
abet
es o
r kid
ney
dise
ase
(but
are
n't
on d
ialy
sis o
rha
ven'
t ha
d a
kidn
eytr
ansp
lant
) whe
n re
ferr
ed b
ya
doct
or. T
hese
serv
ices
can
be g
iven
by
a re
gist
ered
diet
itian
and
may
incl
ude
anu
triti
onal
ass
essm
ent
and
coun
selin
g to
hel
p yo
um
anag
e yo
ur d
iabe
tes
orki
dney
dise
ase
1Pe
rson
aliz
ed P
reve
ntio
n Pl
anSe
rvic
es (A
nnua
l Wel
lnes
sV
isits
)1
Pneu
moc
occa
l Vac
cine
. You
may
onl
y ne
ed t
hePn
eum
onia
vac
cine
onc
e in
your
life
time.
Cal
l you
rdo
ctor
for m
ore
info
rmat
ion.
1Pr
osta
te C
ance
r Scr
eeni
ng1
Pros
tate
Spe
cific
Ant
igen
(PSA
) tes
t on
ly. C
over
edon
ce a
yea
r for
all
men
with
Med
icar
e ov
er a
ge 5
0.
23Pr
even
tive
Serv
ices
,W
elln
ess/
Educ
atio
n an
dot
her S
uppl
emen
tal B
enef
itPr
ogra
ms
Sum
ma
ry o
f Ben
efits
| 1
9
WEL
LCA
RE V
ALU
E (H
MO
-PO
S)O
RIG
INA
L M
EDIC
ARE
BEN
EFIT
Prev
entiv
e Se
rvic
es, W
elln
ess/
Educ
atio
n A
nd O
ther
Sup
plem
enta
l Ben
efit
Prog
ram
s1
Smok
ing
and
Toba
cco
Use
Ces
satio
n (c
ouns
elin
g to
stop
sm
okin
g an
d to
bacc
ous
e). C
over
ed if
ord
ered
by
your
doc
tor.
Incl
udes
tw
oco
unse
ling
atte
mpt
s w
ithin
a 12
-mon
th p
erio
d. E
ach
coun
selin
g at
tem
pt in
clud
esup
to
four
face
-to-
face
visit
s.1
Scre
enin
g an
d be
havi
oral
coun
selin
g in
terv
entio
ns in
prim
ary
care
to
redu
ceal
coho
l misu
se1
Scre
enin
g fo
r dep
ress
ion
inad
ults
1Sc
reen
ing
for s
exua
llytr
ansm
itted
infe
ctio
ns (S
TI)
and
high
-inte
nsity
beha
vior
al c
ouns
elin
g to
prev
ent
STIs
1In
tens
ive
beha
vior
alco
unse
ling
for
Car
diov
ascu
lar D
iseas
e(b
i-ann
ual)
1In
tens
ive
beha
vior
al th
erap
yfo
r obe
sity
23Pr
even
tive
Serv
ices
,W
elln
ess/
Educ
atio
n an
dot
her S
uppl
emen
tal B
enef
itPr
ogra
ms
Sum
ma
ry o
f Ben
efits
| 2
0
WEL
LCA
RE V
ALU
E (H
MO
-PO
S)O
RIG
INA
L M
EDIC
ARE
BEN
EFIT
Prev
entiv
e Se
rvic
es, W
elln
ess/
Educ
atio
n A
nd O
ther
Sup
plem
enta
l Ben
efit
Prog
ram
s1
Wel
com
e to
Med
icar
ePr
even
tive
Visi
t (in
itial
prev
entiv
e ph
ysic
al e
xam
).W
hen
you
join
Med
icar
ePa
rt B
, the
n yo
u ar
e el
igib
leas
follo
ws.
Dur
ing
the
first
12 m
onth
s of
you
r new
Par
tB
cove
rage
, you
can
get
eith
er a
Wel
com
e to
Med
icar
e Pr
even
tive
Visi
t or
an A
nnua
l Wel
lnes
s V
isit.
Aft
er y
our f
irst
12 m
onth
s,yo
u ca
n ge
t on
e A
nnua
lW
elln
ess
Visi
t ev
ery
12m
onth
s.
In-N
etw
ork
20%
coi
nsur
ance
for r
enal
dial
ysis
24Ki
dney
Dis
ease
and
Con
ditio
ns20
% o
f the
cos
t fo
r Med
icar
e-co
vere
d re
nal d
ialy
sis20
% c
oins
uran
ce fo
r kid
ney
dise
ase
educ
atio
n se
rvic
es20
% o
f the
cos
t for
Med
icar
e-co
vere
d ki
dney
dise
ase
educ
atio
nse
rvic
es
Pres
crip
tion
Dru
g Be
nefit
s
Dru
gs c
over
ed u
nder
Med
icar
e Pa
rt B
Mos
t dr
ugs
are
not
cove
red
unde
r Orig
inal
Med
icar
e. Y
ouca
n ad
d pr
escr
iptio
n dr
ugco
vera
ge t
o O
rigin
al M
edic
are
by jo
inin
g a
Med
icar
e
25O
utpa
tient
Pre
scrip
tion
Dru
gs
23Pr
even
tive
Serv
ices
,W
elln
ess/
Educ
atio
n an
dot
her S
uppl
emen
tal B
enef
itPr
ogra
ms
Sum
ma
ry o
f Ben
efits
| 2
1
WEL
LCA
RE V
ALU
E (H
MO
-PO
S)O
RIG
INA
L M
EDIC
ARE
BEN
EFIT
Pres
crip
tion
Dru
g Be
nefit
s
Gen
eral
Pres
crip
tion
Dru
g Pl
an, o
r you
can
get
all y
our M
edic
are
cove
rage
, inc
ludi
ngpr
escr
iptio
n dr
ug c
over
age,
by
join
ing
a M
edic
are
Adv
anta
gePl
an o
r a M
edic
are
Cos
t Pl
anth
at o
ffer
s pr
escr
iptio
n dr
ugco
vera
ge.
20%
of t
he c
ost
for M
edic
are
Part
B c
hem
othe
rapy
dru
gs a
ndot
her P
art
B dr
ugs.
Dru
gs c
over
ed u
nder
Med
icar
e Pa
rt D
Gen
eral
This
plan
use
s a fo
rmul
ary.
The
pla
n w
ill se
nd y
ou th
e fo
rmul
ary.
You
can
also
see
the
form
ular
y at
ww
w.w
ellc
are.
com
on
the
web
.
Diff
eren
t ou
t-of
-poc
ket
cost
s m
ay a
pply
for p
eopl
e w
ho:
-hav
e lim
ited
inco
mes
,
-live
in lo
ng t
erm
car
e fa
cilit
ies,
or
-hav
e ac
cess
to
Indi
an/T
ribal
/Urb
an (I
ndia
n H
ealth
Ser
vice
)pr
ovid
ers.
The
plan
off
ers
natio
nal i
n-ne
twor
k pr
escr
iptio
n co
vera
ge (i
.e.,
this
wou
ld in
clud
e 50
sta
tes
and
the
Dist
rict
of C
olum
bia)
. Thi
sm
eans
that
you
will
pay
the
sam
e co
st-s
harin
g am
ount
for y
our
pres
crip
tion
drug
s if
you
get
them
at
an in
-net
wor
k ph
arm
acy
outs
ide
of th
e pl
an's
serv
ice
area
(for
inst
ance
whe
n yo
u tr
avel
).
Tota
l yea
rly d
rug
cost
s ar
e th
e to
tal d
rug
cost
s pa
id b
y bo
thyo
u an
d a
Part
D p
lan.
The
plan
may
requ
ire y
ou t
o fir
st t
ry o
ne d
rug
to t
reat
you
rco
nditi
on b
efor
e it
will
cov
er a
noth
er d
rug
for t
hat
cond
ition
.
Som
e dr
ugs
have
qua
ntity
lim
its.
Your
pro
vide
r mus
t get
prio
r aut
horiz
atio
n fr
om W
ellC
are
Valu
e(H
MO
-PO
S) fo
r cer
tain
dru
gs.
25O
utpa
tient
Pre
scrip
tion
Dru
gs
Sum
ma
ry o
f Ben
efits
| 2
2
WEL
LCA
RE V
ALU
E (H
MO
-PO
S)O
RIG
INA
L M
EDIC
ARE
BEN
EFIT
Pres
crip
tion
Dru
g Be
nefit
sYo
u m
ust
go t
o ce
rtai
n ph
arm
acie
s fo
r a v
ery
limite
d nu
mbe
rof
dru
gs, d
ue t
o sp
ecia
l han
dlin
g, p
rovi
der c
oord
inat
ion,
or
patie
nt e
duca
tion
requ
irem
ents
tha
t ca
nnot
be
met
by
mos
tph
arm
acie
s in
your
net
wor
k. T
hese
dru
gs a
re li
sted
on
the
plan
'sw
ebsit
e, fo
rmul
ary,
prin
ted
mat
eria
ls, a
s wel
l as o
n th
e M
edic
are
Pres
crip
tion
Dru
g Pl
an F
inde
r on
Med
icar
e.go
v.
If th
e ac
tual
cos
t of
a d
rug
is le
ss t
han
the
norm
al c
ost-
shar
ing
amou
nt fo
r tha
t dru
g, y
ou w
ill p
ay th
e ac
tual
cos
t, no
t the
hig
her
cost
-sha
ring
amou
nt.
The
plan
cha
rges
a m
inim
um c
ost
shar
ing
amou
nt fo
r cer
tain
low
-cos
t dr
ugs.
If yo
u re
ques
t a
form
ular
y ex
cept
ion
for a
dru
g an
d W
ellC
are
Valu
e (H
MO
-PO
S) a
ppro
ves
the
exce
ptio
n, y
ou w
ill p
ay T
ier 3
:N
on-P
refe
rred
Bra
nd c
ost
shar
ing
for t
hat
drug
.
In-N
etw
ork
$0 d
educ
tible
.
Initi
al C
over
age
You
pay
the
follo
win
g un
til to
tal y
early
dru
g co
sts
reac
h $2
,970
:
Reta
il Ph
arm
acy
Tier
1: G
ener
ic1$3
co-
pay
for a
one
-mon
th (3
1-da
y) s
uppl
y of
dru
gs in
thi
stie
r1$6
co-
pay
for a
tw
o-m
onth
(62-
day)
sup
ply
of d
rugs
in t
his
tier
1$9
co-
pay
for a
thr
ee-m
onth
(93-
day)
sup
ply
of d
rugs
in t
his
tier
Tier
2: P
refe
rred
Bra
nd
25O
utpa
tient
Pre
scrip
tion
Dru
gs
Sum
ma
ry o
f Ben
efits
| 2
3
WEL
LCA
RE V
ALU
E (H
MO
-PO
S)O
RIG
INA
L M
EDIC
ARE
BEN
EFIT
Pres
crip
tion
Dru
g Be
nefit
s1$3
9 co
-pay
for a
one
-mon
th (3
1-da
y) s
uppl
y of
dru
gs in
thi
stie
r1$7
8 co
-pay
for a
tw
o-m
onth
(62-
day)
sup
ply
of d
rugs
in t
his
tier
1$1
17 c
o-pa
y fo
r a th
ree-
mon
th (9
3-da
y) su
pply
of d
rugs
in th
istie
rTi
er 3
: Non
-Pre
ferr
ed B
rand
1$6
9 co
-pay
for a
one
-mon
th (3
1-da
y) s
uppl
y of
dru
gs in
thi
stie
r1$1
38 c
o-pa
y fo
r a t
wo-
mon
th (6
2-da
y) s
uppl
y of
dru
gs in
thi
stie
r1$2
07 c
o-pa
y fo
r a t
hree
-mon
th (9
3-da
y) s
uppl
y of
dru
gs in
this
tier
Tier
4: S
peci
alty
Tie
r1
33%
coi
nsur
ance
for a
one
-mon
th (3
1-da
y) s
uppl
y of
dru
gs in
this
tier
Long
Ter
m C
are
Phar
mac
yTi
er 1:
Gen
eric
1$3
co-
pay
for a
one
-mon
th (3
1-da
y) s
uppl
y of
dru
gs in
thi
stie
rTi
er 2
: Pre
ferr
ed B
rand
1$3
9 co
-pay
for a
one
-mon
th (3
1-da
y) s
uppl
y of
dru
gs in
thi
stie
rTi
er 3
: Non
-Pre
ferr
ed B
rand
1$6
9 co
-pay
for a
one
-mon
th (3
1-da
y) s
uppl
y of
dru
gs in
thi
stie
rTi
er 4
: Spe
cial
ty T
ier
133
% c
oins
uran
ce fo
r a o
ne-m
onth
(31-
day)
sup
ply
of d
rugs
inth
is tie
r
25O
utpa
tient
Pre
scrip
tion
Dru
gs
Sum
ma
ry o
f Ben
efits
| 2
4
WEL
LCA
RE V
ALU
E (H
MO
-PO
S)O
RIG
INA
L M
EDIC
ARE
BEN
EFIT
Pres
crip
tion
Dru
g Be
nefit
sPl
ease
not
e th
at b
rand
dru
gs m
ust
be d
ispen
sed
incr
emen
tally
in lo
ng-t
erm
car
e fa
cilit
ies.
Gen
eric
dru
gs m
ay b
e di
spen
sed
incr
emen
tally
. Con
tact
you
r pla
n ab
out
cost
-sha
ring
billi
ng/
colle
ctio
n w
hen
less
tha
n a
one-
mon
th s
uppl
y is
disp
ense
d.
Mai
l Ord
erTi
er 1:
Gen
eric
1$3
co-
pay
for a
one
-mon
th (3
1-da
y) s
uppl
y of
dru
gs in
thi
stie
r fro
m a
pre
ferr
ed m
ail o
rder
pha
rmac
y.1$6
co-
pay
for a
tw
o-m
onth
(62-
day)
sup
ply
of d
rugs
in t
his
tier f
rom
a p
refe
rred
mai
l ord
er p
harm
acy.
1$0
co-
pay
for a
thr
ee-m
onth
(93-
day)
sup
ply
of d
rugs
in t
his
tier f
rom
a p
refe
rred
mai
l ord
er p
harm
acy.
1$9
co-
pay
for a
thr
ee-m
onth
(93-
day)
sup
ply
of d
rugs
in t
his
tier f
rom
a n
on-p
refe
rred
mai
l ord
er p
harm
acy.
Tier
2: P
refe
rred
Bra
nd1$3
9 co
-pay
for a
one
-mon
th (3
1-da
y) s
uppl
y of
dru
gs in
thi
stie
r fro
m a
pre
ferr
ed m
ail o
rder
pha
rmac
y.1$7
8 co
-pay
for a
tw
o-m
onth
(62-
day)
sup
ply
of d
rugs
in t
his
tier f
rom
a p
refe
rred
mai
l ord
er p
harm
acy.
1$7
8 co
-pay
for a
thre
e-m
onth
(93-
day)
supp
ly o
f dru
gs in
this
tier f
rom
a p
refe
rred
mai
l ord
er p
harm
acy.
1$1
17 c
o-pa
y fo
r a th
ree-
mon
th (9
3-da
y) su
pply
of d
rugs
in th
istie
r fro
m a
non
-pre
ferr
ed m
ail o
rder
pha
rmac
y.Ti
er 3
: Non
-Pre
ferr
ed B
rand
1$6
9 co
-pay
for a
one
-mon
th (3
1-da
y) s
uppl
y of
dru
gs in
thi
stie
r fro
m a
pre
ferr
ed m
ail o
rder
pha
rmac
y.1$1
38 c
o-pa
y fo
r a t
wo-
mon
th (6
2-da
y) s
uppl
y of
dru
gs in
thi
stie
r fro
m a
pre
ferr
ed m
ail o
rder
pha
rmac
y.
25O
utpa
tient
Pre
scrip
tion
Dru
gs
Sum
ma
ry o
f Ben
efits
| 2
5
WEL
LCA
RE V
ALU
E (H
MO
-PO
S)O
RIG
INA
L M
EDIC
ARE
BEN
EFIT
Pres
crip
tion
Dru
g Be
nefit
s1$1
38 c
o-pa
y fo
r a t
hree
-mon
th (9
3-da
y) s
uppl
y of
dru
gs in
this
tier f
rom
a p
refe
rred
mai
l ord
er p
harm
acy.
1$2
07 c
o-pa
y fo
r a t
hree
-mon
th (9
3-da
y) s
uppl
y of
dru
gs in
this
tier f
rom
a n
on-p
refe
rred
mai
l ord
er p
harm
acy.
Tier
4: S
peci
alty
Tie
r1
33%
coi
nsur
ance
for a
one
-mon
th (3
1-da
y) s
uppl
y of
dru
gs in
this
tier f
rom
a p
refe
rred
mai
l ord
er p
harm
acy.
133
% c
oins
uran
ce fo
r a o
ne-m
onth
(31-
day)
sup
ply
of d
rugs
inth
is tie
r fro
m a
non
-pre
ferr
ed m
ail o
rder
pha
rmac
y.
Cov
erag
e G
ap
Aft
er y
our t
otal
yea
rly d
rug
cost
s re
ach $2
,970
, you
rece
ive
limite
d co
vera
ge b
y th
e pl
an o
n ce
rtai
n dr
ugs.
You
will
also
rece
ive
a di
scou
nt o
n br
and
nam
e dr
ugs
and
gene
rally
pay
no
mor
e th
an 4
7.5%
for t
he p
lan'
s co
sts
for b
rand
dru
gs a
nd 7
9%of
the
pla
n's
cost
s fo
r gen
eric
dru
gs u
ntil
your
yea
rlyou
t-of
-poc
ket
drug
cos
ts re
ach $4
,750
.
Cat
astr
ophi
c C
over
age
Aft
er y
our y
early
out
-of-
pock
et d
rug
cost
s re
ach $4
,750
, you
pay
the
grea
ter o
f:1
5% c
oins
uran
ce, o
r1$2
.65
co-p
ay fo
r gen
eric
(inc
ludi
ng b
rand
dru
gs t
reat
ed a
sge
neric
) and
a $
6.60
co-
pay
for a
ll ot
her d
rugs
.
Out
-of-
Net
wor
k
25O
utpa
tient
Pre
scrip
tion
Dru
gs
Sum
ma
ry o
f Ben
efits
| 2
6
WEL
LCA
RE V
ALU
E (H
MO
-PO
S)O
RIG
INA
L M
EDIC
ARE
BEN
EFIT
Pres
crip
tion
Dru
g Be
nefit
sPl
an d
rugs
may
be
cove
red
in sp
ecia
l circ
umst
ance
s, fo
r ins
tanc
e,ill
ness
whi
le t
rave
ling
outs
ide
of t
he p
lan'
s se
rvic
e ar
ea w
here
ther
e is
no n
etw
ork
phar
mac
y. Y
ou m
ay h
ave
to p
ay m
ore
than
your
nor
mal
cos
t-sh
arin
g am
ount
if y
ou g
et y
our d
rugs
at
anou
t-of
-net
wor
k ph
arm
acy.
In a
dditi
on, y
ou w
ill li
kely
hav
e to
pay
the
phar
mac
y's
full
char
ge fo
r the
dru
g an
d su
bmit
docu
men
tatio
n to
rece
ive
reim
burs
emen
t fro
m W
ellC
are
Valu
e(H
MO
-PO
S).
Out
-of-
Net
wor
k In
itial
Cov
erag
e
You
will
be
reim
burs
ed u
p to
the
pla
n's
cost
of t
he d
rug
min
usth
e fo
llow
ing
for d
rugs
pur
chas
ed o
ut-o
f-ne
twor
k un
til t
otal
year
ly d
rug
cost
s re
ach $2
,970
:Ti
er 1:
Gen
eric
1$3
co-
pay
for a
one
-mon
th (3
1-da
y) s
uppl
y of
dru
gs in
thi
stie
rTi
er 2
: Pre
ferr
ed B
rand
1$3
9 co
-pay
for a
one
-mon
th (3
1-da
y) s
uppl
y of
dru
gs in
thi
stie
rTi
er 3
: Non
-Pre
ferr
ed B
rand
1$6
9 co
-pay
for a
one
-mon
th (3
1-da
y) s
uppl
y of
dru
gs in
thi
stie
rTi
er 4
: Spe
cial
ty T
ier
133
% c
oins
uran
ce fo
r a o
ne-m
onth
(31-
day)
sup
ply
of d
rugs
inth
is tie
r
You
will
not
be
reim
burs
ed fo
r the
diff
eren
ce b
etw
een
the
Out
-of-
Net
wor
k Ph
arm
acy
char
ge a
nd t
he p
lan'
s In
-Net
wor
kal
low
able
am
ount
.
25O
utpa
tient
Pre
scrip
tion
Dru
gs
Sum
ma
ry o
f Ben
efits
| 2
7
WEL
LCA
RE V
ALU
E (H
MO
-PO
S)O
RIG
INA
L M
EDIC
ARE
BEN
EFIT
Pres
crip
tion
Dru
g Be
nefit
s
Out
-of-
Net
wor
k C
over
age
Gap
You
will
be
reim
burs
ed u
p to
21%
of t
he p
lan
allo
wab
le c
ost
for
gene
ric d
rugs
pur
chas
ed o
ut-o
f-ne
twor
k un
til t
otal
yea
rlyou
t-of
-poc
ket
drug
cos
ts re
ach $4
,750
. Ple
ase
note
tha
t th
epl
an a
llow
able
cos
t m
ay b
e le
ss t
han
the
out-
of-n
etw
ork
phar
mac
y pr
ice
paid
for y
our d
rug(
s).
You
will
be
reim
burs
ed u
p to
52.
5% o
f the
pla
n al
low
able
cos
tfo
r bra
nd n
ame
drug
s pur
chas
ed o
ut-o
f-ne
twor
k un
til y
our t
otal
year
ly o
ut-o
f-po
cket
dru
g co
sts
reac
h $4
,750
. Ple
ase
note
tha
tth
e pl
an a
llow
able
cos
t m
ay b
e le
ss t
han
the
out-
of-n
etw
ork
phar
mac
y pr
ice
paid
for y
our d
rug(
s).
Add
ition
al O
ut-o
f-N
etw
ork
Cov
erag
e G
ap
You
will
not
be
reim
burs
ed fo
r the
diff
eren
ce b
etw
een
the
Out
-of-
Net
wor
k Ph
arm
acy
char
ge a
nd t
he p
lan'
s In
-Net
wor
kal
low
able
am
ount
.
Out
-of-
Net
wor
k C
atas
trop
hic
Cov
erag
e
Aft
er y
our y
early
out
-of-
pock
et d
rug
cost
s re
ach $4
,750
, you
will
be
reim
burs
ed fo
r dru
gs p
urch
ased
out
-of-
netw
ork
up t
oth
e pl
an's
cost
of t
he d
rug
min
us y
our c
ost
shar
e, w
hich
is t
hegr
eate
r of:
15%
coi
nsur
ance
, or
1$2
.65
co-p
ay fo
r gen
eric
(inc
ludi
ng b
rand
dru
gs t
reat
ed a
sge
neric
) and
a $
6.60
co-
pay
for a
ll ot
her d
rugs
.
You
will
not
be
reim
burs
ed fo
r the
diff
eren
ce b
etw
een
the
Out
-of-
Net
wor
k Ph
arm
acy
char
ge a
nd t
he p
lan'
s In
-Net
wor
kal
low
able
am
ount
.
25O
utpa
tient
Pre
scrip
tion
Dru
gs
Sum
ma
ry o
f Ben
efits
| 2
8
WEL
LCA
RE V
ALU
E (H
MO
-PO
S)O
RIG
INA
L M
EDIC
ARE
BEN
EFIT
Out
patie
nt M
edic
al S
ervi
ces
and
Supp
lies
Gen
eral
Prev
entiv
e de
ntal
ser
vice
s(s
uch
as c
lean
ing)
not
cov
ered
.26
Den
tal S
ervi
ces
Aut
horiz
atio
n ru
les
may
app
ly.
In-N
etw
ork
$0 c
o-pa
y fo
r Med
icar
e-co
vere
d de
ntal
ben
efits
1$0
co-
pay
for u
p to
1 or
al e
xam
(s) e
very
six
mon
ths
1$0
co-
pay
for u
p to
1 cl
eani
ng(s
) eve
ry s
ix m
onth
s1$0
co-
pay
for u
p to
1 flu
orid
e tr
eatm
ent(
s) e
very
yea
r1$0
co-
pay
for u
p to
1 de
ntal
X-r
ay(s
)
Plan
off
ers
addi
tiona
l com
preh
ensiv
e de
ntal
ben
efits
.
$500
pla
n co
vera
ge li
mit
for d
enta
l ben
efits
eve
ry y
ear
Gen
eral
Supp
lem
enta
l rou
tine
hear
ing
exam
s an
d he
arin
g ai
ds n
otco
vere
d.
27H
earin
g Se
rvic
es
Aut
horiz
atio
n ru
les
may
app
ly.
In-N
etw
ork
20%
coi
nsur
ance
for d
iagn
ostic
hear
ing
exam
s.$3
5 co
-pay
for M
edic
are-
cove
red
diag
nost
ic h
earin
g ex
ams
$0 c
o-pa
y fo
r up
to 1
supp
lem
enta
l rou
tine
hear
ing
exam
(s) e
very
year
$0 c
o-pa
y fo
r up
to 1
hear
ing
aid
fittin
g-ev
alua
tion(
s) e
very
yea
r
$0 c
o-pa
y fo
r up
to 1
hear
ing
aid(
s) e
very
yea
r
$350
pla
n co
vera
ge li
mit
for h
earin
g ai
ds e
very
yea
r.
Sum
ma
ry o
f Ben
efits
| 2
9
WEL
LCA
RE V
ALU
E (H
MO
-PO
S)O
RIG
INA
L M
EDIC
ARE
BEN
EFIT
Out
patie
nt M
edic
al S
ervi
ces
and
Supp
lies
Gen
eral
20%
coi
nsur
ance
for d
iagn
osis
and
trea
tmen
t of
dise
ases
and
cond
ition
s of
the
eye
.
28Vi
sion
Ser
vice
s
Aut
horiz
atio
n ru
les
may
app
ly.
In-N
etw
ork
Supp
lem
enta
l rou
tine
eye
exam
s and
gla
sses
not
cov
ered
.1$0
co-
pay
for o
ne p
air o
f Med
icar
e-co
vere
d ey
egla
sses
or
cont
act
lens
es a
fter
cat
arac
t su
rger
y.M
edic
are
pays
for o
ne p
air o
fey
egla
sses
or c
onta
ct le
nses
afte
r cat
arac
t su
rger
y.
1$0
to $3
5 co
-pay
for M
edic
are-
cove
red
exam
s to
dia
gnos
ean
d tr
eat
dise
ases
and
con
ditio
ns o
f the
eye
.1$0
co-
pay
for u
p to
1 su
pple
men
tal r
outin
e ey
e ex
am(s
) eve
ryye
arA
nnua
l gla
ucom
a sc
reen
ings
cove
red
for p
eopl
e at
risk
.1$0
co-
pay
for u
p to
1 pa
ir(s)
of g
lass
es e
very
yea
r1$0
co-
pay
for u
p to
1 pa
ir(s)
of c
onta
cts
ever
y ye
ar1$0
co-
pay
for u
p to
1 pa
ir(s)
of l
ense
s ev
ery
year
1$0
co-
pay
for u
p to
1 fr
ame(
s) e
very
yea
r
$100
pla
n co
vera
ge li
mit
for e
ye w
ear e
very
yea
r.
Gen
eral
Not
cov
ered
.O
ver-
the-
Cou
nter
Item
s
Plea
se v
isit
our p
lan
web
site
to s
ee o
ur li
st o
f cov
ered
Ove
r-th
e-C
ount
er it
ems.
OTC
item
s m
ay b
e pu
rcha
sed
only
for t
he e
nrol
lee.
Plea
se c
onta
ct t
he p
lan
for s
peci
fic in
stru
ctio
ns fo
r usin
g th
isbe
nefit
.
Sum
ma
ry o
f Ben
efits
| 3
0
WEL
LCA
RE V
ALU
E (H
MO
-PO
S)O
RIG
INA
L M
EDIC
ARE
BEN
EFIT
Out
patie
nt M
edic
al S
ervi
ces
and
Supp
lies
In-N
etw
ork
Not
cov
ered
.Tr
ansp
orta
tion
(Rou
tine)
$0 c
o-pa
y fo
r up
to 2
0 on
e-w
ay tr
ip(s
) to
plan
-app
rove
d lo
catio
nev
ery
year
In-N
etw
ork
Not
cov
ered
.A
cupu
nctu
re
This
plan
doe
s no
t co
ver A
cupu
nctu
re.
Out
-of-
Net
wor
kYo
u m
ay g
o to
any
doc
tor,
spec
ialis
t or
hos
pita
l tha
tac
cept
s M
edic
are.
Poin
t of
Ser
vice
Poin
t of S
ervi
ce c
over
age
is av
aila
ble
for t
he fo
llow
ing
bene
fits:
Med
icar
e-co
vere
d:1
Inpa
tient
Hos
pita
l Acu
te1
Skill
ed N
ursin
g Fa
cilit
y (S
NF)
1C
ardi
ac R
ehab
ilita
tion
Serv
ices
1In
tens
ive
Car
diac
Reh
abili
tatio
n Se
rvic
es1
Pulm
onar
y Re
habi
litat
ion
Serv
ices
1H
ome
Hea
lth S
ervi
ces
1C
hiro
prac
tic S
ervi
ces
1O
ccup
atio
nal T
hera
py S
ervi
ces
1Ph
ysic
ian
Spec
ialis
t Se
rvic
es1
Podi
atry
Ser
vice
s1
Oth
er H
ealth
Car
e Pr
ofes
siona
l1
Phys
ical
The
rapy
and
Spe
ech-
Lang
uage
Pat
holo
gy S
ervi
ces
1O
utpa
tient
Dia
gnos
tic P
roce
dure
s/Te
sts/
Lab
Serv
ices
1D
iagn
ostic
Rad
iolo
gica
l Ser
vice
s1
Ther
apeu
tic R
adio
logi
cal S
ervi
ces
1O
utpa
tient
X-R
ays
1O
utpa
tient
Hos
pita
l Ser
vice
s
Sum
ma
ry o
f Ben
efits
| 3
1
WEL
LCA
RE V
ALU
E (H
MO
-PO
S)O
RIG
INA
L M
EDIC
ARE
BEN
EFIT
Out
patie
nt M
edic
al S
ervi
ces
and
Supp
lies
1A
mbu
lato
ry S
urgi
cal C
ente
r (A
SC) S
ervi
ces
1O
utpa
tient
Blo
od S
ervi
ces
1A
mbu
lanc
e Se
rvic
es1
Dur
able
Med
ical
Equ
ipm
ent
(DM
E)1
Pros
thet
ics/
Med
ical
Sup
plie
s1
Dia
betic
Sup
plie
s an
d Se
rvic
es1
Kidn
ey D
iseas
e Ed
ucat
ion
Serv
ices
1D
iabe
tes
Self-
Man
agem
ent
Trai
ning
1M
edic
are
Part
B R
x D
rugs
30%
of t
he c
ost
per h
ospi
tal s
tay.
30%
of t
he c
ost
for e
ach
SNF
stay
.
30%
of t
he c
ost
for M
edic
are-
cove
red:
1C
ardi
ac R
ehab
ilita
tion
Serv
ices
1In
tens
ive
Car
diac
Reh
abili
tatio
n Se
rvic
es1
Pulm
onar
y Re
habi
litat
ion
Serv
ices
1H
ome
Hea
lth S
ervi
ces
1C
hiro
prac
tic S
ervi
ces
1O
ccup
atio
nal T
hera
py S
ervi
ces
1Ph
ysic
ian
Spec
ialis
t Se
rvic
es1
Podi
atry
Ser
vice
s1
Oth
er H
ealth
Car
e Pr
ofes
siona
l1
Phys
ical
The
rapy
and
Spe
ech-
Lang
uage
Pat
holo
gy S
ervi
ces
1O
utpa
tient
Dia
gnos
tic P
roce
dure
s/Te
sts/
Lab
Serv
ices
1D
iagn
ostic
Rad
iolo
gica
l Ser
vice
s1
Ther
apeu
tic R
adio
logi
cal S
ervi
ces
1O
utpa
tient
X-R
ays
1O
utpa
tient
Hos
pita
l Ser
vice
s1
Am
bula
tory
Sur
gica
l Cen
ter (
ASC
) Ser
vice
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Poin
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Y0070_NA019598_WCM_INS_MLT CMS Accepted 07102012 © WellCare 2012 NA_06_12 _WC NA3V01MLTINSE 47038
Multi-language Interpreter Services
English: We have free interpreter services to answer any questions you may have about our health or drug plan. To get an interpreter, just call us at 1-877-374-4056. Someone who speaks English can help you. This is a free service. Spanish: Tenemos servicios de intérprete sin costo alguno para responder cualquier pregunta que pueda tener sobre nuestro plan de salud o medicamentos. Para hablar con un intérprete, por favor llame al 1-877-374-4056. Alguien que hable español le podrá ayudar. Este es un servicio gratuito.
Chinese Mandarin: 我们提供免费的翻译服务，帮助您解答关于健康或药物保险的任何疑问。
如果您需要此翻译服务，请致电 1-877-374-4056。我们的中文工作人员很乐意帮助您。这是
一项免费服务。
Chinese Cantonese: 您對我們的健康或藥物保險可能存有疑問，為此我們提供免費的翻譯服
務。如需翻譯服務，請致電 1-877-374-4056。我們講中文的人員將樂意為您提供幫助。這是
一項免費服務。
Tagalog: Mayroon kaming libreng serbisyo sa pagsasaling-wika upang masagot ang anumang mga katanungan ninyo hinggil sa aming planong pangkalusugan o panggamot. Upang makakuha ng tagasaling-wika, tawagan lamang kami sa 1-877-374-4056. Maaari kayong tulungan ng isang nakakapagsalita ng Tagalog. Ito ay libreng serbisyo.
French: Nous proposons des services gratuits d'interprétation pour répondre à toutes vos questions relatives à notre régime de santé ou d'assurance-médicaments. Pour accéder au service d'interprétation, il vous suffit de nous appeler au 1-877-374-4056. Un interlocuteur parlant Français pourra vous aider. Ce service est gratuit.
Vietnamese: Chúng tôi có dịch vụ thông dịch miễn phí để trả lời các câu hỏi về chương sức khỏe và chương trình thuốc men. Nếu quí vị cần thông dịch viên xin gọi 1-877-374-4056 sẽ có nhân viên nói tiếng Việt giúp đỡ quí vị. Đây là dịch vụ miễn phí .
German: Unser kostenloser Dolmetscherservice beantwortet Ihren Fragen zu unserem Gesundheits- und Arzneimittelplan. Unsere Dolmetscher erreichen Sie unter 1-877-374-4056. Man wird Ihnen dort auf Deutsch weiterhelfen. Dieser Service ist kostenlos.
Y0070_NA019598_WCM_INS_MLT CMS Accepted 07102012 © WellCare 2012 NA_06_12 _WC NA3V01MLTINSE 47038
Korean: 당사는 의료 보험 또는 약품 보험에 관한 질문에 답해 드리고자 무료 통역 서비스를
제공하고 있습니다. 통역 서비스를 이용하려면 전화 1-877-374-4056 번으로 문의해
주십시오. 한국어를 하는 담당자가 도와 드릴 것입니다. 이 서비스는 무료로 운영됩니다.
Russian: Если у вас возникнут вопросы относительно страхового или медикаментного плана, вы можете воспользоваться нашими бесплатными услугами переводчиков. Чтобы воспользоваться услугами переводчика, позвоните нам по телефону 1-877-374-4056. Вам окажет помощь сотрудник, который говорит по-pусски. Данная услуга бесплатная.
Arabic: ليس فوري، مترجم على للحصول. لدينا األدوية جدول أو بالصحة تتعلق أسئلة أي عن لإلجابة المجانية الفوري المترجم خدمات نقدم إننا
العربية يتحدث ما شخص سيقوم. 4053-374-777-1 على بنا االتصال سوى عليك مجانية خدمة هذه. بمساعدتك .
Italian: È disponibile un servizio di interpretariato gratuito per rispondere a eventuali domande sul nostro piano sanitario e farmaceutico. Per un interprete, contattare il numero 1-877-374-4056. Un nostro incaricato che parla Italianovi fornirà l'assistenza necessaria. È un servizio gratuito.
Portugués: Dispomos de serviços de interpretação gratuitos para responder a qualquer questão que tenha acerca do nosso plano de saúde ou de medicação. Para obter um intérprete, contacte-nos através do número 1-877-374-4056. Irá encontrar alguém que fale o idioma Português para o ajudar. Este serviço é gratuito.
French Creole: Nou genyen sèvis entèprèt gratis pou reponn tout kesyon ou ta genyen konsènan plan medikal oswa dwòg nou an. Pou jwenn yon entèprèt, jis rele nou nan 1-877-374-4056. Yon moun ki pale Kreyòl kapab ede w. Sa a se yon sèvis ki gratis.
Polish: Umożliwiamy bezpłatne skorzystanie z usług tłumacza ustnego, który pomoże w uzyskaniu odpowiedzi na temat planu zdrowotnego lub dawkowania leków. Aby skorzystać z pomocy tłumacza znającego język polski, należy zadzwonić pod numer 1-877-374-4056. Ta usługa jest bezpłatna.
Hindi: हमारे स्वास््य या दवा की योजना के बारे में आपके ककसी भी प्रश्न के जवाब देने के लिए हमारे पास मुफ्त दभुाषिया सेवाए ँउपिब्ध हैं. एक दभुाषिया प्राप्त करने के लिए, बस हमें 1-877-374-4056 पर फोन करें. कोई व्यक्तत जो हहन्दी बोिता है आपकी मदद कर सकता है. यह एक मुफ्त सेवा है.
Japanese: 当社の健康 健康保険と薬品 処方薬プランに関するご質問にお答えするために
、無料の通訳サービスがありますございます。通訳をご用命になるには、1-877-374-
4056にお電話ください。日本語を話す人 者 が支援いたします。これは無料のサービス
です。
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