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Y0070_NA014694_WCM_BKT_ENG_FINAL_48 CMS Approved 07192011 FL48BKT38306E_0311 ©WellCare 2011 FL_03_11_WC
FloridaBrevard, Indian River, Orange, Osceola,
Seminole and Sumter Counties
WellCare of Florida, Inc. | H1032
01/01/12–12/31/12
WellCare Advance (HMO) | Plan 037
WellCare and YouEnrollment Resource Guide
Coordinated Care Plans
Connecticut: WellCare Access (HMO SNP) .................................................... 1-866-635-7047All other plans .................................................................................. 1-866-579-8006
Florida:WellCare Access (HMO SNP) .................................................... 1-866-637-8041
WellCare Select (HMO SNP/HMO-POS SNP) .................. 1-866-637-8041All other plans .................................................................................. 1-888-888-9355
Georgia: WellCare Access (HMO SNP) .................................................... 1-866-482-3361All other plans .................................................................................. 1-866-334-7730
Illinois: WellCare Access (HMO SNP) .................................................... 1-866-439-1190All other plans .................................................................................. 1-866-334-6876
Louisiana:WellCare Access (HMO SNP) .................................................... 1-866-530-9488All other plans .................................................................................. 1-866-804-5926
Missouri: WellCare Access (HMO SNP) .................................................... 1-866-635-7049All other plans .................................................................................. 1-866-687-8994
New Jersey:WellCare Access (HMO SNP) .................................................... 1-866-530-9496
All other plans .................................................................................. 1-866-687-8570
New York: WellCare Access (HMO SNP) .................................................... 1-866-482-3363All other plans .................................................................................. 1-800-278-5155
Ohio: WellCare Access (HMO SNP) .................................................... 1-866-530-9487All other plans .................................................................................. 1-866-687-8815
Texas: WellCare Access (HMO SNP) .................................................... 1-866-530-9495All other plans .................................................................................. 1-866-687-8878
TTY for all states: ................................................................................................................. 1-877-247-6272
We’re always just a phone call away!If you’re ready to enroll or have questions about enrolling, call 1-877-818-8739.
If you’re already a member, find the number for your state/plan in the list below.
Hours of operation are Monday–Sunday, 8 a.m. to 9 p.m. Eastern. Between 2/15/12 and 10/14/12, representatives are available Monday–Friday, 8 a.m. to 9 p.m. Eastern. Or visit us anytime at www.wellcare.com.
Table of Contents
We Put Members First .....................................................................Section 1 Committed to Delivering Value
How to Enroll with WellCare ......................................................Section 2 Important Enrollment Information and Dates
Summary of Benefits .......................................................................Section 3 A Comparison of Benefits
Dental Booklet .....................................................................................Section 4 Our Dental Coverage
HealthStuffTM .........................................................................................Section 5 Items Available for Pick-up or Delivery
WellCare Extras ..................................................................................Section 6 Value-Added Items and Services
Plan Rating ...........................................................................................Section 7 How We Are Rated in Your Area
Statement of Understanding .....................................................Section 8 What I Understand about WellCare
Appeals and Grievences .............................................................Section 9 What to Do and Whom to Talk to
We Put Members First
Thank you for considering WellCare. We’re dedicated to opening the doors that stand between you and the health care you deserve. In fact, our entire mission revolves around serving our members by creating health plans that are easy to use and provide real savings.
This booklet is your guide to becoming a WellCare member. It explains what you need to know before you enroll and how to enroll. It also outlines some reasons why you might want to enroll with us, like the value we deliver and the benefits we offer that Original Medicare doesn’t.
Section 1
Committed to Delivering Value
WellCare Health Plans specializes in government-sponsored health care programs like Medicare and Medicaid. We have more than 25 years of experience delivering benefits value to our members.
At WellCare, we work each day to…
• Enhance your health and quality of life
• Work with health care providers, pharmacies and government partners to give you quality, cost-effective health care solutions
We’re committed to you.
We Help You Get More from Your Health PlanWhy join a WellCare health plan? We design plans to help you get more value from your health care dollar, and we offer a variety of plans to suit your needs, whether you’re looking for…
• A Medicare Advantage plan with medical coverage only
• A Medicare Advantage plan that includes prescription drug coverage
• A stand-alone Prescription Drug plan
Making a Change? We Make it Easy Switching health care plans should be simple. When you switch to WellCare, we’ll guide you through the process step by step. You’ll get the WellCareRoad Map, which details the transition process in an easy-to-use format. And you’ll get the help of our trained staff, who will answer your questions and make sure you’re getting the most from your new plan.
Preventive Care at No Extra CostThe idea behind preventive care is to find potential health issues early, while they’re easier to treat. WellCare offers many preventive care services with $0 co-pays. They include things like cholesterol tests, blood pressure checks, cancer screenings and your annual physical. Taking advantage of these services is one of the best things you can do for your health.
How to Enroll withWellCare
If you’re thinking about enrolling, this is a good place to start. In this section, you’ll find out what steps to take, the forms you’ll need and all about Medicare enrollment periods.
Section 2
Important Enrollment Information and DatesAnnual Enrollment Period (AEP)For 2012, the Annual Enrollment Period, sometimes called AEP or Annual Election Period, will occur from October 15 through December 7, 2011. Health plan coverage will begin January 1, 2012.
Special Enrollment Period (SEP)In most cases, you must stay enrolled for the calendar year starting the date your coverage begins. But in certain situations, you may be able to join, switch or drop plans during a special enrollment period. These include:
• Moving outside the plan’s service area
• Becoming eligible for both Medicare and Medicaid
• Becoming institutionalized (nursing home, for example)
• Qualifying for Extra Help from Medicare to pay for prescription drugs, based on your yearly income and resources
Additional exceptions and qualifications apply.
Source: www.medicare.gov/Publications/Pubs/pdf/11219.pdf
Questions? Just give us a call!If you have questions about enrolling, just call us at 1-877-818-8739 (TTY 1-877-247-6272). You can also contact Medicare 24 hours a day, seven days a week at 1-800-MEDICARE (1-800-633-4227). TTY users may call 1-877-486-2048. Or visit www.medicare.gov
Summary of Benefits
A lot is at stake when you select a health plan. You’ll want to compare costs and see which plans offer the services that mean the most to your well-being. This section gives you the details you need to make such an important decision. The Summary of Benefits doesn’t list every service, limitation or exclusion. But it allows you to do a side-by-side comparison of out-of-pocket costs and more than 30 common services.
Section 3
Summary of Benefits Coordinated Care Plans
Florida Brevard, Indian River, Orange, Osceola, Seminole, and Sumter Counties
WellCare of Florida, Inc. | H1032
01/01/12 - 12/31/12
WellCare Advance (HMO) | Plan 037
Y0070_NA014770_WCM_SOB_ENG_FINAL_48 CMS Approved 08032011 FL48SB38713E_0311 ©WellCare 2011 FL_03_11
Section I - Introduction to Summary of Benefits
Thank you for your interest in WellCare Advance (HMO). Our plan is offered by WellCare of Florida, Inc./WellCare, a Medicare Advantage Health Maintenance Organization (HMO). This Summary of Benefits tells you some features of our plan. It doesn't list every service that we cover or list every limitation or exclusion. To get a complete list of our benefits, please call WellCare Advance (HMO) 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 the Original (fee-for-service) Medicare Plan. Another option is a Medicare health plan, like WellCare Advance (HMO). You may have other options too. You make the choice. No matter what you decide, you are still in the Medicare Program.
You may join or leave a plan only at certain times. Please call WellCare Advance (HMO) at the telephone number listed at the end of this introduction or 1-800-MEDICARE (1-800-633-4227) for more information. 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 Advance (HMO) and the Original Medicare Plan using this Summary of Benefits. The charts in this booklet list some important health benefits. For each benefit, you can 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 more benefits, which may change from year to year.
Where is WellCare Advance (HMO) available?
The service area for this plan includes: Brevard, Indian River, Orange, Osceola, Seminole, and Sumter counties, FL. You must live in one of these areas to join the plan.
Who is eligible to join WellCare Advance (HMO)?
You can join WellCare Advance (HMO) if you are entitled to Medicare Part A and enrolled in Medicare Part B and live in the service area. However, individuals with End-Stage Renal Disease are generally not eligible to enroll in WellCare Advance (HMO) unless they are members of our organization and have been since their dialysis began.
Can I choose my doctors?
WellCare Advance (HMO) has formed a network of doctors, specialists, and hospitals. You can only use doctors who are part of our network. The health providers in our network can change at any time.
You can ask for a current provider directory. For an updated list, visit us at www.wellcare.com. Our customer service number is listed at the end of this introduction.
Summary of Benefits | 1
Section I - Introduction to Summary of Benefits
What happens if I go to a doctor who's not in your network?
If you choose to go to a doctor outside of our network, you must pay for these services yourself except in limited situations (for example, emergency care). Neither the plan nor the Original Medicare Plan will pay for these services.
Does my plan cover Medicare Part B or Part D drugs?
WellCare Advance (HMO) does cover Medicare Part B prescription drugs. WellCare Advance (HMO) does NOT cover Medicare Part D prescription drugs.
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. Plan benefits and cost-sharing may change from calendar year to calendar year. Each year, plans can decide whether to continue to participate with Medicare Advantage. A plan may continue in their entire service area (geographic area where the plan accepts members) or choose to continue only in certain areas. Also, Medicare may decide to end a contract with a plan. Even if your Medicare Advantage Plan leaves the program, you will not lose Medicare coverage. If a plan decides not to continue for an additional calendar year, it must send you a letter at least 90 days before your coverage will end. The letter will explain your options for Medicare coverage in your area.
As a member of WellCare Advance (HMO), you have the right to request an organization determination, 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 if you want us to provide or pay for an item or service that you believe should be covered. If we deny coverage for your requested item or service, you have the right to appeal and ask us to review our decision. You may ask us for an expedited (fast) coverage determination or appeal if you believe that waiting for a decision could seriously put your life or health at risk, or affect your ability to regain maximum function. If your doctor makes or supports the expedited request, we must expedite our decision. Finally, you have the right to file a grievance with us if you have any type of problem with us or one of our network providers that does not involve coverage for an item or service. If your problem involves quality of care, you also have the right to file a grievance with the Quality Improvement Organization (QIO) for your state. Please refer to the Evidence of Coverage (EOC) for the QIO contact information.
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 Advance (HMO) for more details.
1 Some Antigens: If they are prepared by a doctor and administered by a properly instructed person (who could be the patient) under doctor supervision.
1 Osteoporosis Drugs: Injectable drugs for osteoporosis for certain women with Medicare.
Summary of Benefits | 2
Section I - Introduction to Summary of Benefits
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 treat anemia.
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 was paid for by Medicare, or paid by a private insurance that paid as a primary payer to your Medicare Part A coverage, in a Medicare-certified facility.
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 DME.
Where can I find information on plan ratings?
The Medicare program rates how well plans perform in different categories (for example, detecting and 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 "Compare Drug and Health Plans" to compare the plan ratings for Medicare plans in your area. You can also call us directly to obtain a copy of the plan ratings for this plan. Our customer service number is listed below.
Summary of Benefits | 3
Section I - Introduction to Summary of Benefits
Please call WellCare for more information about WellCare Advance (HMO).
Visit us at www.wellcare.com or, call us:
Customer Service Hours: Sunday, Monday, Tuesday, Wednesday, Thursday, Friday, Saturday, 8:00 a.m. - 9:00 p.m. Eastern
Current members should call toll-free or locally (888)-888-9355. (TTY/TDD (877)-247-6272)
Prospective members should call toll-free or locally (877)-817-5794. (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 days a week. Or, visit www.medicare.gov on the Web.
This document may be available in other formats such as Braille, large print or other alternate formats. 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 información adicional, llame a Servicio al Cliente al número de teléfono indicado más arriba.
Summary of Benefits | 4
If yo
u ha
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uest
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abo
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his
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nefit
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cos
ts, p
leas
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ntac
t W
ellC
are
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etai
ls.
Sect
ion
II -
Sum
ma
ry o
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s Fo
r Con
trac
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1032
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n 03
7
WEL
LCA
RE A
DVA
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E (H
MO
) O
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INA
L M
EDIC
ARE
BE
NEF
IT
Impo
rtan
t In
form
atio
n
Gen
eral
In
201
1 the
mon
thly
Par
t B
Prem
ium
was
$96
.40
and
may
ch
ange
for 2
012
and
the
annu
al
Part
B d
educ
tible
am
ount
was
$1
62 a
nd m
ay c
hang
e fo
r 201
2.
1Pr
emiu
m a
nd O
ther
Im
port
ant
Info
rmat
ion
$0 m
onth
ly p
lan
prem
ium
in a
dditi
on to
you
r mon
thly
Med
icar
e Pa
rt B
pre
miu
m.
Mos
t pe
ople
will
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the
sta
ndar
d m
onth
ly P
art
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ad
ditio
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the
ir M
A p
lan
prem
ium
. How
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ople
will
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high
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ium
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of t
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ver
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info
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abou
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rt B
pre
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at 1-
800-
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ay a
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call
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5-07
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doct
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ac
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ass
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ofte
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gher
, whi
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yo
u pa
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ore.
Mos
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ople
will
pay
the
st
anda
rd m
onth
ly P
art
B pr
emiu
m. H
owev
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ome
peop
le w
ill p
ay a
hig
her
prem
ium
bec
ause
of t
heir
In-N
etw
ork
$6,7
00 o
ut-o
f-po
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lim
it fo
r Med
icar
e-co
vere
d se
rvic
es.
year
ly in
com
e (o
ver $
85,0
00
for s
ingl
es, $
170,
000
for m
arrie
d co
uple
s). F
or m
ore
info
rmat
ion
abou
t Pa
rt B
pre
miu
ms
base
d on
inco
me,
cal
l Med
icar
e at
1-
800-
MED
ICA
RE Su
mm
ary
of B
enef
its |
5
WEL
LCA
RE A
DVA
NC
E (H
MO
) O
RIG
INA
L M
EDIC
ARE
BE
NEF
IT
Impo
rtan
t In
form
atio
n (1-
800-
633-
4227
). TT
Y u
sers
sh
ould
cal
l 1-8
77-4
86-2
048.
You
m
ay a
lso c
all S
ocia
l Sec
urity
at
1-80
0-77
2-12
13. T
TY u
sers
sh
ould
cal
l 1-8
00-3
25-0
778.
In-N
etw
ork
You
may
go
to a
ny d
octo
r, sp
ecia
list
or h
ospi
tal t
hat
acce
pts
Med
icar
e.
2D
octo
r and
Hos
pita
l Cho
ice
(For
mor
e in
form
atio
n, s
ee
Emer
genc
y C
are
- #1
5 an
d U
rgen
tly N
eede
d C
are
- #16
.)
You
mus
t go
to
netw
ork
doct
ors,
spec
ialis
ts, a
nd h
ospi
tals
.
Refe
rral
requ
ired
for n
etw
ork
spec
ialis
ts (f
or c
erta
in b
enef
its).
Inpa
tient
Car
e
In-N
etw
ork
In 2
011 t
he a
mou
nts
for e
ach
bene
fit p
erio
d w
ere:
3
Inpa
tient
Hos
pita
l Car
e (in
clud
es S
ubst
ance
Abu
se
and
Reha
bilit
atio
n Se
rvic
es)
No
limit
to t
he n
umbe
r of d
ays
cove
red
by t
he p
lan
each
ho
spita
l sta
y.
1D
ays
1 - 6
0: $
1132
dedu
ctib
le
1D
ays
61 -
90:
$28
3 pe
r day
Fo
r Med
icar
e-co
vere
d ho
spita
l sta
ys:
1D
ays
91 -
150:
$56
6 pe
r lif
etim
e re
serv
e da
y.
1D
ays
1 - 9
0: $
0 co
-pay
per
day
$0 c
o-pa
y fo
r add
ition
al h
ospi
tal d
ays
Thes
e am
ount
s may
cha
nge
for
2012
. Ex
cept
in a
n em
erge
ncy,
you
r doc
tor m
ust t
ell t
he p
lan
that
you
ar
e go
ing
to b
e ad
mitt
ed t
o th
e ho
spita
l. C
all 1
-800
-MED
ICA
RE
(1-80
0-63
3-42
27) f
or
info
rmat
ion
abou
t lif
etim
e re
serv
e da
ys.
Life
time
rese
rve
days
can
onl
y be
use
d on
ce.
1Pr
emiu
m a
nd O
ther
Im
port
ant
Info
rmat
ion
Sum
ma
ry o
f Ben
efits
| 6
BEN
EFIT
Inpa
tient
Car
e
43In
patie
nt H
ospi
tal C
are
(incl
udes
Sub
stan
ce A
buse
an
d Re
habi
litat
ion
Serv
ices
)
Inpa
tient
Men
tal H
ealt
h C
are
ORI
GIN
AL
MED
ICA
RE
A "b
enef
it pe
riod"
sta
rts
the
day
you
go in
to a
hos
pita
l or
skill
ed n
ursi
ng fa
cilit
y. It
end
s w
hen
you
go fo
r 60
days
in a
ro
w w
ithou
t hos
pita
l or s
kille
d nu
rsin
g ca
re. I
f you
go
into
the
ho
spita
l aft
er o
ne b
enef
it pe
riod
has
ende
d, a
new
be
nefit
per
iod
begi
ns. Y
ou
mus
t pay
the
inpa
tient
hos
pita
l de
duct
ible
for e
ach
bene
fit
perio
d. T
here
is n
o lim
it to
the
nu
mbe
r of b
enef
it pe
riods
you
ca
n ha
ve.
In 2
011 t
he a
mou
nts
for e
ach
bene
fit p
erio
d w
ere:
1
Day
s 1 -
60:
$113
2 de
duct
ible
1
Day
s 61
- 9
0: $
283
per d
ay
1D
ays
91 -
150:
$56
6 pe
r lif
etim
e re
serv
e da
y.
Thes
e am
ount
s may
cha
nge
for
2012
.
You
get
up t
o 19
0 da
ys o
f in
patie
nt p
sych
iatr
ic h
ospi
tal
care
in a
life
time.
Inpa
tient
ps
ychi
atric
hos
pita
l ser
vice
s co
unt
tow
ard
the
190-
day
WEL
LCA
RE A
DVA
NC
E (H
MO
)
In-N
etw
ork
You
get
up t
o 19
0 da
ys o
f inp
atie
nt p
sych
iatr
ic h
ospi
tal c
are
in
a lif
etim
e. In
patie
nt p
sych
iatr
ic h
ospi
tal s
ervi
ces
coun
t to
war
d th
e 19
0-da
y lif
etim
e lim
itatio
n on
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.
For M
edic
are-
cove
red
hosp
ital s
tays
: 1
Day
s 1 -
90:
$0
co-p
ay p
er d
ay
Exce
pt in
an
emer
genc
y, y
our d
octo
r mus
t tel
l the
pla
n th
at y
ou
are
goin
g to
be
adm
itted
to
the
hosp
ital.
Sum
ma
ry o
f Ben
efits
| 7
BEN
EFIT
Inpa
tient
Car
e
4In
patie
nt M
enta
l Hea
lth
Car
e
5Sk
illed
Nur
sing
Faci
lity
(SN
F)
(in a
Med
icar
e-ce
rtifi
ed
skill
ed n
ursin
g fa
cilit
y)
ORI
GIN
AL
MED
ICA
RE
lifet
ime
limita
tion
only
if
cert
ain
cond
ition
s are
met
. Thi
s lim
itatio
n do
es n
ot a
pply
to
inpa
tient
psy
chia
tric
ser
vice
s fu
rnish
ed in
a g
ener
al h
ospi
tal.
In 2
011 t
he a
mou
nts
for e
ach
bene
fit p
erio
d af
ter a
t le
ast
a 3-
day
cove
red
hosp
ital s
tay
wer
e:
1D
ays
1 - 2
0: $
0 pe
r day
1
Day
s 21
- 10
0: $
141.5
0 pe
r day
Thes
e am
ount
s may
cha
nge
for
2012
.
100
days
for e
ach
bene
fit
perio
d.
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
er
one
bene
fit p
erio
d ha
s en
ded,
a
new
ben
efit
perio
d be
gins
.
WEL
LCA
RE A
DVA
NC
E (H
MO
)
Gen
eral
Aut
horiz
atio
n ru
les
may
app
ly.
In-N
etw
ork
Plan
cov
ers
up t
o 10
0 da
ys e
ach
bene
fit p
erio
d
No
prio
r hos
pita
l sta
y is
requ
ired.
For S
NF
stay
s:
1D
ays
1 - 2
0: $
0 co
-pay
per
day
1
Day
s 21
- 10
0: $
146
co-p
ay p
er d
ay
Sum
ma
ry o
f Ben
efits
| 8
WEL
LCA
RE A
DVA
NC
E (H
MO
) O
RIG
INA
L M
EDIC
ARE
BE
NEF
IT
Inpa
tient
Car
e Yo
u m
ust
pay
the
inpa
tient
ho
spita
l ded
uctib
le fo
r eac
h be
nefit
per
iod.
The
re is
no
limit
to t
he n
umbe
r of b
enef
it pe
riods
you
can
hav
e.
Gen
eral
$0
co-
pay
6H
ome
Hea
lth
Car
e (in
clud
es m
edic
ally
ne
cess
ary
inte
rmitt
ent
skill
ed n
ursin
g ca
re, h
ome
heal
th a
ide
serv
ices
, and
re
habi
litat
ion
serv
ices
, etc
.)
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
Yo
u pa
y pa
rt o
f the
cos
t fo
r ou
tpat
ient
dru
gs a
nd in
patie
nt
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
M
edic
are-
cert
ified
hos
pice
.
Out
patie
nt C
are
In-N
etw
ork
20%
coi
nsur
ance
8
Doc
tor O
ffic
e Vi
sits
$0 c
o-pa
y fo
r eac
h pr
imar
y ca
re d
octo
r visi
t fo
r M
edic
are-
cove
red
bene
fits.
$30
co-p
ay fo
r eac
h in
-are
a, n
etw
ork
urge
nt c
are
Med
icar
e-co
vere
d vi
sit
5Sk
illed
Nur
sing
Faci
lity
(SN
F)
(in a
Med
icar
e-ce
rtifi
ed
skill
ed n
ursin
g fa
cilit
y)
Sum
ma
ry o
f Ben
efits
| 9
BEN
EFIT
Out
patie
nt C
are
Doc
tor O
ffic
e Vi
sits
9 10 118
Chi
ropr
actic
Ser
vice
s
Podi
atry
Ser
vice
s
Out
patie
nt M
enta
l Hea
lth
Car
e
ORI
GIN
AL
MED
ICA
RE
Supp
lem
enta
l rou
tine
care
not
co
vere
d
20%
coi
nsur
ance
for m
anua
l m
anip
ulat
ion
of t
he s
pine
to
corr
ect
subl
uxat
ion
(a
disp
lace
men
t or
mis
alig
nmen
t of
a jo
int
or b
ody
part
) if y
ou
get
it fr
om a
chi
ropr
acto
r or
othe
r qua
lifie
d pr
ovid
ers.
Supp
lem
enta
l rou
tine
care
not
co
vere
d.
20%
coi
nsur
ance
for m
edic
ally
ne
cess
ary
foot
car
e, in
clud
ing
care
for m
edic
al c
ondi
tions
af
fect
ing
the
low
er li
mbs
.
40%
coi
nsur
ance
for m
ost
outp
atie
nt m
enta
l hea
lth
serv
ices
WEL
LCA
RE A
DVA
NC
E (H
MO
)
$20
co-p
ay fo
r eac
h sp
ecia
list
visit
for M
edic
are-
cove
red
bene
fits.
In-N
etw
ork
$20
co-p
ay fo
r eac
h M
edic
are-
cove
red
visit
$20
co-p
ay fo
r up
to 2
4 su
pple
men
tal r
outin
e vi
sit(s
) eve
ry y
ear
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
or
mis
alig
nmen
t of
a jo
int
or b
ody
part
) if y
ou g
et it
from
a
chiro
prac
tor o
r oth
er q
ualif
ied
prov
ider
s.
In-N
etw
ork
$20
co-p
ay fo
r eac
h M
edic
are-
cove
red
visit
Med
icar
e-co
vere
d po
diat
ry b
enef
its a
re fo
r med
ical
ly-n
eces
sary
fo
ot c
are.
Gen
eral
Aut
horiz
atio
n ru
les
may
app
ly.
In-N
etw
ork
Sum
ma
ry o
f Ben
efits
| 1
0
BEN
EFIT
Out
patie
nt C
are
11O
utpa
tient
Men
tal H
ealt
h C
are
12O
utpa
tient
Sub
stan
ce
Abu
se C
are
ORI
GIN
AL
MED
ICA
RE
Spec
ified
co-
paym
ent
for
outp
atie
nt p
artia
l ho
spita
lizat
ion
prog
ram
se
rvic
es fu
rnish
ed b
y a
hosp
ital
or c
omm
unity
men
tal h
ealth
ce
nter
(CM
HC
). C
o-pa
y ca
nnot
ex
ceed
the
Par
t A
inpa
tient
ho
spita
l ded
uctib
le.
"Par
tial h
ospi
taliz
atio
n pr
ogra
m" i
s a
stru
ctur
ed
prog
ram
of a
ctiv
e ou
tpat
ient
ps
ychi
atric
tre
atm
ent
that
is
mor
e in
tens
e th
an t
he c
are
rece
ived
in y
our d
octo
r's o
r th
erap
ist's
offic
e an
d is
an
alte
rnat
ive
to in
patie
nt
hosp
italiz
atio
n.
20%
coi
nsur
ance
WEL
LCA
RE A
DVA
NC
E (H
MO
)
$20
co-p
ay fo
r eac
h M
edic
are-
cove
red
indi
vidu
al t
hera
py v
isit
$10
co-p
ay fo
r eac
h M
edic
are-
cove
red
grou
p th
erap
y vi
sit
$20
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
$10
co-p
ay fo
r eac
h M
edic
are-
cove
red
grou
p th
erap
y vi
sit w
ith
a ps
ychi
atris
t
$0 c
o-pa
y fo
r Med
icar
e-co
vere
d pa
rtia
l hos
pita
lizat
ion
prog
ram
se
rvic
es
Gen
eral
Aut
horiz
atio
n ru
les
may
app
ly.
In-N
etw
ork
$20
co-p
ay fo
r Med
icar
e-co
vere
d in
divi
dual
visi
ts
$10
co-p
ay fo
r Med
icar
e-co
vere
d gr
oup
visit
s
Sum
ma
ry o
f Ben
efits
| 1
1
BEN
EFIT
Out
patie
nt C
are
13 14 15
Out
patie
nt S
ervi
ces/
Su
rger
y
Am
bula
nce
Serv
ices
(m
edic
ally
nec
essa
ry
ambu
lanc
e se
rvic
es)
Emer
genc
y C
are
(You
may
go
to a
ny
emer
genc
y ro
om if
you
re
ason
ably
bel
ieve
you
nee
d em
erge
ncy
care
.)
ORI
GIN
AL
MED
ICA
RE
20%
coi
nsur
ance
for t
he
doct
or's
serv
ices
Spec
ified
co-
paym
ent
for
outp
atie
nt h
ospi
tal f
acili
ty
serv
ices
. Co-
pay
cann
ot
exce
ed t
he P
art
A in
patie
nt
hosp
ital d
educ
tible
.
20%
coi
nsur
ance
for
ambu
lato
ry s
urgi
cal c
ente
r fa
cilit
y se
rvic
es
20%
coi
nsur
ance
20%
coi
nsur
ance
for t
he
doct
or's
serv
ices
Spec
ified
co-
paym
ent
for
outp
atie
nt h
ospi
tal f
acili
ty
emer
genc
y se
rvic
es.
Emer
genc
y se
rvic
es c
o-pa
y ca
nnot
exc
eed
Part
A in
patie
nt
hosp
ital d
educ
tible
for e
ach
serv
ice
prov
ided
by
the
hosp
ital.
WEL
LCA
RE A
DVA
NC
E (H
MO
)
Gen
eral
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
ambu
lato
ry su
rgic
al c
ente
r vi
sit
$0 c
o-pa
y fo
r eac
h M
edic
are-
cove
red
outp
atie
nt h
ospi
tal f
acili
ty
visit
Gen
eral
Aut
horiz
atio
n ru
les
may
app
ly.
In-N
etw
ork
$100
co-
pay
for M
edic
are-
cove
red
ambu
lanc
e be
nefit
s.
Gen
eral
$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
sa
me
cond
ition
, you
pay
$0
for t
he e
mer
genc
y ro
om v
isit.
Sum
ma
ry o
f Ben
efits
| 1
2
BEN
EFIT
Out
patie
nt C
are
16 1715Em
erge
ncy
Car
e (Y
ou m
ay g
o to
any
em
erge
ncy
room
if y
ou
reas
onab
ly b
elie
ve y
ou n
eed
emer
genc
y ca
re.)
Urg
ently
Nee
ded
Car
e (T
his
is N
OT
emer
genc
y ca
re, a
nd in
mos
t ca
ses,
is ou
t of
the
ser
vice
are
a.)
Out
patie
nt R
ehab
ilita
tion
Serv
ices
(O
ccup
atio
nal T
hera
py,
Phys
ical
The
rapy
, Spe
ech
and
Lang
uage
The
rapy
)
ORI
GIN
AL
MED
ICA
RE
You
don'
t ha
ve t
o pa
y th
e em
erge
ncy
room
co-
pay
if yo
u ar
e ad
mitt
ed to
the
hosp
ital a
s an
inpa
tient
for t
he s
ame
cond
ition
with
in 3
day
s of
the
em
erge
ncy
room
visi
t.
Not
cov
ered
out
side
the
U.S
. ex
cept
und
er li
mite
d ci
rcum
stan
ces.
20%
coi
nsur
ance
, or a
set
co
-pay
NO
T co
vere
d ou
tsid
e th
e U
.S.
exce
pt u
nder
lim
ited
circ
umst
ance
s.
20%
coi
nsur
ance
WEL
LCA
RE A
DVA
NC
E (H
MO
)
Gen
eral
$30
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
sa
me
cond
ition
, you
pay
$0
for t
he u
rgen
tly-n
eede
d-ca
re v
isit.
Gen
eral
Aut
horiz
atio
n ru
les
may
app
ly.
In-N
etw
ork
$20
co-p
ay fo
r Med
icar
e-co
vere
d O
ccup
atio
nal T
hera
py v
isits
$20
co-p
ay fo
r Med
icar
e-co
vere
d Ph
ysic
al a
nd/o
r Spe
ech
and
Lang
uage
The
rapy
visi
ts
Sum
ma
ry o
f Ben
efits
| 1
3
BEN
EFIT
O
RIG
INA
L M
EDIC
ARE
Out
patie
nt M
edic
al S
ervi
ces
and
Supp
lies
18 19 20 21
Dur
able
Med
ical
Equ
ipm
ent
20%
coi
nsur
ance
(in
clud
es w
heel
chai
rs,
oxyg
en, e
tc.)
Pros
thet
ic D
evic
es
20%
coi
nsur
ance
(in
clud
es b
race
s, ar
tific
ial
limbs
and
eye
s, et
c.)
Dia
bete
s Pr
ogra
ms
and
20%
coi
nsur
ance
for d
iabe
tes
Supp
lies
self-
man
agem
ent
trai
ning
20%
coi
nsur
ance
for d
iabe
tes
supp
lies
20%
coi
nsur
ance
for d
iabe
tic
ther
apeu
tic s
hoes
or i
nser
ts
Dia
gnos
tic T
ests
, X-R
ays,
20%
coi
nsur
ance
for d
iagn
ostic
La
b Se
rvic
es, a
nd R
adio
logy
te
sts
and
X-r
ays
Serv
ices
$0
co-
pay
for
Med
icar
e-co
vere
d la
b se
rvic
es
WEL
LCA
RE A
DVA
NC
E (H
MO
)
Gen
eral
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
item
s
Gen
eral
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
item
s
Gen
eral
Aut
horiz
atio
n ru
les
may
app
ly.
In-N
etw
ork
$0 c
o-pa
y fo
r dia
bete
s se
lf-m
anag
emen
t tr
aini
ng
0% o
f the
cos
t fo
r dia
bete
s m
onito
ring
supp
lies
20%
of t
he c
ost
for T
hera
peut
ic s
hoes
or i
nser
ts
Gen
eral
Aut
horiz
atio
n ru
les
may
app
ly.
In-N
etw
ork
$0 t
o $2
0 co
-pay
for M
edic
are-
cove
red
lab
serv
ices
Sum
ma
ry o
f Ben
efits
| 1
4
BEN
EFIT
O
RIG
INA
L M
EDIC
ARE
Out
patie
nt M
edic
al S
ervi
ces
and
Supp
lies
Dia
gnos
tic T
ests
, X-R
ays,
Lab
Serv
ices
: Med
icar
e co
vers
La
b Se
rvic
es, a
nd R
adio
logy
m
edic
ally
nec
essa
ry d
iagn
ostic
Se
rvic
es
lab
serv
ices
tha
t ar
e or
dere
d by
you
r tre
atin
g do
ctor
whe
n th
ey a
re p
rovi
ded
by a
Clin
ical
La
bora
tory
Impr
ovem
ent
Am
endm
ents
(CLI
A) c
ertif
ied
labo
rato
ry t
hat
part
icip
ates
in
Med
icar
e. D
iagn
ostic
lab
serv
ices
are
don
e to
hel
p yo
ur
doct
or d
iagn
ose
or ru
le o
ut a
su
spec
ted
illne
ss o
r con
ditio
n.
Med
icar
e do
es n
ot c
over
mos
t su
pple
men
tal r
outin
e sc
reen
ing
test
s, lik
e ch
ecki
ng y
our
chol
este
rol.
2221
20%
coi
nsur
ance
for d
igita
l re
ctal
exa
m a
nd o
ther
rela
ted
serv
ices
.
Cov
ered
onc
e a
year
for a
ll m
en w
ith M
edic
are
over
age
50
.
Car
diac
and
Pul
mon
ary
20%
coi
nsur
ance
Car
diac
Re
habi
litat
ion
Serv
ices
Re
habi
litat
ion
serv
ices
.
20%
coi
nsur
ance
for P
ulm
onar
y Re
habi
litat
ion
serv
ices
.
WEL
LCA
RE A
DVA
NC
E (H
MO
)
$20
to $
50 c
o-pa
y fo
r Med
icar
e-co
vere
d di
agno
stic
pro
cedu
res
and
test
s
$0 t
o $2
0 co
-pay
for M
edic
are-
cove
red
X-r
ays
$50
co-p
ay fo
r Med
icar
e-co
vere
d di
agno
stic
radi
olog
y se
rvic
es
(not
incl
udin
g X
-ray
s)
$20
co-p
ay fo
r Med
icar
e-co
vere
d th
erap
eutic
radi
olog
y se
rvic
es
Gen
eral
Aut
horiz
atio
n ru
les
may
app
ly.
Sum
ma
ry o
f Ben
efits
| 1
5
WEL
LCA
RE A
DVA
NC
E (H
MO
) O
RIG
INA
L M
EDIC
ARE
BE
NEF
IT
Out
patie
nt M
edic
al S
ervi
ces
and
Supp
lies
In-N
etw
ork
20%
coi
nsur
ance
for I
nten
sive
Car
diac
Reh
abili
tatio
n se
rvic
es
$20
co-p
ay fo
r Med
icar
e-co
vere
d C
ardi
ac R
ehab
ilita
tion
Serv
ices
Th
is ap
plie
s to
pro
gram
se
rvic
es p
rovi
ded
in a
doc
tor's
of
fice.
Spe
cifie
d co
st s
harin
g fo
r pro
gram
ser
vice
s pr
ovid
ed
by h
ospi
tal o
utpa
tient
de
part
men
ts.
$20
co-p
ay fo
r Med
icar
e-co
vere
d In
tens
ive
Car
diac
Re
habi
litat
ion
Serv
ices
$20
co-p
ay fo
r Med
icar
e-co
vere
d Pu
lmon
ary
Reha
bilit
atio
n Se
rvic
es
Prev
entiv
e Se
rvic
es
Gen
eral
N
o co
insu
ranc
e, c
o-pa
ymen
t or
ded
uctib
le fo
r the
follo
win
g:
23Pr
even
tive
Serv
ices
and
W
elln
ess/
Educ
atio
n Pr
ogra
ms
$0 c
o-pa
y fo
r all
prev
entiv
e se
rvic
es c
over
ed u
nder
Orig
inal
M
edic
are
at z
ero
cost
sha
ring:
1
Abd
omin
al A
ortic
Ane
urys
m
Scre
enin
g 1
Abd
omin
al A
ortic
Ane
urys
m s
cree
ning
1
Bone
Mas
s M
easu
rem
ent.
Cov
ered
onc
e ev
ery
24
mon
ths
(mor
e of
ten
if m
edic
ally
nec
essa
ry) i
f you
m
eet
cert
ain
med
ical
co
nditi
ons.
1Bo
ne M
ass
Mea
sure
men
t 1
Car
diov
ascu
lar S
cree
ning
1
Cer
vica
l and
Vag
inal
Can
cer S
cree
ning
(Pap
Tes
t an
d Pe
lvic
Ex
am)
1C
olor
ecta
l Can
cer S
cree
ning
1
Dia
bete
s Sc
reen
ing
1C
ardi
ovas
cula
r Scr
eeni
ng 1
Influ
enza
Vac
cine
1
Cer
vica
l and
Vag
inal
Can
cer
Scre
enin
g. C
over
ed o
nce
ever
y 2
year
s. C
over
ed o
nce
a ye
ar fo
r wom
en w
ith
Med
icar
e at
hig
h ris
k.
1H
epat
itis
B Va
ccin
e 1
HIV
Scr
eeni
ng
1Br
east
Can
cer S
cree
ning
(Mam
mog
ram
) 1
Med
ical
Nut
ritio
n Th
erap
y Se
rvic
es
1Pe
rson
aliz
ed P
reve
ntio
n Pl
an S
ervi
ces (
Ann
ual W
elln
ess V
isits
) 1
Col
orec
tal C
ance
r Scr
eeni
ng 1
Pneu
moc
occa
l Vac
cine
1
Dia
bete
s Sc
reen
ing
22C
ardi
ac a
nd P
ulm
onar
y Re
habi
litat
ion
Serv
ices
Sum
ma
ry o
f Ben
efits
| 1
6
WEL
LCA
RE A
DVA
NC
E (H
MO
) O
RIG
INA
L M
EDIC
ARE
BE
NEF
IT
Prev
entiv
e Se
rvic
es
1Pr
osta
te C
ance
r Scr
eeni
ng (P
rost
ate
Spec
ific
Ant
igen
(PSA
) te
st o
nly)
1
Influ
enza
Vac
cine
1
Hep
atiti
s B
Vacc
ine
for
peop
le w
ith M
edic
are
who
ar
e at
risk
1
Smok
ing
Ces
satio
n (C
ouns
elin
g to
sto
p sm
okin
g)
1W
elco
me
to M
edic
are
Phys
ical
Exa
m (I
nitia
l Pre
vent
ive
Phys
ical
Exa
m)
1H
IV S
cree
ning
. $0
co-p
ay fo
r th
e H
IV s
cree
ning
, but
you
ge
nera
lly p
ay 2
0% o
f the
M
edic
are-
appr
oved
am
ount
fo
r the
doc
tor's
visi
t. H
IV
scre
enin
g is
cove
red
for
peop
le w
ith M
edic
are
who
ar
e pr
egna
nt a
nd p
eopl
e at
in
crea
sed
risk
for t
he
infe
ctio
n, in
clud
ing
anyo
ne
who
ask
s fo
r the
tes
t. M
edic
are
cove
rs t
his
test
on
ce e
very
12 m
onth
s or
up
to t
hree
tim
es d
urin
g a
preg
nanc
y.
HIV
scr
eeni
ng is
cov
ered
for p
eopl
e w
ith M
edic
are
who
are
pr
egna
nt a
nd p
eopl
e at
incr
ease
d ris
k fo
r the
infe
ctio
n, in
clud
ing
anyo
ne w
ho a
sks
for t
he t
est.
Med
icar
e co
vers
thi
s te
st o
nce
ever
y 12
mon
ths o
r up
to th
ree
times
dur
ing
a pr
egna
ncy.
Ple
ase
cont
act
plan
for d
etai
ls.
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
Writ
ten
heal
th e
duca
tion
mat
eria
ls, i
nclu
ding
new
slett
ers
1H
ealth
Clu
b M
embe
rshi
p/Fi
tnes
s C
lass
es
1N
ursin
g H
otlin
e
1Br
east
Can
cer S
cree
ning
(M
amm
ogra
m).
Med
icar
e co
vers
scr
eeni
ng
mam
mog
ram
s onc
e ev
ery
12
mon
ths
for a
ll w
omen
with
M
edic
are
age
40 a
nd o
lder
. M
edic
are
cove
rs o
ne
base
line
mam
mog
ram
for
wom
en b
etw
een
ages
35-
39.
23Pr
even
tive
Serv
ices
and
W
elln
ess/
Educ
atio
n Pr
ogra
ms
Sum
ma
ry o
f Ben
efits
| 1
7
BEN
EFIT
O
RIG
INA
L M
EDIC
ARE
W
ELLC
ARE
AD
VAN
CE
(HM
O)
Prev
entiv
e Se
rvic
es
Prev
entiv
e Se
rvic
es a
nd
1M
edic
al N
utrit
ion
Ther
apy
Wel
lnes
s/Ed
ucat
ion
Serv
ices
. Nut
ritio
n th
erap
y Pr
ogra
ms
is fo
r peo
ple
who
hav
e di
abet
es o
r kid
ney
dise
ase
(but
are
n't
on d
ialy
sis o
r ha
ven'
t ha
d a
kidn
ey
tran
spla
nt) w
hen
refe
rred
by
a do
ctor
. The
se se
rvic
es c
an
be g
iven
by
a re
gist
ered
di
etiti
an a
nd m
ay in
clud
e a
nutr
ition
al a
sses
smen
t an
d co
unse
ling
to h
elp
you
man
age
your
dia
bete
s or
ki
dney
dise
ase.
1
Pers
onal
ized
Pre
vent
ion
Plan
Se
rvic
es (A
nnua
l Wel
lnes
s V
isits
) 1
Pneu
moc
occa
l Vac
cine
. You
m
ay o
nly
need
the
Pn
eum
onia
vac
cine
onc
e in
yo
ur li
fetim
e. C
all y
our
doct
or fo
r mor
e in
form
atio
n.
1Pr
osta
te C
ance
r Scr
eeni
ng
Pros
tate
Spe
cific
Ant
igen
(P
SA) t
est
only
. Cov
ered
on
ce a
yea
r for
all
men
with
M
edic
are
over
age
50.
23
Sum
ma
ry o
f Ben
efits
| 1
8
BEN
EFIT
O
RIG
INA
L M
EDIC
ARE
W
ELLC
ARE
AD
VAN
CE
(HM
O)
Prev
entiv
e Se
rvic
es
23Pr
even
tive
Serv
ices
and
1
Smok
ing
Ces
satio
n
Wel
lnes
s/Ed
ucat
ion
(cou
nsel
ing
to s
top
Pr
ogra
ms
smok
ing)
. Cov
ered
if
orde
red
by y
our d
octo
r.
Incl
udes
tw
o co
unse
ling
at
tem
pts
with
in a
12-m
onth
pe
riod.
Eac
h co
unse
ling
at
tem
pt in
clud
es u
p to
four
fa
ce-t
o-fa
ce v
isits
. 1
Wel
com
e to
Med
icar
e
Phys
ical
Exa
m (i
nitia
l pr
even
tive
phys
ical
exa
m).
W
hen
you
join
Med
icar
e
Part
B, t
hen
you
are
elig
ible
as
follo
ws:
Dur
ing
the
first
12
mon
ths
of y
our n
ew P
art
B
cove
rage
, you
can
get
ei
ther
a W
elco
me
to
Med
icar
e Ph
ysic
al E
xam
or
an A
nnua
l Wel
lnes
s V
isit.
A
fter
you
r firs
t 12
mon
ths,
yo
u ca
n ge
t on
e A
nnua
l W
elln
ess
Visi
t ev
ery
12
mon
ths.
Sum
ma
ry o
f Ben
efits
| 1
9
BEN
EFIT
Prev
entiv
e Se
rvic
es
24 25 26
Kidn
ey D
isea
se a
nd
Con
ditio
ns
Out
patie
nt P
resc
riptio
n D
rugs
Den
tal S
ervi
ces
ORI
GIN
AL
MED
ICA
RE
20%
coi
nsur
ance
for r
enal
di
alys
is
20%
coi
nsur
ance
for k
idne
y di
seas
e ed
ucat
ion
serv
ices
Mos
t dr
ugs
are
not
cove
red
unde
r Orig
inal
Med
icar
e. Y
ou
can
add
pres
crip
tion
drug
co
vera
ge t
o O
rigin
al M
edic
are
by jo
inin
g a
Med
icar
e Pr
escr
iptio
n D
rug
Plan
, or y
ou
can
get
all y
our M
edic
are
cove
rage
, inc
ludi
ng
pres
crip
tion
drug
cov
erag
e, b
y jo
inin
g a
Med
icar
e A
dvan
tage
Pl
an o
r a M
edic
are
Cos
t Pl
an
that
off
ers
pres
crip
tion
drug
co
vera
ge.
Prev
entiv
e de
ntal
ser
vice
s (s
uch
as c
lean
ing)
not
cov
ered
.
WEL
LCA
RE A
DVA
NC
E (H
MO
)
In-N
etw
ork
20%
of t
he c
ost
for r
enal
dia
lysis
20%
of t
he c
ost
for k
idne
y di
seas
e ed
ucat
ion
serv
ices
Dru
gs c
over
ed u
nder
Med
icar
e Pa
rt B
Gen
eral
Mos
t dr
ugs
not
cove
red.
20%
of t
he c
ost
for P
art
B-co
vere
d ch
emot
hera
py d
rugs
and
ot
her P
art
B-co
vere
d dr
ugs.
Dru
gs c
over
ed u
nder
Med
icar
e Pa
rt D
Gen
eral
This
plan
doe
s no
t of
fer p
resc
riptio
n dr
ug c
over
age.
Gen
eral
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 c
o-pa
y fo
r up
to 1
oral
exa
m(s
) eve
ry s
ix m
onth
s 1
$0 c
o-pa
y fo
r up
to 1
clea
ning
(s) e
very
six
mon
ths
1$0
co-
pay
for u
p to
1 de
ntal
X-r
ay(s
)
Sum
ma
ry o
f Ben
efits
| 2
0
BEN
EFIT
Prev
entiv
e Se
rvic
es
Hea
ring
Serv
ices
27 28
Visi
on S
ervi
ces
ORI
GIN
AL
MED
ICA
RE
Supp
lem
enta
l rou
tine
hear
ing
exam
s an
d he
arin
g ai
ds n
ot
cove
red.
20%
coi
nsur
ance
for d
iagn
ostic
he
arin
g ex
ams.
20%
coi
nsur
ance
for d
iagn
osis
and
trea
tmen
t of
dise
ases
and
co
nditi
ons
of t
he e
ye.
Supp
lem
enta
l rou
tine
eye
exam
s and
gla
sses
not
cov
ered
.
Med
icar
e pa
ys fo
r one
pai
r of
eyeg
lass
es o
r con
tact
lens
es
afte
r cat
arac
t su
rger
y.
Ann
ual g
lauc
oma
scre
enin
gs
cove
red
for p
eopl
e at
risk
.
WEL
LCA
RE A
DVA
NC
E (H
MO
)
In-N
etw
ork
1 $
20 c
o-pa
y fo
r Med
icar
e-co
vere
d di
agno
stic
hea
ring
exam
s 1
$0
co-p
ay fo
r up
to 1
supp
lem
enta
l rou
tine
hear
ing
exam
(s)
ever
y ye
ar
1 $
0 co
-pay
for u
p to
1 he
arin
g ai
d fit
ting-
eval
uatio
n(s)
eve
ry
thre
e ye
ars
1 $
0 co
-pay
for u
p to
1 he
arin
g ai
d(s)
eve
ry t
hree
yea
rs
$50
plan
cov
erag
e lim
it fo
r sup
plem
enta
l rou
tine
hear
ing
exam
s ev
ery
year
.
$350
pla
n co
vera
ge li
mit
for h
earin
g ai
ds e
very
thr
ee y
ears
.
In-N
etw
ork
1 $
0 co
-pay
for o
ne p
air o
f eye
glas
ses
or c
onta
ct le
nses
aft
er
cata
ract
sur
gery
. 1
$0
to $
20 c
o-pa
y fo
r exa
ms
to d
iagn
ose
and
trea
t di
seas
es
and
cond
ition
s of
the
eye
. 1
$0
co-p
ay fo
r up
to 1
supp
lem
enta
l rou
tine
eye
exam
(s) e
very
ye
ar
1 $
0 co
-pay
for u
p to
1 pa
ir(s)
of g
lass
es e
very
yea
r 1
$0
co-p
ay fo
r up
to 1
pair(
s) o
f con
tact
s ev
ery
year
1
$0
co-p
ay fo
r up
to 1
pair(
s) o
f len
ses
ever
y ye
ar
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.
Sum
ma
ry o
f Ben
efits
| 2
1
BEN
EFIT
O
RIG
INA
L M
EDIC
ARE
W
ELLC
ARE
AD
VAN
CE
(HM
O)
Prev
entiv
e Se
rvic
es
Ove
r-th
e-C
ount
er It
ems
Not
cov
ered
. G
ener
al
Plea
se v
isit
our p
lan
web
site
to s
ee o
ur li
st o
f cov
ered
O
ver-
the-
Cou
nter
item
s.
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
is be
nefit
.
Tran
spor
tatio
n N
ot c
over
ed.
In-N
etw
ork
(Rou
tine)
Th
is pl
an d
oes
not
cove
r sup
plem
enta
l rou
tine
tran
spor
tatio
n.
Acu
punc
ture
N
ot c
over
ed.
In-N
etw
ork
This
plan
doe
s no
t co
ver A
cupu
nctu
re.
Sum
ma
ry o
f Ben
efits
| 2
2
P.O. Box 31389 | Tampa, FL 33631-3389 www.wellcare.com | (888)-888-9355
TTY/TDD: (877)-247-6272 Monday - Sunday, 8am to 9pm Eastern 38
713
Taking care of your teeth and gums is a big part of your overall health. That’s why we include dental coverage with a focus on preventive care.
On the next few pages, you’ll find details on what we cover and how to use your dental benefits.
Dental BookletSection 4
WellCare is pleased to offer you dental coverage that focuses on the importance of preventive care. Taking care of your teeth
and gums begins with regular checkups and services.
Florida
Dental CoverageCoordinated Care Plans
H1032_FL015504_WCM_BRO_ENG CMS Approved 08022011 FLDENBRO39835E_06_11©WellCare 2011 FL_07_11_WC
TAKE A BITE OUT OF YOUR DENTAL COSTSOur coverage features fixed co-payments for many basic preventive procedures and may include additional services. Knowing what you have to pay ahead of time makes it easier for you to budget your dental dollars.
BRIDGE THE GAP: SEE YOUR DENTIST REGULARLYA key to good dental health is regular visits to the dentist. Our coverage of routine preventive services will keep your smile healthy. And our low or no co-payments keep your wallet feeling healthy, too. It’s a combination that makes it easy to see your dentist often.
BRUSH UP ON HOW TO GET YOUR DENTAL BENEFITSWellCare offers you a network of participating dentists to choose from. To start getting dental care, simply call one of our network dentists. For full information on the dental benefits offered or for a listing of participating dental providers, call WellCare at 1-888-888-9355(TTY 1-877-247-6272), Monday–Sunday, 8 a.m. to 9 p.m. Eastern. Between 2/15/12 and 10/14/12, representatives are available Monday–Friday, 8 a.m. to 9 p.m. Eastern.
Please refer to your WellCare Evidence of Coverage booklet to find out which dental plan you have. Then refer to the corresponding column on the benefit chart (starting on the next page) to learn the specific items covered on your plan. On the chart, the first column is labeled “ADA Code.” ADA stands for American Dental Association. These are the billing codes that dentists use when they bill for services. Ask your dentist for the ADA Codes that he/she will use for the services you need. You can then look up the codes to see if they are covered on your plan. Before obtaining services, you should discuss your treatment options with your dental provider. You may be responsible for the cost of dental services not covered by the plan. Authorization rules may apply.
DENTAL COVERAGE YOU CAN SINK YOUR TEETH INTOWellCare offers you dental coverage with:
• Preventive services such as exams, X-rays and cleanings
• Low or no co-payments for many services
• Virtually no paperwork
• No deductible
In addition, some of our plans cover restorative care,such as fillings.
AD
A C
ode
Des
crip
tion
of S
ervi
ceC
o-pa
yLi
mita
tions
Dental—PreventiveWellCare Choice 002 (HMO-POS)
WellCare Advance 037 (HMO)
WellCare Essential 173 (HMO) Dental—500 WellCare Choice 008 (HMO)
WellCare Dividend 040 (HMO)
WellCare Select 061 (HMO-POS SNP)
WellCare Value 027 (HMO-POS) Dental—750 WellCare Access 124 (HMO SNP) Dental—1000 WellCare Access 170 (HMO SNP)
WellCare Essential 174 (HMO)
Max
imum
pla
n be
nefit
cov
erag
e am
ount
* pe
r ca
lend
ar y
ear:
NA
$500
$750
$100
0
*For
all
cove
red
supp
lem
enta
l den
tal s
ervi
ces.
Any
unu
sed
port
ion
may
not
be
car
ried
over
to
the
next
cal
enda
r ye
ar.
Cle
anin
gs
D111
0Pr
ophy
laxi
s –
Adu
lt$0
1 eve
ry 6
mos
. per
pr
oced
ure
✓✓
✓✓
Fluo
ride
D12
04To
pica
l Flu
orid
e –
Adu
lt$0
1 eve
ry 12
mos
. per
pr
oced
ure
✓✓
✓
Exam
s
D01
20Pe
riodi
c O
ral
Eval
uatio
n$0
1 eve
ry 6
mos
. per
pr
oced
ure
✓✓
✓✓
D01
40Li
mite
d O
ral
Eval
uatio
n$0
1 eve
ry 6
mos
. per
pr
oced
ure
✓✓
✓✓
D01
50C
ompr
ehen
sive
Ora
l Ex
am
$01 e
very
6 m
os. p
er
proc
edur
e✓
✓✓
✓
D01
60Ex
tens
ive
Ora
l Exa
m
$01 e
very
6 m
os. p
er
proc
edur
e✓
✓✓
✓
D01
70Re
-Eva
luat
ion
$01 e
very
6 m
os. p
er
proc
edur
e✓
✓✓
✓
D01
80C
ompr
ehen
sive
Perio
dont
al E
valu
atio
n$0
1 eve
ry 6
mos
. per
pr
oced
ure
✓✓
✓✓
Prev
enti
ve S
ervi
ces
2012
Den
tal C
over
age
| 1
D93
10
Con
sulta
tion
– D
iagn
ostic
Ser
vice
Pr
ovid
ed B
y D
entis
t O
r Ph
ysic
ian
Oth
er
Than
Req
uest
ing
Den
tist
Or
Phys
icia
n
$01 e
very
6 m
os. p
er
proc
edur
e✓
D94
10H
ouse
/Ext
ende
d C
are
Faci
lity
Cal
l$0
1 eve
ry 6
mos
. per
pr
oced
ure
✓
D94
20H
ospi
tal C
all
$01 e
very
6 m
os. p
er
proc
edur
e✓
D94
30
Off
ice
Vis
it Fo
r O
bser
vatio
n (D
urin
g Re
gula
rly S
ched
uled
H
ours
) – N
o O
ther
Se
rvic
es P
erfo
rmed
$01 e
very
6 m
os. p
er
proc
edur
e✓
D94
40O
ffic
e V
isit
– A
fter
Re
gula
rly S
ched
uled
H
ours
$01 e
very
6 m
os. p
er
proc
edur
e✓
D94
50
Cas
e Pr
esen
tatio
n,
Det
aile
d A
nd
Exte
nsiv
e Tr
eatm
ent
Plan
ning
$01 e
very
6 m
os. p
er
proc
edur
e✓
X-R
ays
D02
10In
trao
ral –
Com
plet
e Se
ries
$01 e
very
36
mos
. per
pr
oced
ure
✓✓
✓✓
D02
20In
trao
ral –
1st
Peria
pica
l$0
1 per
pro
cedu
re✓
✓✓
✓
D02
30In
trao
ral –
Eac
h A
dditi
onal
Per
iapi
cal
$04
per
proc
edur
e✓
✓✓
✓
D02
40In
trao
ral –
Occ
lusa
l$0
2 ev
ery
12 m
os. p
er
proc
edur
e✓
✓✓
D02
50Ex
trao
ral –
Firs
t Fi
lm$0
1 eve
ry 12
mos
. per
pr
oced
ure
✓
D02
60Ex
trao
ral –
Eac
h A
dditi
onal
Film
$02
ever
y 12
mos
. per
pr
oced
ure
✓
D02
70Si
ngle
Bite
win
g$0
4 ev
ery
12 m
os. p
er
proc
edur
e✓
✓✓
✓
2012
Den
tal C
over
age
| 2
AD
A C
ode
Des
crip
tion
of S
ervi
ceC
o-pa
yLi
mita
tions
Dental—PreventiveWellCare Choice 002 (HMO-POS)
WellCare Advance 037 (HMO)
WellCare Essential 173 (HMO) Dental—500 WellCare Choice 008 (HMO)
WellCare Dividend 040 (HMO)
WellCare Select 061 (HMO-POS SNP)
WellCare Value 027 (HMO-POS) Dental—750 WellCare Access 124 (HMO SNP) Dental—1000 WellCare Access 170 (HMO SNP)
WellCare Essential 174 (HMO)
X-R
ays
D02
72Tw
o Bi
tew
ings
$02
ever
y 12
mos
. per
pr
oced
ure
✓✓
✓✓
D02
73Th
ree
Bite
win
gs$0
1 eve
ry 12
mos
. per
pr
oced
ure
✓✓
✓✓
D02
74Fo
ur B
itew
ings
$01 e
very
12 m
os. p
er
proc
edur
e✓
✓✓
✓
D02
77V
ertic
al B
itew
ings
– 7
to
8 F
ilms
$01 e
very
36
mos
. per
pr
oced
ure
✓✓
✓✓
D02
90Po
ster
ior-
Ant
erio
r O
r La
tera
l Sku
ll A
nd F
acia
l Bo
ne S
urve
y Fi
lm$0
1 eve
ry 3
6 m
os. p
er
proc
edur
e✓
D03
10Si
alog
raph
y$0
1 eve
ry 3
6 m
os. p
er
proc
edur
e✓
D03
20Te
mpo
rom
andi
bula
r Jo
int
Art
hrog
ram
, In
clud
ing
Inje
ctio
n$0
1 eve
ry 3
6 m
os. p
er
proc
edur
e✓
D03
21O
ther
Te
mpo
rom
andi
bula
r Jo
int
Film
s$0
1 eve
ry 3
6 m
os. p
er
proc
edur
e✓
D03
22To
mog
raph
ic S
urve
y$0
1 eve
ry 3
6 m
os. p
er
proc
edur
e✓
D03
30Pa
nora
mic
Film
$0
1 eve
ry 3
6 m
os. p
er
proc
edur
e✓
✓✓
✓
D03
40C
epha
lom
etric
Film
$01 e
very
36
mos
. per
pr
oced
ure
✓
Prev
enti
ve S
ervi
ces
2012
Den
tal C
over
age
| 3
D03
50O
ral/
Faci
al
Phot
ogra
phic
Imag
es$0
1 eve
ry 3
6 m
os. p
er
proc
edur
e✓
D03
60C
one
Beam
CT,
C
rani
ofac
ial D
ata
Cap
ture
$01 e
very
36
mos
. per
pr
oced
ure
✓
D03
62C
one
Beam
, Tw
o-D
imen
siona
l Im
age
Reco
nstr
uctio
n $0
1 eve
ry 3
6 m
os. p
er
proc
edur
e✓
D03
63C
one
Beam
, Thr
ee-
Dim
ensio
nal I
mag
e Re
cons
truc
tion
$01 e
very
36
mos
. per
pr
oced
ure
✓
Ad
dit
ion
al C
omp
reh
ensi
ve S
ervi
ces
Test
s—Pr
even
tive
D04
15C
olle
ctio
n O
f M
icro
orga
nism
s Fo
r C
ultu
re$0
1 eve
ry 12
mos
. per
tes
t✓
D04
16V
iral C
ultu
re$0
1 eve
ry 12
mos
. per
tes
t✓
D04
21G
enet
ic T
est
For
Susc
eptib
ility
$0
1 eve
ry 12
mos
. per
tes
t✓
D04
25C
arie
s Su
scep
tibili
ty
Test
$01 e
very
12 m
os. p
er t
est
✓
D04
31A
djun
ctiv
e Pr
e-D
iagn
ostic
Tes
ts$0
1 eve
ry 12
mos
. per
tes
t✓
D04
60Pu
lp V
italit
y Te
sts
$01 e
very
12 m
os. p
er t
est
✓✓
D04
70D
iagn
ostic
Cas
ts$0
1 eve
ry 12
mos
. per
tes
t✓
D04
72A
cces
sion
Of
Tiss
ue,
Gro
ss E
xam
$01 e
very
12 m
os. p
er t
est
✓
D04
73A
cces
sion
Of
Tiss
ue, G
ross
And
M
icro
scop
ic E
xam
$0
1 eve
ry 12
mos
. per
tes
t✓
2012
Den
tal C
over
age
| 4
AD
A C
ode
Des
crip
tion
of S
ervi
ceC
o-pa
yLi
mita
tions
Dental—PreventiveWellCare Choice 002 (HMO-POS)
WellCare Advance 037 (HMO)
WellCare Essential 173 (HMO) Dental—500 WellCare Choice 008 (HMO)
WellCare Dividend 040 (HMO)
WellCare Select 061 (HMO-POS SNP)
WellCare Value 027 (HMO-POS) Dental—750 WellCare Access 124 (HMO SNP) Dental—1000 WellCare Access 170 (HMO SNP)
WellCare Essential 174 (HMO)
Test
s—Pr
even
tive
D04
74
Acc
essio
n O
f Ti
ssue
, Gro
ss A
nd
Mic
rosc
opic
Exa
m,
Incl
udin
g Su
rgic
al
Mar
gins
$01 e
very
12 m
os. p
er t
est
✓
D04
75D
ecal
cific
atio
n Pr
oced
ure
$01 e
very
12 m
os. p
er t
est
✓
D04
76Sp
ecia
l Sta
ins
For
Mic
roor
gani
sms
$01 e
very
12 m
os. p
er t
est
✓
D04
77Sp
ecia
l Sta
ins
Not
For
M
icro
orga
nism
s$0
1 eve
ry 12
mos
. per
tes
t✓
D04
78Im
mun
ohist
oche
mic
al
Stai
ns$0
1 eve
ry 12
mos
. per
tes
t✓
D04
79Ti
ssue
In-S
itu
Hyb
ridiz
atio
n$0
1 eve
ry 12
mos
. per
tes
t✓
D04
80A
cces
sion
Of
Exfo
liativ
e C
ytol
ogic
al
Smea
rs$0
1 eve
ry 12
mos
. per
tes
t✓
D04
81El
ectr
on M
icro
scop
y$0
1 eve
ry 12
mos
. per
tes
t✓
D04
82D
irect
Im
mun
oflu
ores
cenc
e$0
1 eve
ry 12
mos
. per
tes
t✓
D04
83In
dire
ct
Imm
unof
luor
esce
nce
$01 e
very
12 m
os. p
er t
est
✓
D04
84C
onsu
ltatio
n O
n Sl
ides
Pre
pare
d El
sew
here
$01 e
very
12 m
os. p
er t
est
✓
Ad
dit
ion
al
Com
pre
hen
sive
Ser
vice
s
2012
Den
tal C
over
age
| 5
Test
s—Pr
even
tive
D04
85C
onsu
ltatio
n In
clud
ing
Prep
Of
Slid
es F
rom
Bi
opsy
$0
1 eve
ry 12
mos
. per
tes
t✓
D04
86A
cces
sion
Of
Brus
h Bi
opsy
Sam
ple
$01 e
very
12 m
os. p
er t
est
✓
D05
02O
ther
Ora
l Pat
holo
gy$0
1 eve
ry 12
mos
. per
tes
t✓
D09
99U
nspe
cifie
d D
iagn
ostic
$01 e
very
12 m
os. p
er t
est
✓
Basi
c Re
stor
ativ
e
D21
40A
mal
gam
– O
ne
Surf
ace,
Prim
ary
Or
Perm
anen
t$0
1 eve
ry 3
6 m
os. p
er t
ooth
✓✓
✓
D21
50A
mal
gam
– T
wo
Surf
aces
, Prim
ary
Or
Perm
anen
t$0
1 eve
ry 3
6 m
os. p
er t
ooth
✓✓
✓
D21
60A
mal
gam
– T
hree
Su
rfac
es, P
rimar
y O
r Pe
rman
ent
$01 e
very
36
mos
. per
too
th✓
✓✓
D21
61A
mal
gam
– F
our
Surf
aces
, Prim
ary
Or
Perm
anen
t$0
1 eve
ry 3
6 m
os. p
er t
ooth
✓✓
✓
Resi
n Re
stor
ativ
e
D23
30Re
sin-B
ased
Com
posit
e –
1 Sur
face
, Ant
erio
r$0
1 eve
ry 3
6 m
os. p
er t
ooth
✓✓
✓
D23
31Re
sin-B
ased
Com
posit
e –
2 Su
rfac
es, A
nter
ior
$01 e
very
36
mos
. per
too
th✓
✓✓
D23
32Re
sin-B
ased
Com
posit
e –
3 Su
rfac
es, A
nter
ior
$01 e
very
36
mos
. per
too
th✓
✓✓
D23
35Re
sin-B
ased
Com
posit
e
– 4+
Sur
face
s, A
nter
ior
$01 e
very
36
mos
. per
too
th✓
✓✓
D23
90Re
sin-B
ased
Com
posit
e C
row
n, A
nter
ior
$01 e
very
36
mos
. per
too
th✓
✓✓
D23
91Re
sin-B
ased
Com
posit
e –
1 Sur
face
, Pos
terio
r $0
1 eve
ry 3
6 m
os. p
er t
ooth
✓✓
✓
2012
Den
tal C
over
age
| 6
AD
A C
ode
Des
crip
tion
of S
ervi
ceC
o-pa
yLi
mita
tions
Dental—PreventiveWellCare Choice 002 (HMO-POS)
WellCare Advance 037 (HMO)
WellCare Essential 173 (HMO) Dental—500 WellCare Choice 008 (HMO)
WellCare Dividend 040 (HMO)
WellCare Select 061 (HMO-POS SNP)
WellCare Value 027 (HMO-POS) Dental—750 WellCare Access 124 (HMO SNP) Dental—1000 WellCare Access 170 (HMO SNP)
WellCare Essential 174 (HMO)
Resi
n Re
stor
ativ
e
D23
92Re
sin-B
ased
Com
posit
e –
2 Su
rfac
es, P
oste
rior
$01 e
very
36
mos
. per
too
th✓
✓✓
D23
93Re
sin-B
ased
Com
posit
e –
3 Su
rfac
es, P
oste
rior
$01 e
very
36
mos
. per
too
th✓
✓✓
D23
94Re
sin-B
ased
Com
posit
e –
4+ S
urfa
ces,
Post
erio
r $0
1 eve
ry 3
6 m
os. p
er t
ooth
✓✓
✓
Endo
dont
ics
D31
10Pu
lp C
ap –
Dire
ct
(Exc
ludi
ng F
inal
Re
stor
atio
n)$0
1 per
life
time
per
toot
h✓
D31
20Pu
lp C
ap –
Indi
rect
(E
xclu
ding
Fin
al
Rest
orat
ion)
$01 p
er li
fetim
e pe
r to
oth
✓
D32
20Th
erap
eutic
Pu
lpot
omy
$01 p
er li
fetim
e pe
r to
oth
✓
D32
21Pu
lpal
Deb
ridem
ent,
Prim
ary
And
Pe
rman
ent
Teet
h$0
1 per
life
time
per
toot
h✓
✓
D32
30
Pulp
al T
hera
py
(Res
orba
ble
Filli
ng)
– A
nter
ior,
Prim
ary
Toot
h (E
xclu
ding
Fin
al
Rest
orat
ion)
$01 p
er li
fetim
e pe
r to
oth
✓
Ad
dit
ion
al
Com
pre
hen
sive
Ser
vice
s
2012
Den
tal C
over
age
| 7
D32
40
Pulp
al T
hera
py
(Res
orba
ble
Filli
ng)
– Po
ster
ior,
Prim
ary
Toot
h (E
xclu
ding
Fin
al
Rest
orat
ion)
$01 p
er li
fetim
e pe
r to
oth
✓
D33
10Ro
ot C
anal
, Ant
erio
r$0
1 per
life
time
per
toot
h✓
✓D
3320
Root
Can
al, B
icus
pid
$01 p
er li
fetim
e pe
r to
oth
✓✓
D33
30Ro
ot C
anal
, Mol
ar$0
1 per
life
time
per
toot
h✓
✓
D33
31Tr
eatm
ent
Of
Root
C
anal
Obs
truc
tion;
N
onsu
rgic
al A
cces
s$0
1 per
life
time
per
toot
h✓
✓
D33
32
Inco
mpl
ete
Endo
doni
c Th
erap
y; In
oper
able
, U
nres
tora
ble
Or
Frac
ture
d To
oth
$01 p
er li
fetim
e pe
r to
oth
✓✓
D33
33In
tern
al R
oot
Repa
ir O
f Pe
rfor
atio
n D
efec
ts$0
1 per
life
time
per
toot
h✓
✓
D33
46Re
trea
tmen
t O
f Pr
evio
us R
oot
Can
al
Ther
apy
– A
nter
ior
$01 p
er li
fetim
e pe
r to
oth
✓✓
D33
47Re
trea
tmen
t O
f Pr
evio
us R
oot
Can
al
Ther
apy
– Bi
cusp
id$0
1 per
life
time
per
toot
h✓
✓
D33
48Re
trea
tmen
t O
f Pr
evio
us R
oot
Can
al
Ther
apy
– M
olar
$01 p
er li
fetim
e pe
r to
oth
✓✓
D33
51
Ape
xific
atio
n/Re
calc
ifica
tion
– In
itial
V
isit
(Api
cal C
losu
re/
Cal
cific
Rep
air
Of
Perf
orat
ions
, Roo
t Re
sorp
tion,
Etc
.)
$01 p
er li
fetim
e pe
r to
oth
✓
2012
Den
tal C
over
age
| 8
AD
A C
ode
Des
crip
tion
of S
ervi
ceC
o-pa
yLi
mita
tions
Dental—PreventiveWellCare Choice 002 (HMO-POS)
WellCare Advance 037 (HMO)
WellCare Essential 173 (HMO) Dental—500 WellCare Choice 008 (HMO)
WellCare Dividend 040 (HMO)
WellCare Select 061 (HMO-POS SNP)
WellCare Value 027 (HMO-POS) Dental—750 WellCare Access 124 (HMO SNP) Dental—1000 WellCare Access 170 (HMO SNP)
WellCare Essential 174 (HMO)
Endo
dont
ics
D33
52
Ape
xific
atio
n/Re
calc
ifica
tion
– In
terim
Med
icat
ion
Repl
acem
ent
(Api
cal C
losu
re/
Cal
cific
Rep
air
Of
Perf
orat
ions
, Roo
t Re
sorp
tion,
Etc
.)
$01 p
er li
fetim
e pe
r to
oth
✓
D33
53
Ape
xific
atio
n/Re
calc
ifica
tion
– Fi
nal
Visi
t (A
pica
l Clo
sure
/C
alci
fic R
epai
r O
f Pe
rfor
atio
ns, R
oot
Reso
rptio
n, E
tc.)
$01 p
er li
fetim
e pe
r to
oth
✓
D34
10A
pico
ecto
my/
Perir
adic
ular
Sur
gery
–
Ant
erio
r$0
1 per
life
time
per
toot
h✓
D34
21A
pico
ecto
my/
Perir
adic
ular
Sur
gery
–
Bicu
spid
(Firs
t Ro
ot)
$01 p
er li
fetim
e pe
r to
oth
✓
D34
25A
pico
ecto
my/
Perir
adic
ular
Sur
gery
–
Mol
ar (F
irst
Root
)$0
1 per
life
time
per
toot
h✓
D34
26A
pico
ecto
my/
Perir
adic
ular
Sur
gery
(E
ach
Add
ition
al R
oot)
$01 p
er li
fetim
e pe
r to
oth
✓
Ad
dit
ion
al
Com
pre
hen
sive
Ser
vice
s
2012
Den
tal C
over
age
| 9
D34
30Re
trog
rade
Fill
ing
– Pe
r Ro
ot$0
1 per
life
time
per
toot
h✓
D34
50Ro
ot A
mpu
tatio
n –
Per
Root
$01 p
er li
fetim
e pe
r to
oth
✓
D34
60En
dodo
ntic
En
doss
eous
Impl
ant
$01 p
er li
fetim
e pe
r to
oth
✓
D34
70
Inte
ntio
nal
Reim
plan
tatio
n (In
clud
ing
Nec
essa
ry
Splin
ting)
$01 p
er li
fetim
e pe
r to
oth
✓
D39
10Su
rgic
al P
roce
dure
For
Is
olat
ion
Of
Toot
h W
ith R
ubbe
r D
am$0
1 per
life
time
per
toot
h✓
D39
20
Hem
isect
ion
(Incl
udin
g A
ny R
oot
Rem
oval
), N
ot In
clud
ing
Root
C
anal
The
rapy
$01 p
er li
fetim
e pe
r to
oth
✓
D39
50C
anal
Pre
para
tion
And
Fi
ttin
g O
f Pr
efor
med
D
owel
Or
Post
$01 p
er li
fetim
e pe
r to
oth
✓
D39
99U
nspe
cifie
d En
dodo
ntic
Pr
oced
ure,
By
Repo
rt$0
1 per
life
time
per
toot
h✓
Perio
dont
ics
D42
10
Gin
give
ctom
y O
r G
ingi
vopl
asty
– F
our
Or
Mor
e C
ontig
uous
Te
eth
Or
Boun
ded
Teet
h Sp
aces
Per
Q
uadr
ant
$01 e
very
24
mos
. per
qu
adra
nt✓
D42
11
Gin
give
ctom
y O
r G
ingi
vopl
asty
– O
ne
To T
hree
Con
tiguo
us
Teet
h O
r Bo
unde
d Te
eth
Spac
es P
er
Qua
dran
t
$01 e
very
24
mos
. per
qu
adra
nt✓
2012
Den
tal C
over
age
| 10
AD
A C
ode
Des
crip
tion
of S
ervi
ceC
o-pa
yLi
mita
tions
Dental—PreventiveWellCare Choice 002 (HMO-POS)
WellCare Advance 037 (HMO)
WellCare Essential 173 (HMO) Dental—500 WellCare Choice 008 (HMO)
WellCare Dividend 040 (HMO)
WellCare Select 061 (HMO-POS SNP)
WellCare Value 027 (HMO-POS) Dental—750 WellCare Access 124 (HMO SNP) Dental—1000 WellCare Access 170 (HMO SNP)
WellCare Essential 174 (HMO)
Perio
dont
ics
D42
30
Ana
tom
ical
Cro
wn
Expo
sure
– F
our
Or
Mor
e C
ontig
uous
Te
eth
Per
Qua
dran
t
$01 e
very
24
mos
. per
qu
adra
nt✓
D42
31
Ana
tom
ical
Cro
wn
Expo
sure
– O
ne T
o Th
ree
Teet
h Pe
r Q
uadr
ant
$01 e
very
24
mos
. per
qu
adra
nt✓
D42
40
Gin
giva
l Fla
p Pr
oced
ure,
Incl
udin
g Ro
ot P
lani
ng –
Fou
r O
r M
ore
Con
tiguo
us
Teet
h O
r Bo
unde
d Te
eth
Spac
es P
er
Qua
dran
t
$01 e
very
24
mos
. per
qu
adra
nt✓
D42
41
Gin
giva
l Fla
p Pr
oced
ure,
Incl
udin
g Ro
ot P
lani
ng –
One
To
Thr
ee C
ontig
uous
Te
eth
Or
Boun
ded
Teet
h Sp
aces
Per
Q
uadr
ant
$01 e
very
24
mos
. per
qu
adra
nt✓
D42
45A
pica
lly P
ositi
oned
Fl
ap$0
1 eve
ry 2
4 m
os. p
er
quad
rant
✓
D42
49C
linic
al C
row
n Le
ngth
enin
g –
Har
d Ti
ssue
$01 p
er li
fetim
e pe
r to
oth
✓
Ad
dit
ion
al
Com
pre
hen
sive
Ser
vice
s
2012
Den
tal C
over
age
| 11
D42
60
Oss
eous
Sur
gery
(In
clud
ing
Flap
Ent
ry
And
Clo
sure
) – F
our
Or
Mor
e C
ontig
uous
Te
eth
Or
Boun
ded
Teet
h Sp
aces
Per
Q
uadr
ant
$01 e
very
24
mos
. per
qu
adra
nt✓
D42
61
Oss
eous
Sur
gery
(In
clud
ing
Flap
Ent
ry
And
Clo
sure
) –
One
To
Thr
ee C
ontig
uous
Te
eth
Or
Boun
ded
Teet
h Sp
aces
Per
Q
uadr
ant
$01 e
very
24
mos
. per
qu
adra
nt✓
D42
63Bo
ne R
epla
cem
ent
Gra
ft –
Firs
t Si
te In
Q
uadr
ant
$01 e
very
24
mos
. per
too
th✓
D42
64
Bone
Rep
lace
men
t G
raft
– E
ach
Add
ition
al S
ite In
Q
uadr
ant
$01 e
very
24
mos
. per
too
th✓
D42
65
Biol
ogic
Mat
eria
ls
To A
id In
Sof
t A
nd
Oss
eous
Tiss
ue
Rege
nera
tion
$01 e
very
24
mos
. per
too
th✓
D42
66
Gui
ded
Tiss
ue
Rege
nera
tion
– Re
sorb
able
Bar
rier,
Per
Site
$01 e
very
24
mos
. per
too
th✓
D42
67
Gui
ded
Tiss
ue
Rege
nera
tion
– N
onre
sorb
able
Bar
rier,
Per
Site
(Inc
lude
s M
embr
ane
Rem
oval
)
$01 e
very
24
mos
. per
too
th✓
D42
68Su
rgic
al R
evisi
on
Proc
edur
e, P
er T
ooth
$01 e
very
24
mos
. per
too
th✓
D42
70Pe
dicl
e So
ft T
issue
G
raft
Pro
cedu
re$0
1 eve
ry 2
4 m
os. p
er t
ooth
✓
2012
Den
tal C
over
age
| 12
AD
A C
ode
Des
crip
tion
of S
ervi
ceC
o-pa
yLi
mita
tions
Dental—PreventiveWellCare Choice 002 (HMO-POS)
WellCare Advance 037 (HMO)
WellCare Essential 173 (HMO) Dental—500 WellCare Choice 008 (HMO)
WellCare Dividend 040 (HMO)
WellCare Select 061 (HMO-POS SNP)
WellCare Value 027 (HMO-POS) Dental—750 WellCare Access 124 (HMO SNP) Dental—1000 WellCare Access 170 (HMO SNP)
WellCare Essential 174 (HMO)
Perio
dont
ics
D42
71Fr
ee S
oft
Tiss
ue G
raft
Pr
oced
ure
(Incl
udin
g D
onor
Site
Sur
gery
)$0
1 eve
ry 2
4 m
os. p
er t
ooth
✓
D42
73
Sube
pith
elia
l C
onne
ctiv
e Ti
ssue
G
raft
Pro
cedu
res,
Per
Toot
h
$01 e
very
24
mos
. per
too
th✓
D42
74
Dis
tal O
r Pr
oxim
al
Wed
ge P
roce
dure
(W
hen
Not
Per
form
ed
In C
onju
nctio
n W
ith
Surg
ical
Pro
cedu
res
In
The
Sam
e A
nato
mic
al
Are
a)
$01 e
very
24
mos
. per
too
th✓
D42
75So
ft T
issu
e A
llogr
aft
$01 e
very
24
mos
. per
too
th✓
D42
76
Com
bine
d C
onne
ctiv
e Ti
ssue
And
Dou
ble
Pedi
cle
Gra
ft, P
er
Toot
h
$01 e
very
24
mos
. per
too
th✓
D43
20Pr
ovis
iona
l Spl
intin
g –
Intr
acor
onal
$01 e
very
24
mos
. per
arc
h✓
D43
21Pr
ovis
iona
l Spl
intin
g –
Extr
acor
onal
$01 e
very
24
mos
. per
arc
h✓
D43
41Pe
riodo
ntal
Sca
ling
And
Roo
t Pl
anin
g –
4+
Teet
h Pe
r Q
uadr
ant
$01 e
very
24
mos
. per
qu
adra
nt✓
✓
Ad
dit
ion
al
Com
pre
hen
sive
Ser
vice
s
2012
Den
tal C
over
age
| 13
D43
42
Perio
dont
al S
calin
g A
nd R
oot
Plan
ing
– 1 t
o 3
Teet
h Pe
r Q
uadr
ant
$01 e
very
24
mos
. per
qu
adra
nt✓
✓
D43
55
Full
Mou
th
Deb
ridem
ent
To
Enab
le C
ompr
ehen
sive
Eval
uatio
n A
nd
Dia
gnos
is
$01 e
very
36
mos
. per
pr
oced
ure
✓✓
✓
D43
81
Loca
lized
Del
iver
y O
f A
ntim
icro
bial
Age
nts
Via
A C
ontr
olle
d Re
leas
e V
ehic
le In
to
Dis
ease
d C
revi
cula
r Ti
ssue
, Per
Too
th, B
y Re
port
$01 e
very
12 m
os. p
er t
ooth
✓
D49
10Pe
riodo
ntal
M
aint
enan
ce$0
1 eve
ry 6
mos
. per
pr
oced
ure
✓✓
D49
20
Uns
ched
uled
Dre
ssin
g C
hang
e (B
y So
meo
ne
Oth
er T
han
Trea
ting
Den
tist)
$01 e
very
12 m
os. p
er
proc
edur
e✓
D49
99U
nspe
cifie
d Pe
riodo
ntal
Pr
oced
ure,
By
Repo
rt$0
1 eve
ry 12
mos
. per
pr
oced
ure
✓
Extr
actio
ns
D71
40Ex
trac
tion,
Eru
pted
To
oth
Or
Expo
sed
Root
$01 p
er li
fetim
e pe
r to
oth
✓✓
✓
Cro
wns
D27
10C
row
n –
Resi
n-Ba
sed
Com
posi
te (I
ndire
ct)
$01 e
very
60
mos
. per
too
th✓
D27
12C
row
n –
3/4
Resi
n-Ba
sed
Com
posi
te
(Indi
rect
)$0
1 eve
ry 6
0 m
os. p
er t
ooth
✓
2012
Den
tal C
over
age
| 14
AD
A C
ode
Des
crip
tion
of S
ervi
ceC
o-pa
yLi
mita
tions
Dental—PreventiveWellCare Choice 002 (HMO-POS)
WellCare Advance 037 (HMO)
WellCare Essential 173 (HMO) Dental—500 WellCare Choice 008 (HMO)
WellCare Dividend 040 (HMO)
WellCare Select 061 (HMO-POS SNP)
WellCare Value 027 (HMO-POS) Dental—750 WellCare Access 124 (HMO SNP) Dental—1000 WellCare Access 170 (HMO SNP)
WellCare Essential 174 (HMO)
Cro
wns
D27
21C
row
n –
Resi
n W
ith
Pred
omin
antly
Bas
e M
etal
$01 e
very
60
mos
. per
too
th✓
D27
22C
row
n –
Resin
With
N
oble
Met
al$0
1 eve
ry 6
0 m
os. p
er t
ooth
✓
D27
40C
row
n –
Porc
elai
n/C
eram
ic S
ubst
rate
$01 e
very
60
mos
. per
too
th✓
D27
51
Cro
wn
– Po
rcel
ain
Fuse
d To
Pr
edom
inan
tly B
ase
Met
al
$01 e
very
60
mos
. per
too
th✓
D27
52C
row
n –
Porc
elai
n Fu
sed
To N
oble
Met
al$0
1 eve
ry 6
0 m
os. p
er t
ooth
✓
D27
81C
row
n –
3/4
Cas
t Pr
edom
inan
tly B
ase
Met
al$0
1 eve
ry 6
0 m
os. p
er t
ooth
✓
D27
82C
row
n –
3/4
Cas
t N
oble
Met
al$0
1 eve
ry 6
0 m
os. p
er t
ooth
✓
D27
83C
row
n –
3/4
Porc
elai
n/C
eram
ic$0
1 eve
ry 6
0 m
os. p
er t
ooth
✓
D27
91C
row
n –
Full
Cas
t Pr
edom
inan
tly B
ase
Met
al$0
1 eve
ry 6
0 m
os. p
er t
ooth
✓
D27
92C
row
n –
Full
Cas
t N
oble
Met
al$0
1 eve
ry 6
0 m
os. p
er t
ooth
✓
Ad
dit
ion
al
Com
pre
hen
sive
Ser
vice
s
2012
Den
tal C
over
age
| 15
D29
10Re
cem
ent
Inla
y, O
nlay
O
r Pa
rtia
l Cov
erag
e Re
stor
atio
n$0
1 eve
ry 12
mos
. per
too
th✓
D29
15Re
cem
ent
Cas
t O
r Pr
efab
ricat
ed P
ost
And
Cor
e$0
1 eve
ry 12
mos
. per
too
th✓
D29
20Re
cem
ent
Cro
wn
$01 e
very
12 m
os. p
er t
ooth
✓
D29
31Pr
efab
ricat
ed S
tain
less
St
eel C
row
n –
Perm
anen
t To
oth
$01 e
very
36
mos
. per
too
th✓
D29
32Pr
efab
ricat
ed R
esin
C
row
n$0
1 eve
ry 3
6 m
os. p
er t
ooth
✓
D29
33Pr
efab
ricat
ed S
tain
less
St
eel C
row
n W
ith
Resin
Win
dow
$01 e
very
36
mos
. per
too
th✓
D29
34
Pref
abric
ated
Est
hetic
C
oate
d St
ainl
ess
Stee
l C
row
n –
Prim
ary
Toot
h
$01 e
very
36
mos
. per
too
th✓
D29
40Se
dativ
e Fi
lling
$0un
limite
d pe
r to
oth
✓
D29
50C
ore
Build
up,
Incl
udin
g A
ny P
ins
$01 e
very
60
mos
. per
too
th✓
D29
51Pi
n Re
tent
ion
– Pe
r To
oth,
In A
dditi
on T
o Re
stor
atio
n$0
1 eve
ry 6
0 m
os. p
er t
ooth
✓
D29
52Po
st A
nd C
ore
In
Add
ition
To
Cro
wn,
In
dire
ctly
Fab
ricat
ed$0
1 eve
ry 6
0 m
os. p
er t
ooth
✓
D29
53Ea
ch A
dditi
onal
In
dire
ctly
Fab
ricat
ed
Post
– S
ame
Toot
h$0
1 eve
ry 6
0 m
os. p
er t
ooth
✓
D29
54Pr
efab
ricat
ed P
ost
And
Cor
e In
Add
ition
To
Cro
wn
$01 e
very
60
mos
. per
too
th✓
2012
Den
tal C
over
age
| 16
AD
A C
ode
Des
crip
tion
of S
ervi
ceC
o-pa
yLi
mita
tions
Dental—PreventiveWellCare Choice 002 (HMO-POS)
WellCare Advance 037 (HMO)
WellCare Essential 173 (HMO) Dental—500 WellCare Choice 008 (HMO)
WellCare Dividend 040 (HMO)
WellCare Select 061 (HMO-POS SNP)
WellCare Value 027 (HMO-POS) Dental—750 WellCare Access 124 (HMO SNP) Dental—1000 WellCare Access 170 (HMO SNP)
WellCare Essential 174 (HMO)
Cro
wns
D29
55Po
st R
emov
al (N
ot
In C
onju
nctio
n W
ith
Endo
dont
ic T
hera
py)
$01 e
very
60
mos
. per
too
th✓
D29
57
Each
Add
ition
al
Pref
abric
ated
Pos
t –
Sam
e To
oth
(Rep
ort
In A
dditi
on T
o C
ode
D29
54)
$01 e
very
60
mos
. per
too
th✓
D29
70Te
mpo
rary
Cro
wn
(Fra
ctur
ed T
ooth
)
$01 e
very
60
mos
. per
too
th✓
D29
71
Add
ition
al P
roce
dure
s To
Con
stru
ct N
ew
Cro
wn
Und
er E
xist
ing
Part
ial D
entu
re
Fram
ewor
k
$01 e
very
60
mos
. per
too
th✓
D29
75C
opin
g$0
1 eve
ry 6
0 m
os. p
er t
ooth
✓
D29
80
Cro
wn
Repa
ir, B
y Re
port
(Per
tinen
t D
ocum
enta
tion
To
Eval
uate
Med
ical
A
ppro
pria
tene
ss
Shou
ld B
e In
clud
ed
Whe
n Th
is C
ode
Is
Repo
rted
.)
$01 e
very
60
mos
. per
too
th✓
Ad
dit
ion
al
Com
pre
hen
sive
Ser
vice
s
2012
Den
tal C
over
age
| 17
D29
99
Uns
peci
fied
Rest
orat
ive
Proc
edur
e,
By R
epor
t (D
eter
min
e If
An
Alte
rnat
ive
HC
PCS
Leve
l II O
r A
CPT
Cod
e Be
tter
D
escr
ibes
The
Ser
vice
Be
ing
Repo
rted
. Th
is C
ode
Shou
ld
Be U
sed
Onl
y If
A
Mor
e Sp
ecifi
c C
ode
Is
Una
vaila
ble.
)
$01 e
very
60
mos
. per
too
th✓
D62
05Po
ntic
– In
dire
ct R
esin
- Ba
sed
Com
posit
e$0
1 eve
ry 6
0 m
os. p
er t
ooth
✓
D62
10Po
ntic
– C
ast
Hig
h N
oble
Met
al$0
1 eve
ry 6
0 m
os. p
er t
ooth
✓
D62
11Po
ntic
– C
ast
Pred
omin
antly
Bas
e M
etal
$01 e
very
60
mos
. per
too
th✓
D62
12Po
ntic
– C
ast
Nob
le
Met
al$0
1 eve
ry 6
0 m
os. p
er t
ooth
✓
D62
41
Pont
ic –
Por
cela
in
Fuse
d To
Pr
edom
inan
tly B
ase
Met
al
$01 e
very
60
mos
. per
too
th✓
D62
42Po
ntic
– P
orce
lain
Fu
sed
To N
oble
Met
al$0
1 eve
ry 6
0 m
os. p
er t
ooth
✓
D62
45Po
ntic
– P
orce
lain
/C
eram
ic$0
1 eve
ry 6
0 m
os. p
er t
ooth
✓
D62
51Po
ntic
– R
esin
With
Pr
edom
inan
tly B
ase
Met
al$0
1 eve
ry 6
0 m
os. p
er t
ooth
✓
D62
52Po
ntic
– R
esin
With
N
oble
Met
al$0
1 eve
ry 6
0 m
os. p
er t
ooth
✓
D62
53Pr
ovis
iona
l Pon
tic$0
1 eve
ry 6
0 m
os. p
er t
ooth
✓
D65
45Re
tain
er –
Cas
t M
etal
Fo
r Re
sin-B
onde
d Fi
xed
Pros
thes
is$0
1 eve
ry 6
0 m
os. p
er t
ooth
✓
2012
Den
tal C
over
age
| 18
AD
A C
ode
Des
crip
tion
of S
ervi
ceC
o-pa
yLi
mita
tions
Dental—PreventiveWellCare Choice 002 (HMO-POS)
WellCare Advance 037 (HMO)
WellCare Essential 173 (HMO) Dental—500 WellCare Choice 008 (HMO)
WellCare Dividend 040 (HMO)
WellCare Select 061 (HMO-POS SNP)
WellCare Value 027 (HMO-POS) Dental—750 WellCare Access 124 (HMO SNP) Dental—1000 WellCare Access 170 (HMO SNP)
WellCare Essential 174 (HMO)
Cro
wns
D65
48
Reta
iner
– P
orce
lain
/C
eram
ic F
or R
esin
- Bo
nded
Fix
ed
Pros
thes
is
$01 e
very
60
mos
. per
too
th✓
D66
00In
lay
– Po
rcel
ain/
Cer
amic
, Tw
o Su
rfac
es$0
1 eve
ry 6
0 m
os. p
er t
ooth
✓
D66
01In
lay
– Po
rcel
ain/
Cer
amic
, Thr
ee O
r M
ore
Surf
aces
$01 e
very
60
mos
. per
too
th✓
D66
02In
lay
– C
ast
Hig
h N
oble
Met
al, T
wo
Surf
aces
$01 e
very
60
mos
. per
too
th✓
D66
03In
lay
– C
ast
Hig
h N
oble
Met
al, T
hree
O
r M
ore
Surf
aces
$01 e
very
60
mos
. per
too
th✓
D66
04In
lay
– C
ast
Pred
omin
antly
Bas
e M
etal
, Tw
o Su
rfac
es$0
1 eve
ry 6
0 m
os. p
er t
ooth
✓
D66
05
Inla
y –
Cas
t Pr
edom
inan
tly B
ase
Met
al, T
hree
Or
Mor
e Su
rfac
es
$01 e
very
60
mos
. per
too
th✓
D66
06In
lay
– C
ast
Nob
le
Met
al, T
wo
Surf
aces
$01 e
very
60
mos
. per
too
th✓
Ad
dit
ion
al
Com
pre
hen
sive
Ser
vice
s
2012
Den
tal C
over
age
| 19
D66
07In
lay
– C
ast
Nob
le
Met
al, T
hree
Or
Mor
e Su
rfac
es$0
1 eve
ry 6
0 m
os. p
er t
ooth
✓
D66
08O
nlay
– P
orce
lain
/C
eram
ic, T
wo
Surf
aces
$01 e
very
60
mos
. per
too
th✓
D66
09O
nlay
– P
orce
lain
/C
eram
ic, T
hree
Or
Mor
e Su
rfac
es$0
1 eve
ry 6
0 m
os. p
er t
ooth
✓
D66
12O
nlay
– C
ast
Pred
omin
antly
Bas
e M
etal
, Tw
o Su
rfac
es$0
1 eve
ry 6
0 m
os. p
er t
ooth
✓
D66
13
Onl
ay –
Cas
t Pr
edom
inan
tly B
ase
Met
al, T
hree
Or
Mor
e Su
rfac
es
$01 e
very
60
mos
. per
too
th✓
D66
14O
nlay
– C
ast
Nob
le
Met
al, T
wo
Surf
aces
$01 e
very
60
mos
. per
too
th✓
D66
15O
nlay
– C
ast
Nob
le
Met
al, T
hree
Or
Mor
e Su
rfac
es$0
1 eve
ry 6
0 m
os. p
er t
ooth
✓
D67
10C
row
n –
Indi
rect
Res
in-
Base
d C
ompo
site
$01 e
very
60
mos
. per
too
th✓
D67
21C
row
n –
Resin
With
Pr
edom
inan
tly B
ase
Met
al$0
1 eve
ry 6
0 m
os. p
er t
ooth
✓
D67
22C
row
n –
Resin
With
N
oble
Met
al$0
1 eve
ry 6
0 m
os. p
er t
ooth
✓
D67
40C
row
n –
Porc
elai
n/C
eram
ic$0
1 eve
ry 6
0 m
os. p
er t
ooth
✓
D67
51
Cro
wn
– Po
rcel
ain
Fuse
d To
Pr
edom
inan
tly B
ase
Met
al
$01 e
very
60
mos
. per
too
th✓
D67
52C
row
n –
Porc
elai
n Fu
sed
To N
oble
Met
al$0
1 eve
ry 6
0 m
os. p
er t
ooth
✓
2012
Den
tal C
over
age
| 2
0
AD
A C
ode
Des
crip
tion
of S
ervi
ceC
o-pa
yLi
mita
tions
Dental—PreventiveWellCare Choice 002 (HMO-POS)
WellCare Advance 037 (HMO)
WellCare Essential 173 (HMO) Dental—500 WellCare Choice 008 (HMO)
WellCare Dividend 040 (HMO)
WellCare Select 061 (HMO-POS SNP)
WellCare Value 027 (HMO-POS) Dental—750 WellCare Access 124 (HMO SNP) Dental—1000 WellCare Access 170 (HMO SNP)
WellCare Essential 174 (HMO)
Cro
wns
D67
81C
row
n –
3/4
Cas
t Pr
edom
inan
tly B
ase
Met
al$0
1 eve
ry 6
0 m
os. p
er t
ooth
✓
D67
82C
row
n –
3/4
Cas
t N
oble
Met
al$0
1 eve
ry 6
0 m
os. p
er t
ooth
✓
D67
83C
row
n –
3/4
Porc
elai
n/C
eram
ic$0
1 eve
ry 6
0 m
os. p
er t
ooth
✓
D67
91C
row
n –
Full
Cas
t Pr
edom
inan
tly B
ase
Met
al$0
1 eve
ry 6
0 m
os. p
er t
ooth
✓
D67
92C
row
n –
Full
Cas
t N
oble
Met
al$0
1 eve
ry 6
0 m
os. p
er t
ooth
✓
D67
93Pr
ovis
iona
l Ret
aine
r C
row
n$0
1 eve
ry 6
0 m
os. p
er t
ooth
✓
D69
20C
onne
ctor
Bar
$01 e
very
24
mos
. per
too
th✓
D69
30Re
cem
ent
Fixe
d Pa
rtia
l D
entu
re$0
1 eve
ry 2
4 m
os. p
er t
ooth
✓
D69
40St
ress
Bre
aker
$01 e
very
24
mos
. per
too
th✓
D69
50Pr
ecis
ion
Att
achm
ent
$01 e
very
24
mos
. per
too
th✓
D69
70
Post
And
Cor
e In
A
dditi
on T
o Fi
xed
Part
ial D
entu
re
Reta
iner
, Ind
irect
ly
Fabr
icat
ed
$01 e
very
60
mos
. per
too
th✓
Ad
dit
ion
al
Com
pre
hen
sive
Ser
vice
s
2012
Den
tal C
over
age
| 2
1
D69
72
Pref
abric
ated
Pos
t A
nd C
ore
+ Fi
xed
Part
ial D
entu
re
Reta
iner
$01 e
very
60
mos
. per
too
th✓
D69
73C
ore
Build
Up
For
Reta
iner
, Inc
ludi
ng
Any
Pin
s$0
1 eve
ry 6
0 m
os. p
er t
ooth
✓
D69
75C
opin
g –
Met
al$0
1 eve
ry 6
0 m
os. p
er t
ooth
✓
D69
76Ea
ch A
dditi
onal
In
dire
ctly
Fab
ricat
ed
Post
– S
ame
Toot
h$0
1 eve
ry 6
0 m
os. p
er t
ooth
✓
D69
77Ea
ch A
dditi
onal
Pr
efab
ricat
ed P
ost
– Sa
me
Toot
h$0
1 eve
ry 6
0 m
os. p
er t
ooth
✓
D69
80Fi
xed
Part
ial D
entu
re
Repa
ir, B
y Re
port
$01 e
very
24
mos
. per
too
th✓
D69
99U
nspe
cifie
d Fi
xed
Pros
thod
ontic
Pr
oced
ure,
By
Repo
rt$0
1 eve
ry 2
4 m
os. p
er a
rch
✓
Den
ture
D51
10C
ompl
ete
Den
ture
–
Max
illar
y$0
1 eve
ry 6
0 m
os. p
er
proc
edur
e✓
✓
D51
20C
ompl
ete
Den
ture
–
Man
dibu
lar
$01 e
very
60
mos
. per
pr
oced
ure
✓✓
D51
30Im
med
iate
Den
ture
–
Max
illar
y$0
1 eve
ry 6
0 m
os. p
er
proc
edur
e✓
✓
D51
40Im
med
iate
Den
ture
–
Man
dibu
lar
$01 e
very
60
mos
. per
pr
oced
ure
✓✓
D52
11
Max
illar
y Pa
rtia
l D
entu
re –
Res
in
Base
(Inc
ludi
ng A
ny
Con
vent
iona
l Cla
sps,
Rest
s A
nd T
eeth
)
$01 e
very
60
mos
. per
pr
oced
ure
✓✓
D52
12
Man
dibu
lar
Part
ial
Den
ture
– R
esin
Ba
se (I
nclu
ding
Any
C
onve
ntio
nal C
lasp
s, Re
sts
And
Tee
th)
$01 e
very
60
mos
. per
pr
oced
ure
✓✓
2012
Den
tal C
over
age
| 2
2
AD
A C
ode
Des
crip
tion
of S
ervi
ceC
o-pa
yLi
mita
tions
Dental—PreventiveWellCare Choice 002 (HMO-POS)
WellCare Advance 037 (HMO)
WellCare Essential 173 (HMO) Dental—500 WellCare Choice 008 (HMO)
WellCare Dividend 040 (HMO)
WellCare Select 061 (HMO-POS SNP)
WellCare Value 027 (HMO-POS) Dental—750 WellCare Access 124 (HMO SNP) Dental—1000 WellCare Access 170 (HMO SNP)
WellCare Essential 174 (HMO)
Den
ture
D52
13
Max
illar
y Pa
rtia
l D
entu
re –
Cas
t M
etal
Fra
mew
ork
With
Res
in D
entu
re
Base
s (In
clud
ing
Any
C
onve
ntio
nal C
lasp
s, Re
sts
And
Tee
th)
$01 e
very
60
mos
. per
pr
oced
ure
✓✓
D52
14
Man
dibu
lar
Part
ial
Den
ture
– C
ast
Met
al F
ram
ewor
k W
ith R
esin
Den
ture
Ba
ses
(Incl
udin
g A
ny
Con
vent
iona
l Cla
sps,
Rest
s A
nd T
eeth
)
$01 e
very
60
mos
. per
pr
oced
ure
✓✓
D52
25
Max
illar
y Pa
rtia
l D
entu
re –
Fle
xibl
e Ba
se (I
nclu
ding
Any
C
lasp
s, Re
sts
And
Te
eth)
$01 e
very
60
mos
. per
pr
oced
ure
✓✓
D52
26
Man
dibu
lar
Part
ial
Den
ture
– F
lexi
ble
Base
(Inc
ludi
ng A
ny
Cla
sps,
Rest
s A
nd
Teet
h)
$01 e
very
60
mos
. per
pr
oced
ure
✓✓
Ad
dit
ion
al
Com
pre
hen
sive
Ser
vice
s
2012
Den
tal C
over
age
| 2
3
D52
81
Rem
ovab
le U
nila
tera
l Pa
rtia
l Den
ture
– O
ne
Piec
e C
ast
Met
al
(Incl
udin
g C
lasp
s A
nd
Teet
h)
$01 e
very
60
mos
. per
pr
oced
ure
✓✓
D54
10A
djus
t C
ompl
ete
Den
ture
– M
axill
ary
$01 e
very
12 m
os. p
er
proc
edur
e✓
✓
D54
11A
djus
t C
ompl
ete
Den
ture
– M
andi
bula
r$0
1 eve
ry 12
mos
. per
pr
oced
ure
✓✓
D54
21A
djus
t Pa
rtia
l Den
ture
–
Max
illar
y$0
1 eve
ry 12
mos
. per
pr
oced
ure
✓✓
D54
22A
djus
t Pa
rtia
l Den
ture
–
Man
dibu
lar
$01 e
very
12 m
os. p
er
proc
edur
e✓
✓
D55
10Re
pair
Brok
en
Com
plet
e D
entu
re
Base
$01 e
very
12 m
os. p
er a
rch
✓✓
D55
20
Repl
ace
Miss
ing
Or
Brok
en T
eeth
–
Com
plet
e D
entu
re
(Eac
h To
oth)
$01 e
very
12 m
os. p
er a
rch
✓✓
D56
10Re
pair
Resin
Den
ture
Ba
se$0
1 eve
ry 12
mos
. per
arc
h✓
✓
D56
20Re
pair
Cas
t Fr
amew
ork
$01 e
very
12 m
os. p
er a
rch
✓✓
D56
30Re
pair
Or
Repl
ace
Brok
en C
lasp
$01 e
very
12 m
os. p
er a
rch
✓✓
D56
40Re
plac
e Br
oken
Tee
th
– Pe
r To
oth
$01 e
very
12 m
os. p
er a
rch
✓✓
D56
50A
dd T
ooth
To
Exist
ing
Part
ial D
entu
re$0
1 eve
ry 12
mos
. per
arc
h✓
✓
D56
60A
dd C
lasp
To
Exist
ing
Part
ial D
entu
re$0
1 eve
ry 12
mos
. per
arc
h✓
✓
D56
70Re
plac
e A
ll Te
eth
And
A
cryl
ic O
n C
ast
Met
al
Fram
ewor
k (M
axill
ary)
$01 e
very
24
mos
. per
arc
h✓
✓
2012
Den
tal C
over
age
| 2
4
AD
A C
ode
Des
crip
tion
of S
ervi
ceC
o-pa
yLi
mita
tions
Dental—PreventiveWellCare Choice 002 (HMO-POS)
WellCare Advance 037 (HMO)
WellCare Essential 173 (HMO) Dental—500 WellCare Choice 008 (HMO)
WellCare Dividend 040 (HMO)
WellCare Select 061 (HMO-POS SNP)
WellCare Value 027 (HMO-POS) Dental—750 WellCare Access 124 (HMO SNP) Dental—1000 WellCare Access 170 (HMO SNP)
WellCare Essential 174 (HMO)
Den
ture
D56
71
Repl
ace
All
Teet
h A
nd A
cryl
ic O
n C
ast
Met
al F
ram
ewor
k (M
andi
bula
r)
$01 e
very
24
mos
. per
arc
h✓
✓
D57
10Re
base
Com
plet
e M
axill
ary
Den
ture
$01 e
very
24
mos
. per
pr
oced
ure
✓✓
D57
11Re
base
Com
plet
e M
andi
bula
r D
entu
re$0
1 eve
ry 2
4 m
os. p
er
proc
edur
e✓
✓
D57
20Re
base
Max
illar
y Pa
rtia
l Den
ture
$01 e
very
24
mos
. per
pr
oced
ure
✓✓
D57
21Re
base
Man
dibu
lar
Part
ial D
entu
re$0
1 eve
ry 2
4 m
os. p
er
proc
edur
e✓
✓
D57
30Re
line
Com
plet
e M
axill
ary
Den
ture
(C
hairs
ide)
$01 e
very
24
mos
. per
pr
oced
ure
✓✓
D57
31Re
line
Com
plet
e M
andi
bula
r D
entu
re
(Cha
irsid
e)$0
1 eve
ry 2
4 m
os. p
er
proc
edur
e✓
✓
D57
40Re
line
Max
illar
y Pa
rtia
l D
entu
re (C
hairs
ide)
$01 e
very
24
mos
. per
pr
oced
ure
✓✓
D57
41Re
line
Man
dibu
lar
Part
ial D
entu
re
(Cha
irsid
e)$0
1 eve
ry 2
4 m
os. p
er
proc
edur
e✓
✓
D57
50Re
line
Com
plet
e M
axill
ary
Den
ture
(L
abor
ator
y)$0
1 eve
ry 2
4 m
os. p
er
proc
edur
e✓
✓
Ad
dit
ion
al
Com
pre
hen
sive
Ser
vice
s
2012
Den
tal C
over
age
| 2
5
D57
51Re
line
Com
plet
e M
andi
bula
r D
entu
re
(Lab
orat
ory)
$01 e
very
24
mos
. per
pr
oced
ure
✓✓
D57
60Re
line
Max
illar
y Pa
rtia
l D
entu
re (L
abor
ator
y)$0
1 eve
ry 2
4 m
os. p
er
proc
edur
e✓
✓
D57
61Re
line
Man
dibu
lar
Part
ial D
entu
re
(Lab
orat
ory)
$01 e
very
24
mos
. per
pr
oced
ure
✓✓
D58
10In
terim
Com
plet
e D
entu
re (M
axill
ary)
$01 e
very
60
mos
. per
pr
oced
ure
✓
D58
11In
terim
Com
plet
e D
entu
re (M
andi
bula
r)$0
1 eve
ry 6
0 m
os. p
er
proc
edur
e✓
D58
20In
terim
Par
tial D
entu
re
(Max
illar
y)$0
1 eve
ry 6
0 m
os. p
er
proc
edur
e✓
D58
21In
terim
Par
tial D
entu
re
(Man
dibu
lar)
$01 e
very
60
mos
. per
pr
oced
ure
✓
D58
50Ti
ssue
Con
ditio
ning
, M
axill
ary
$01 e
very
12 m
os. p
er
proc
edur
e✓
D58
51Ti
ssue
Con
ditio
ning
, M
andi
bula
r$0
1 eve
ry 12
mos
. per
pr
oced
ure
✓
D58
60O
verd
entu
re –
C
ompl
ete,
By
Repo
rt$0
1 eve
ry 6
0 m
os. p
er a
rch
✓
D58
61O
verd
entu
re –
Par
tial,
By R
epor
t$0
1 eve
ry 6
0 m
os. p
er a
rch
✓
D58
62Pr
ecisi
on A
ttac
hmen
t, By
Rep
ort
$01 e
very
60
mos
. per
pr
oced
ure
✓
D58
67
Repl
acem
ent
Of
Repl
acea
ble
Part
Of
Sem
i-Pre
cisio
n O
r Pr
ecis
ion
Att
achm
ent
$01 e
very
60
mos
. per
pr
oced
ure
✓
D58
75
Mod
ifica
tion
Of
Rem
ovab
le P
rost
hesis
Fo
llow
ing
Impl
ant
Surg
ery
$01 e
very
60
mos
. per
pr
oced
ure
✓
D58
99
Uns
peci
fied
Rem
ovab
le
Pros
thod
ontic
Pr
oced
ure,
By
Repo
rt
$01 e
very
60
mos
. per
pr
oced
ure
✓
2012
Den
tal C
over
age
| 2
6
AD
A C
ode
Des
crip
tion
of S
ervi
ceC
o-pa
yLi
mita
tions
Dental—PreventiveWellCare Choice 002 (HMO-POS)
WellCare Advance 037 (HMO)
WellCare Essential 173 (HMO) Dental—500 WellCare Choice 008 (HMO)
WellCare Dividend 040 (HMO)
WellCare Select 061 (HMO-POS SNP)
WellCare Value 027 (HMO-POS) Dental—750 WellCare Access 124 (HMO SNP) Dental—1000 WellCare Access 170 (HMO SNP)
WellCare Essential 174 (HMO)
Inla
ys/O
nlay
s
D25
10In
lay
– M
etal
lic –
One
Su
rfac
e$0
1 eve
ry 6
0 m
os. p
er t
ooth
✓
D25
20In
lay
– M
etal
lic –
Tw
o Su
rfac
es$0
1 eve
ry 6
0 m
os. p
er t
ooth
✓
D25
30In
lay
– M
etal
lic
– Th
ree
Or
Mor
e Su
rfac
es
$01 e
very
60
mos
. per
too
th✓
D25
42O
nlay
– M
etal
lic –
Tw
o Su
rfac
es$0
1 eve
ry 6
0 m
os. p
er t
ooth
✓
D25
43O
nlay
– M
etal
lic –
Th
ree
Surf
aces
$01 e
very
60
mos
. per
too
th✓
D25
44O
nlay
– M
etal
lic
– Fo
ur O
r M
ore
Surf
aces
$01 e
very
60
mos
. per
too
th✓
D26
10In
lay
– Po
rcel
ain/
Cer
amic
– O
ne
Surf
ace
$01 e
very
60
mos
. per
too
th✓
D26
20In
lay
– Po
rcel
ain/
Cer
amic
– T
wo
Surf
aces
$01 e
very
60
mos
. per
too
th✓
D26
30In
lay
– Po
rcel
ain/
Cer
amic
– T
hree
Or
Mor
e Su
rfac
es$0
1 eve
ry 6
0 m
os. p
er t
ooth
✓
D26
42O
nlay
– P
orce
lain
/C
eram
ic –
Tw
o Su
rfac
es$0
1 eve
ry 6
0 m
os. p
er t
ooth
✓
Ad
dit
ion
al
Com
pre
hen
sive
Ser
vice
s
2012
Den
tal C
over
age
| 2
7
D26
43O
nlay
– P
orce
lain
/C
eram
ic –
Thr
ee
Surf
aces
$01 e
very
60
mos
. per
too
th✓
D26
44O
nlay
– P
orce
lain
/C
eram
ic –
Fou
r O
r M
ore
Surf
aces
$01 e
very
60
mos
. per
too
th✓
D26
50In
lay
– Re
sin-
Base
d C
ompo
site
– O
ne
Surf
ace
$01 e
very
60
mos
. per
too
th✓
D26
51In
lay
– Re
sin-B
ased
C
ompo
site
– Tw
o Su
rfac
es$0
1 eve
ry 6
0 m
os. p
er t
ooth
✓
D26
52In
lay
– Re
sin-
Base
d C
ompo
site
– T
hree
Or
Mor
e Su
rfac
es$0
1 eve
ry 6
0 m
os. p
er t
ooth
✓
D26
62O
nlay
– R
esin
-Bas
ed
Com
posi
te –
Tw
o Su
rfac
es$0
1 eve
ry 6
0 m
os. p
er t
ooth
✓
D26
63O
nlay
– R
esin
-Bas
ed
Com
posi
te –
Thr
ee
Surf
aces
$01 e
very
60
mos
. per
too
th✓
D26
64O
nlay
– R
esin
-Bas
ed
Com
posit
e –
Four
Or
Mor
e Su
rfac
es$0
1 eve
ry 6
0 m
os. p
er t
ooth
✓
Oth
er O
ral M
axill
ofac
ial S
urge
ry
D72
10Su
rgic
al R
emov
al O
f Er
upte
d To
oth
$01 p
er li
fetim
e pe
r to
oth
✓✓
✓
D72
20Re
mov
al O
f Im
pact
ed
Toot
h –
Soft
Tiss
ue$0
1 per
life
time
per
toot
h✓
✓✓
D72
30Re
mov
al O
f Im
pact
ed
Toot
h –
Part
ially
Bon
y$0
1 per
life
time
per
toot
h✓
✓✓
D72
40Re
mov
al O
f Im
pact
ed
Toot
h –
Com
plet
ely
Bony
$01 p
er li
fetim
e pe
r to
oth
✓✓
✓
D72
41
Rem
oval
Of
Impa
cted
To
oth
– C
ompl
etel
y Bo
ny, W
ith U
nusu
al
Surg
ical
Com
plic
atio
ns
$01 p
er li
fetim
e pe
r to
oth
✓✓
✓
2012
Den
tal C
over
age
| 2
8
AD
A C
ode
Des
crip
tion
of S
ervi
ceC
o-pa
yLi
mita
tions
Dental—PreventiveWellCare Choice 002 (HMO-POS)
WellCare Advance 037 (HMO)
WellCare Essential 173 (HMO) Dental—500 WellCare Choice 008 (HMO)
WellCare Dividend 040 (HMO)
WellCare Select 061 (HMO-POS SNP)
WellCare Value 027 (HMO-POS) Dental—750 WellCare Access 124 (HMO SNP) Dental—1000 WellCare Access 170 (HMO SNP)
WellCare Essential 174 (HMO)
Oth
er O
ral M
axill
ofac
ial S
urge
ry
D72
50Su
rgic
al R
emov
al O
f Re
sidua
l Roo
ts$0
1 per
life
time
per
toot
h✓
✓✓
D72
60O
roan
tral
Fist
ula
Clo
sure
$01 e
very
60
mos
. per
pr
oced
ure
✓✓
✓
D72
61Pr
imar
y C
losu
re O
f A
Si
nus
Perf
orat
ion
$01 e
very
60
mos
. per
pr
oced
ure
✓
D72
70
Toot
h Re
impl
anta
tion
And
/Or
Stab
iliza
tion
Of
Acc
iden
tally
Ev
ulse
d O
r D
ispla
ced
Toot
h
$01 e
very
60
mos
. per
pr
oced
ure
✓
D72
72
Toot
h Tr
ansp
lant
atio
n (In
clud
es
Reim
plan
tatio
n Fr
om
One
Site
To
Ano
ther
A
nd S
plin
ting
And
/Or
Stab
iliza
tion)
$01 e
very
60
mos
. per
pr
oced
ure
✓
D72
80Su
rgic
al A
cces
s O
f A
n U
neru
pted
Too
th$0
1 eve
ry 6
0 m
os. p
er
proc
edur
e✓
D72
82
Mob
iliza
tion
Of
Erup
ted
Or
Mal
posi
tione
d To
oth
To A
id E
rupt
ion
$01 e
very
60
mos
. per
pr
oced
ure
✓
D72
83Pl
acem
ent
Of
Dev
ice
To F
acili
tate
Eru
ptio
n O
f Im
pact
ed T
ooth
$01 e
very
60
mos
. per
pr
oced
ure
✓
Ad
dit
ion
al
Com
pre
hen
sive
Ser
vice
s
2012
Den
tal C
over
age
| 2
9
D72
85Bi
opsy
Of
Ora
l Tis
sue
– H
ard
(Bon
e, T
ooth
)$0
1 eve
ry 6
0 m
os. p
er
proc
edur
e✓
D72
86Bi
opsy
Of
Ora
l Tis
sue
– So
ft$0
1 eve
ry 6
0 m
os. p
er
proc
edur
e✓
D72
87Ex
folia
tive
Cyt
olog
ical
Sa
mpl
e C
olle
ctio
n$0
1 eve
ry 6
0 m
os. p
er
proc
edur
e✓
D72
88Br
ush
Biop
sy –
Tr
anse
pith
elia
l Sam
ple
Col
lect
ion
$01 e
very
60
mos
. per
pr
oced
ure
✓
D72
90Su
rgic
al R
epos
ition
ing
Of
Teet
h$0
1 eve
ry 6
0 m
os. p
er
proc
edur
e✓
D72
91
Tran
ssep
tal
Fibe
roto
my/
Supr
a C
rest
al F
iber
otom
y,
By R
epor
t
$01 e
very
60
mos
. per
pr
oced
ure
✓
D72
92
Surg
ical
Pla
cem
ent:
Tem
pora
ry A
ncho
rage
D
evic
e (S
crew
- Re
tain
ed P
late
) Re
quiri
ng S
urgi
cal F
lap
$01 e
very
60
mos
. per
pr
oced
ure
✓
D72
93
Surg
ical
Pla
cem
ent:
Tem
pora
ry A
ncho
rage
D
evic
e Re
quiri
ng
Surg
ical
Fla
p
$01 e
very
60
mos
. per
pr
oced
ure
✓
D72
94
Surg
ical
Pla
cem
ent:
Tem
pora
ry A
ncho
rage
D
evic
e W
ithou
t Su
rgic
al F
lap
$01 e
very
60
mos
. per
pr
oced
ure
✓
D73
10
Alv
eolo
plas
ty In
C
onju
nctio
n W
ith
Extr
actio
ns –
Fou
r O
r M
ore
Teet
h O
r To
oth
Spac
es, P
er Q
uadr
ant
$01 e
very
60
mos
. per
qu
adra
nt✓
D73
11
Alv
eolo
plas
ty In
C
onju
nctio
n W
ith
Extr
actio
ns –
One
To
Thre
e Te
eth
Or
Toot
h Sp
aces
, Per
Qua
dran
t
$01 e
very
60
mos
. per
qu
adra
nt✓
2012
Den
tal C
over
age
| 3
0
AD
A C
ode
Des
crip
tion
of S
ervi
ceC
o-pa
yLi
mita
tions
Dental—PreventiveWellCare Choice 002 (HMO-POS)
WellCare Advance 037 (HMO)
WellCare Essential 173 (HMO) Dental—500 WellCare Choice 008 (HMO)
WellCare Dividend 040 (HMO)
WellCare Select 061 (HMO-POS SNP)
WellCare Value 027 (HMO-POS) Dental—750 WellCare Access 124 (HMO SNP) Dental—1000 WellCare Access 170 (HMO SNP)
WellCare Essential 174 (HMO)
Oth
er O
ral M
axill
ofac
ial S
urge
ry
D73
20
Alv
eolo
plas
ty N
ot
In C
onju
nctio
n W
ith
Extr
actio
ns –
Fou
r O
r M
ore
Teet
h O
r To
oth
Spac
es, P
er Q
uadr
ant
$01 e
very
60
mos
. per
qu
adra
nt✓
D73
21
Alv
eolo
plas
ty N
ot
In C
onju
nctio
n W
ith
Extr
actio
ns –
One
To
Thre
e Te
eth
Or
Toot
h Sp
aces
, Per
Qua
dran
t
$01 e
very
60
mos
. per
qu
adra
nt✓
D73
40
Ves
tibul
opla
sty
– Ri
dge
Exte
nsio
n (S
econ
dary
Ep
ithel
ializ
atio
n)
$01 e
very
60
mos
. per
qu
adra
nt✓
D73
50
Ves
tibul
opla
sty
– Ri
dge
Exte
nsio
n (In
clud
ing
Soft
Ti
ssue
Gra
fts,
Mus
cle
Reat
tach
men
t, Re
visio
n O
f So
ft
Tiss
ue A
ttac
hmen
t A
nd M
anag
emen
t O
f H
yper
trop
hied
And
H
yper
plas
tic T
issue
)
$01 e
very
60
mos
. per
qu
adra
nt✓
D74
10Ex
cisio
n O
f Be
nign
Le
sion
Up
To 1.
25 C
M$0
unlim
ited
per
proc
edur
e✓
Ad
dit
ion
al
Com
pre
hen
sive
Ser
vice
s
2012
Den
tal C
over
age
| 3
1
D74
11Ex
cisio
n O
f Be
nign
Le
sion
Gre
ater
Tha
n 1.2
5 C
M$0
unlim
ited
per
proc
edur
e✓
D74
12Ex
cisio
n O
f Be
nign
Le
sion,
Com
plic
ated
$0un
limite
d pe
r pr
oced
ure
✓
D74
13Ex
cisio
n O
f M
alig
nant
Le
sion
Up
To 1.
25 C
M$0
unlim
ited
per
proc
edur
e✓
D74
14Ex
cisio
n O
f M
alig
nant
Le
sion
Gre
ater
Tha
n 1.2
5 C
M$0
unlim
ited
per
proc
edur
e✓
D74
15Ex
cisio
n O
f M
alig
nant
Le
sion,
Com
plic
ated
$0un
limite
d pe
r pr
oced
ure
✓
D74
40
Exci
sion
Of
Mal
igna
nt
Tum
or –
Les
ion
Dia
met
er U
p To
1.25
C
M
$0un
limite
d pe
r pr
oced
ure
✓
D74
41
Exci
sion
Of
Mal
igna
nt
Tum
or –
Les
ion
Dia
met
er G
reat
er
Than
1.25
CM
$0un
limite
d pe
r pr
oced
ure
✓
D74
50
Rem
oval
Of
Beni
gn
Odo
ntog
enic
Cys
t O
r Tu
mor
– L
esio
n D
iam
eter
Up
To 1.
25
CM
$0un
limite
d pe
r pr
oced
ure
✓
D74
51
Rem
oval
Of
Beni
gn
Odo
ntog
enic
Cys
t O
r Tu
mor
– L
esio
n D
iam
eter
Gre
ater
Th
an 1.
25 C
M
$0un
limite
d pe
r pr
oced
ure
✓
D74
60
Rem
oval
Of
Beni
gn
Non
odon
toge
nic
Cys
t O
r Tu
mor
– L
esio
n D
iam
eter
Up
To 1.
25
CM
$0un
limite
d pe
r pr
oced
ure
✓
2012
Den
tal C
over
age
| 3
2
AD
A C
ode
Des
crip
tion
of S
ervi
ceC
o-pa
yLi
mita
tions
Dental—PreventiveWellCare Choice 002 (HMO-POS)
WellCare Advance 037 (HMO)
WellCare Essential 173 (HMO) Dental—500 WellCare Choice 008 (HMO)
WellCare Dividend 040 (HMO)
WellCare Select 061 (HMO-POS SNP)
WellCare Value 027 (HMO-POS) Dental—750 WellCare Access 124 (HMO SNP) Dental—1000 WellCare Access 170 (HMO SNP)
WellCare Essential 174 (HMO)
Oth
er O
ral M
axill
ofac
ial S
urge
ry
D74
61
Rem
oval
Of
Beni
gn
Non
odon
toge
nic
Cys
t O
r Tu
mor
– L
esio
n D
iam
eter
Gre
ater
Th
an 1.
25 C
M
$0un
limite
d pe
r pr
oced
ure
✓
D74
65
Des
truc
tion
Of
Lesio
n(s)
By
Phys
ical
O
r C
hem
ical
Met
hod,
By
Rep
ort
$0un
limite
d pe
r pr
oced
ure
✓
D74
71Re
mov
al O
f La
tera
l Ex
osto
sis (M
axill
a O
r M
andi
ble)
$01 p
er li
fetim
e pe
r pr
oced
ure
✓
D74
72Re
mov
al O
f To
rus
Pala
tinus
$01 p
er li
fetim
e pe
r pr
oced
ure
✓
D74
73Re
mov
al O
f To
rus
Man
dibu
laris
$01 p
er li
fetim
e pe
r pr
oced
ure
✓
D74
85Su
rgic
al R
educ
tion
Of
Oss
eous
Tub
eros
ity$0
1 per
life
time
per
proc
edur
e✓
D74
90Ra
dica
l Res
ectio
n O
f M
axill
a O
r M
andi
ble
$01 p
er li
fetim
e pe
r pr
oced
ure
✓
D75
10In
cisi
on A
nd D
rain
age
Of
Abs
cess
– In
trao
ral
Soft
Tis
sue
$0un
limite
d pe
r pr
oced
ure
✓
Ad
dit
ion
al
Com
pre
hen
sive
Ser
vice
s
2012
Den
tal C
over
age
| 3
3
D75
11
Inci
sion
And
Dra
inag
e O
f A
bsce
ss –
Intr
aora
l So
ft T
issu
e –
Com
plic
ated
(Inc
lude
s D
rain
age
Of
Mul
tiple
Fa
scia
l Spa
ces)
$0un
limite
d pe
r pr
oced
ure
✓
D75
20In
cisi
on A
nd D
rain
age
Of
Abs
cess
– E
xtra
oral
So
ft T
issue
$0un
limite
d pe
r pr
oced
ure
✓
D75
21
Inci
sion
And
Dra
inag
e O
f A
bsce
ss –
Ext
raor
al
Soft
Tis
sue
– C
ompl
icat
ed (I
nclu
des
Dra
inag
e O
f M
ultip
le
Fasc
ial S
pace
s)
$0un
limite
d pe
r pr
oced
ure
✓
D75
30
Rem
oval
Of
Fore
ign
Body
Fro
m M
ucos
a,
Skin
, Or
Subc
utan
eous
A
lveo
lar
Tiss
ue
$0un
limite
d pe
r pr
oced
ure
✓
D75
40
Rem
oval
Of
Reac
tion-
Prod
ucin
g Fo
reig
n Bo
dies
, M
uscu
losk
elet
al
Syst
em
$0un
limite
d pe
r pr
oced
ure
✓
D79
60
Fren
ulec
tom
y (F
rene
ctom
y O
r Fr
enot
omy)
–
Sepa
rate
Pro
cedu
re
$01 e
very
60
mos
. per
pr
oced
ure
✓
D79
63Fr
enul
opla
sty
$01 e
very
60
mos
. per
pr
oced
ure
✓
D79
70Ex
cisio
n O
f H
yper
plas
tic T
issue
–
Per
Arc
h$0
1 eve
ry 6
0 m
os. p
er
proc
edur
e✓
D79
71Ex
cisio
n O
f Pe
ricor
onal
Gin
giva
$01 p
er li
fetim
e pe
r pr
oced
ure
✓
D79
72Su
rgic
al R
educ
tion
Of
Fibr
ous
Tube
rosit
y$0
1 per
life
time
per
proc
edur
e✓
2012
Den
tal C
over
age
| 3
4
AD
A C
ode
Des
crip
tion
of S
ervi
ceC
o-pa
yLi
mita
tions
Dental—PreventiveWellCare Choice 002 (HMO-POS)
WellCare Advance 037 (HMO)
WellCare Essential 173 (HMO) Dental—500 WellCare Choice 008 (HMO)
WellCare Dividend 040 (HMO)
WellCare Select 061 (HMO-POS SNP)
WellCare Value 027 (HMO-POS) Dental—750 WellCare Access 124 (HMO SNP) Dental—1000 WellCare Access 170 (HMO SNP)
WellCare Essential 174 (HMO)
Oth
er O
ral M
axill
ofac
ial S
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ry
D79
97
App
lianc
e Re
mov
al
(Not
By
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tist
Who
Pl
aced
App
lianc
e),
Incl
udes
Rem
oval
Of
Arc
hbar
$01 e
very
60
mos
. per
pr
oced
ure
✓
D79
99U
nspe
cifie
d O
ral
Surg
ery
Proc
edur
e, B
y Re
port
$01 e
very
60
mos
. per
pr
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ure
✓
Oth
er S
ervi
ces
D92
10
Loca
l Ane
sthe
sia
Not
In
Con
junc
tion
With
O
pera
tive
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D92
11Re
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lock
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limite
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D92
12Tr
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$0un
limite
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D92
15Lo
cal A
nest
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$0un
limite
d pe
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✓
D92
20D
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Seda
tion/
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30 M
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D92
21
Dee
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–
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$0un
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Ad
dit
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pre
hen
sive
Ser
vice
s
2012
Den
tal C
over
age
| 3
5
D92
30A
nalg
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, Anx
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sis,
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latio
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f N
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limite
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D92
41In
trav
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datio
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–
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t 30
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D92
42
Intr
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15
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$0un
limite
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D92
48N
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per
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D91
20Fi
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entu
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ng$0
1 eve
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mos
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pr
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✓
D96
10Th
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Pa
rent
eral
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g, S
ingl
e A
dmin
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tion
$01 e
very
6 m
os. p
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proc
edur
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D96
12
Ther
apeu
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aren
tera
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, Tw
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ore
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ratio
ns,
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$01 e
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D96
30O
ther
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gs A
nd/
Or
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rt$0
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D99
10A
pplic
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$01 e
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D99
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D99
20Be
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or
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agem
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Repo
rt$0
1 eve
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2012
Den
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over
age
| 3
6
AD
A C
ode
Des
crip
tion
of S
ervi
ceC
o-pa
yLi
mita
tions
Dental—PreventiveWellCare Choice 002 (HMO-POS)
WellCare Advance 037 (HMO)
WellCare Essential 173 (HMO) Dental—500 WellCare Choice 008 (HMO)
WellCare Dividend 040 (HMO)
WellCare Select 061 (HMO-POS SNP)
WellCare Value 027 (HMO-POS) Dental—750 WellCare Access 124 (HMO SNP) Dental—1000 WellCare Access 170 (HMO SNP)
WellCare Essential 174 (HMO)
Oth
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D99
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D99
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52O
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7
3983
5
WellCare is a Coordinated Care Plan with a Medicare Advantage contract. The benefit information provided herein is a brief summary, not a comprehensive description of benefits.
For more information, contact the plan. Benefits, limitations, co-payments and restrictions may vary by plan and by county. Benefits, formulary, pharmacy network, premium and/or co-payments/coinsurance may change on January 1, 2013. You must continue to pay your
Medicare Part B premium. If you meet certain eligibility requirements for both Medicare and Medicaid, your Part B premiums may be covered in full. Members also enrolled in Medicaid may be eligible for secondary coverage of their routine dental services by the state. Before
obtaining these dental services, ask the provider if they are able to bill Medicaid as the secondary payer. Be sure to show your Medicaid identification card. Please contact WellCare for details. You must use network dental providers. If you obtain care from out-of-network dental providers, neither Medicare nor WellCare will be responsible for the costs. Contact
WellCare for more information.
We want to pick up the tab for some of the stuff you buy at your local drug store. You know, the everyday, over-the-counter stuff you don’t need a prescription to buy. That’s why we created the HealthStuff™ benefit. It lets you get non-prescription drugs and general health items at no cost to you every month.
Just ahead, you’ll find a list of items you can get. There are also directions for ordering your selections. You can call us to have your items mailed right to your door, or you can buy them at your neighborhood drug store and we’ll reimburse you.
HealthStuffTM
Section 5
2012 HealthStuffTM
Get the over-the-counter medications you need. Free.Coordinated Care Plans
Y0070_NA015426_WCM_BKT_ENG CMS Approved 08112011 NACATOTC39700E_0611 ©WellCare 2011 NA_06_11_WC
2012 Over-the-Counter Items Catalog | 1
The Benefits of WellCare Add Up.As a part of your plan, you get HealthStuff™ — monthly spending money that can help you save your own. Here’s how it works: We give you a monthly fixed-dollar amount to buy over-the-counter (OTC) medications and products you need to stay well — things like bandages, pain relievers, cold remedies, toothpaste and much more. You even have the flexibility to pick generic or brand-name items. If you order through this catalog, we’ll even ship your items right to your door. Or buy your selections at any retail store, and we’ll reimburse you.
Not sure what your HealthStuff™ allowance amounts to? Check your Evidenceof Coverage. And, remember: Your HealthStuff™ benefit and any OTC items you select are for you and you alone.
How Do I Use My HealthStuff™ Benefit?There are two easy ways to get your HealthStuff™:
1. Call your state’s Customer Service number listed on the last page. Tell us the ID numbers of the items you want, which you’ll find in the section titled “Items You Can Order from Us.” We’ll then send your stuff right to your door.
2. Buy eligible items at a retail store. We’ll cover the cost of your purchases up to the dollar amount of your OTC benefit.(You’ll have to pay for any amount above your OTC benefit.) Send us a claim form and itemized receipt within 90 days. You’ll find a claims form and details on getting your reimbursement starting on page 10.
2012 Over-the-Counter Items Catalog | 2
What Types of Items Are Eligible for my HealthStuff™ Selection?On the next few pages, you’ll find a list of products that you may order from us or buy at a store. Examples of other types of products that you can buy at a store include:
• Over-the-counter (OTC) items, ointments and sprays with active medical ingredients that cure, diminish or remove symptoms
• Dental-care items such as toothbrushes, toothpaste, floss and denture adhesives, as well as items that treat gum problems, thrush and mouth sores
• Incontinence supplies such as adult diapers/briefs and underpads
• Sunscreen lotions
• Support items such as compression hosiery, rib belts, braces and orthopedic supports
Dual-purpose items*What are dual-purpose items? They’re medicines and products that some people use for a medical condition, while others use them for general health and well-being. HealthStuff™ items are covered as dual-purpose products if:
• You use them to treat a specific diagnosis or medical condition
• Your treating physician recommends the product or medicine
Dual-purpose items include:• Diagnostic equipment such as equipment diagnosing blood pressure,
cholesterol, diabetes, colorectal screenings and HIV. Sometimes diagnostic equipment and smoking-cessation aids are covered under your Part B (or Part D benefits). You should access these items the same way you would any other Part B (or Part D) covered item rather than using your HealthStuff™ benefit.
• Hormone replacement such as phytohormones (plant hormones) and natural progesterone
• Vitamins and minerals
• Weight-loss items such as Alli® and hoodia
*Talk with your doctor before buying dual-purpose items. WellCare recommends that you use a dual-purpose item only after your doctor has recommended it for a specific diagnosed condition.
2012 Over-the-Counter Items Catalog | 3
Items You Can Order from Us or Purchase at a Retail StoreYou can choose lower-cost generic or familiar brand-name products. Order from the following list by calling and letting us know the ID numbers of the items you want. Or buy these items at a store near you and get a reimbursement.
ID# GenerIc DescrIptIon prIce ID# BrAnD nAme prIce
ALLERGY PREVENTION AND TREATMENT ALLERGY PREVENTION AND TREATMENT
1 Loratadine 10mg Tablets $5 500 Claritin® $10
2 Cetirizine 10mg Tablets $7 501 Zyrtec® $15
3 Diphenhydramine 25mg Capsules $4 502 Benadryl® $6
137 Chlorpheniramine 4mg Allergy Tablets $3 503 Chlor-Trimeton Tablets $7
ANALGESICS AND ANTIPYRETICS (PAIN RELIEVERS)
ANALGESICS AND ANTIPYRETICS (PAIN RELIEVERS)
4 Aspirin 325mg Tablets $3 504 Bayer® Aspirin $7
5 Aspirin Enteric Coated 81mg Tablets $5 505 Bayer® EC Aspirin (Adult
Regimen) $8
6 Enteric Coated Aspirin 325mg Tablets $4 506 Ecotrin® Tablets $9
7 Acetaminophen 325mg Tablets $6 507 Tylenol® Regular Strength
Tablets $10
8 Acetaminophen 500mg Tablets $5 508 Tylenol® Extra Strength
Caplets $7
9 Pre-Menstrual Relief Tablets $7 509 Midol® $8
136 Pain Relief PM $3 510 Tylenol® PM $6
ANTACIDS AND ACID REDUCERS ANTACIDS AND ACID REDUCERS
10 Gas Relief 80mg tablets $8 511 Gas-X® 80mg Tablets $15
11 Omeprazole 20mg $10 512 Prilosec® $12
12 Calcium Carbonate 500mg Tablets $4 513 Tums® Tablets $6
13 Ranitidine HCL 75mg Tablets $8 514 Zantac® Tablets $10
2012 Over-the-Counter Items Catalog | 4
ID# GenerIc DescrIptIon prIce ID# BrAnD compArABLe prIce
ANTACIDS AND ACID REDUCERS ANTACIDS AND ACID REDUCERS
14 Famotidine 10mg Tablets $6 515 Pepcid® $11
15 Gas Relief (Extra Strength) 125mg Tablets $5 516 Gas-X® Extra Strength $8
ARTHRITIS MEDICINE ARTHRITIS MEDICINE
16 Acetaminophen 650mg Tablets $6 517 Tylenol® Arthritis Pain
Tablets $9
17 Glucosamine 1500mg/Chondroitin 1200mg $9 Glucosamine/Chondroitin
DS® N/A
ANTICANDIAL (YEAST) ANTICANDIAL (YEAST)
18 Clotrimazole Vaginal 1% Cream - 1 Application $8 518 Gyne-Lotrimin® $11
19 Miconazole-3 Vaginal Cream $12 519 Monistat-3® $18
ANTIDIARRHEAL AND LAXATIVES ANTIDIARRHEAL AND LAXATIVES
20 Docusate Sodium 100mg Capsules $8 520 Colace® Softgels $13
21 Adult Glycerin Suppositories $4 521 Fleet® Adult
Suppositories $6
22 Bisacodyl 10mg Suppositories $6 522 Dulcolax® Suppositories $13
23 Bisacodyl 5mg Tablets $5 523 Dulcolax® Tablets $7
24 Loperamide 2mg Capsules $5 524 Imodium® Caplets $8
25 Antinausea Liquid $7 525 Emetrol® $9
26 Bismuth Subsalicylate 262mg Tablet $4 526 Pepto-Bismol® Chewable
Tablets $5
27 Senna Laxative Tablets $7 527 Senokot® Tablets $15
MOTION SICkNESS MEDICATION MOTION SICkNESS MEDICATION
28 Dimenhydrinate 50mg Tablets $4 528 Dramamine® Motion
Sickness $6
2012 Over-the-Counter Items Catalog | 5
ID# GenerIc DescrIptIon prIce ID# BrAnD compArABLe prIce
TOPICAL OINTMENTS AND CREAMS TOPICAL OINTMENTS AND CREAMS
29 Diphenhydramine Anti-Itch Cream $4 529 Benadryl® Cream $6
30 Menthol 10%/Methyl Salicylate 15% Cream $3 530 Bengay® $6
31 Triple Antibiotic Ointment $5 531 Neosporin® Ointment $6
32 Clotrimazole 1% Cream $6 532 Lotrimin® AF $10
33 Tolnaftate 1% Cream $6 533 Tinactin® Cream $10
34 Cold Sore Treatment $13 Cold Sore Treatment N/A
35Hydrocortisone 1% Maximum Strength Cream
$4 534 Cortizone-10® Cream $5
134 Capsaicin Cream $6 535 Zostrix Cream $20
COLD, FLU, DECONGESTANT AND SINUS REMEDIES
COLD, FLU, DECONGESTANT AND SINUS REMEDIES
36Oxymetazoline Hydrochloride 0.05% Solution
$5 536 Afrin® Nasal Spray $9
37 Saline Nasal Spray $3 537 Ocean® Nasal Spray $5
38 Throat Lozenges–Assorted Flavors $2 538 Halls® Cough Drops $3
39 Guaifenesin 100mg/5ml $5 539 Robitussin® Syrup $7
40 Guaifenesin 100mg/5ml-Sugar-Free $5 540 Robitussin® Sugar-Free
Syrup $7
41 Vicks VapoRub $6 541 Vicks® VapoRub $8
42Acetaminophen 325mg/Dextromethorphan 10mg/Phenylephrine 5mg Tab
$6 542 DayQuil® Caplets $8
43Acetaminophen 325mg tab/Dextromethorphan 15mg/Doxylamine 6.25mg Tab
$4 543 NyQuil® Caplets $7
2012 Over-the-Counter Items Catalog | 6
ID# GenerIc DescrIptIon prIce ID# BrAnD compArABLe prIce
COLD, FLU, DECONGESTANT AND SINUS REMEDIES
COLD, FLU, DECONGESTANT AND SINUS REMEDIES
44
ASA 325mg/Sodium Bicarbonate 1916mg/ Citric Acid 1000mg Tablets
$5 544 Alka-Seltzer® $6
45 Guaifenesin 600mg Tablets $9 545 Mucinex® $15
46Guaifenesin 600mg/Dextromethorphan 30mg Tablets
$10 546 Mucinex-DM® $15
47 Phenylephrine HCL 10mg Tablets $4 547 Sudafed® PE $7
48 APAP Sinus Congestion $5 548 Tylenol® Sinus & Congestion Tablets $8
DENTAL AND DENTURE CARE DENTAL AND DENTURE CARE
49 Benzocaine 20% Oral Anesthetic $5 549 Anbesol® $8
50 Denture Adhesive Cream $4 550 Fixodent® $5
51 Toothbrush $2 551 Toothbrush $3
52 Fluoride Toothpaste $3 552 Colgate® $4
53 Waxed Dental Floss $2 553 Waxed Dental Floss $3
EAR CARE EAR CARE
54 Ear Syringe $4 Ear Syringe N/A
55 Carbamide Peroxide (6.5%) Solution $7 554 Debrox® Ear Wax
Removal $8
EYE CARE EYE CARE
56Polyvinyl Alcohol 0.5%/Povidone 0.6% Lubricant Eye Drops
$5 555 Murine® Tears $7
57 Tetrahydrozoline HCl 0.05% $4 556 Visine® Drops $5
2012 Over-the-Counter Items Catalog | 7
ID# GenerIc DescrIptIon prIce ID# BrAnD compArABLe prIce
FIBER SUPPLEMENTS* FIBER SUPPLEMENTS*
58 Fiber Tabs $9 557 FiberCon $13
FIRST AID AND MEDICAL SUPPLIES FIRST AID AND MEDICAL SUPPLIES
59 Athletic Bandage $3 Ace® Bandage N/A
60 Adhesive Tape 1/2 Inch x 5 Yards $2 Adhesive Tape N/A
61 Alcohol Swabs $3 Alcohol Swabs N/A
62 Bandages-Assorted $2 Band-Aids® N/A
63 Butterfly Closures $2 Butterfly® Closures N/A
64 Cotton Balls $2 Cotton Balls N/A
65 Cotton Swabs $3 Q-Tips® Cotton Swabs N/A
66 Ice Bag $5 Ice Bag N/A
67 Stretch Gauze Bandage 2" x 5 Yards $2 Johnson & Johnson®
Gauze N/A
68 Oral Thermometer $6 Oral Thermometer N/A
69 Flexible Tip Thermometer $10 Flexible Tip Thermometer N/A
70 Thermometer Probe Covers $3 Thermometer Probe Covers N/A
71 Menthol 5% Patches $6 Icy Hot® Patches-Large N/A
72 Corn and Callus Remover $5 Dr. Scholl’s® Corn and Callus Remover N/A
73 Salicylic Acid (17% w/w) Liquid $7 Compound W®
Wart Remover N/A
HEMORRHOIDAL PREPARATIONS HEMORRHOIDAL PREPARATIONS
74Mineral Oil 46.6% /Pramoxine HCL 1%/ Zinc Oxide 12.5%
$4 558 Tucks® Hemorrhoidal Ointment $8
75
Mineral Oil 14%/Petrolatum 71.9%/ Phenylephrine 0.25%/Shark Oil 3% Cream
$8 559 Preparation H® Ointment $13
2012 Over-the-Counter Items Catalog | 8
ID# GenerIc DescrIptIon prIce ID# BrAnD compArABLe prIce
HEMORRHOIDAL PREPARATIONS HEMORRHOIDAL PREPARATIONS
76 Witch Hazel 50% Pads $8 560 Tucks® Medicated Pads $10
LACTOSE INTOLERANCE LACTOSE INTOLERANCE
77 Lactase Enzyme $12 561 Lactaid® Tablets $12
HEADACHE RELIEF HEADACHE RELIEF
78Acetaminophen 250mg/Aspirin 250mg/ Caffeine 65mg Tablets
$4 562 Excedrin® Migraine $6
79Acetaminophen 500mg/Diphenhydramine Citrate 38mg
$6 563 Excedrin® PM Tablets $8
ANTI-INFLAMMATORY ANTI-INFLAMMATORY
80 Ibuprofen 200mg FC Tablets $5 564 Advil® Tablets $6
81 Naproxen Sodium 220mg Caplets $6 565 Aleve® Caplets $6
82 Ibuprofen 200mg Liquid Gel Caps $5 566 Advil® Liquid GelCaps $6
PEDICULICIDES (HEAD LICE TREATMENTS) PEDICULICIDES (HEAD LICE TREATMENTS)
83 Lice Treatment Maximum Strength Shampoo $10 567 Rid® Extra Strength
Shampoo $12
84 Lice Comb $5 Lice Comb N/A
SLEEPING AIDS SLEEPING AIDS
85 Diphenhydramine 25mg Capsules $5 568 Unisom® Sleep Tabs $7
VITAMINS AND MINERALS* VITAMINS AND MINERALS*
86 B-Complex/B-12 Vitamins $6 B-Complex/B-12 Vitamins N/A
87 Adult Multi-Vitamin Tablets $9 Centrum® Multi-Vitamin
Tablets N/A
88 Prenatal Vitamins $10 Stuart Prenatal® Vitamins N/A
89 Vitamin C 500mg Tablets $4 Vitamin C 500mg Tablets N/A
2012 Over-the-Counter Items Catalog | 9
ID# GenerIc DescrIptIon prIce ID# BrAnD compArABLe prIce
VITAMINS AND MINERALS* VITAMINS AND MINERALS*
90 Vitamin E 400 IU Caplets $7 Vitamin E 400 IU Caplets N/A
91 Vitamin A 10,000 IU Caplet $4 Vitamin A 10,000 IU
Caplets N/A
92 Elemental Iron 65mg Tablets $7 Feosol® N/A
93 Folic Acid 400mcg Tablets $5 Folic Acid 400mcg
Tablets N/A
94 Magnesium 250mg Tablets $3 Magnesium 250mg
Tablets N/A
95 Zinc 50mg Tablets $5 Zinc 50mg Tablets N/A
96 Synthetic Vitamin B-1 100mg Tablets $4 Vitamin B-1 100mg Tablets N/A
97 Synthetic B-12 500mcg Tablets $6 Vitamin B-12 500mcg
Tablets N/A
98 Synthetic Vitamin B-6 100mg Tablets $5 Vitamin B-6 100mg
Tablets N/A
99Calcium Carbonate 600mg/Vitamin D 400 IU Tablets
$6 Caltrate® 600 + D N/A
100 Calcium Carbonate 600mg Tablets $5 Caltrate® 600 N/A
2012 Over-the-Counter Items Catalog | 10
How Do I Get Reimbursed if I Purchase Items from a Store?Submit a claim form along with the itemized receipt from the store. Claims must be submitted within 90 days of the date of purchase on your receipt.
• For your convenience, we’ve enclosed a claim form on the next page. To get more forms, just call Customer Service at one of the numbers listed on the inside back cover.
• You can also download the claim form from our website at www.wellcare.com.
• If your receipt does not include the name of items purchased, no problem!
– Just send us the label from the product or its packaging.
– Circle the correct amount on your receipt.
– Submit this information with your signed claim form.
We will process your claim within 30 days.
Non-Eligible ItemsThe following items are not eligible for the HealthStuff™ benefit. They cannot be ordered from the plan, and you cannot be reimbursed by the plan if you purchase these items. Only the dual-purpose and eligible categories of items are included in your HealthStuff™ benefit.
• Homeopathic and alternative medicines such as botanicals, herbals, probiotics and nutraceuticals
• Baby items such as baby medicines
• Family planning such as contraceptives and pregnancy tests
• Convenience (non-medical) items such as scales, fans, flashlights, magnifying glasses, ear plugs, shoe insoles and arches, and gloves
• Cosmetics such as bad-breath items; deodorants and antiperspirants; dry-skin lotions, such as Eucerin® and Aquaphor®; facial cleansers; feminine products; grooming devices; hair-loss products; hair removers and bleaches; hand sanitizers; lip balm; moisturizers; mouthwashes; perfumes; shampoos and conditioners, including dandruff shampoos and therapeutic shampoos; shaving and men’s grooming items; soaps and medicated soaps; teeth whiteners
• Food supplements such as any foods, even if heavily supplemented by nutrients, like Lactaid® milk and food with fiber added; Dairy Care®; dehydration drinks; energy bars; Ensure®; Glucerna®; liquid energizers; power drinks; protein bars and shakes; sugar/salt supplements
• Replacement items, attachments and peripherals such as contact lens containers, hearing aid batteries, etc., when not factory packaged with original item
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rm p
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ount
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App
licab
le)
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Tota
l Cla
im
Am
ount
(Add
Am
ount
A a
nd B
)*1.
____
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the
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for r
eim
burs
emen
t is
for e
ligib
le o
ver-
the-
coun
ter i
tem
s an
d is
not
cove
red
by a
ny o
ther
pl
an o
r pro
gram
. (If
you
have
que
stio
ns re
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ing
elig
ible
item
s, pl
ease
refe
r to
your
Hea
lthSt
uff™
cat
alog
or c
all C
usto
mer
Ser
vice
.)
* See
sam
ple
clai
m s
ubm
issio
n on
nex
t pag
e.
Tota
l cla
im a
mou
nt s
houl
d in
clud
e ta
x fo
r eac
h ite
m.
Mem
ber N
ame:
___
____
____
____
____
____
____
____
____
_M
embe
r ID
: ___
____
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ere
if ne
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ress
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: ___
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ate:
___
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_ZI
P C
ode:
___
____
____
____
____
Tele
phon
e:__
____
____
____
____
____
____
____
____
____
___
Rece
ipts
mus
t be
subm
itted
with
in 9
0 da
ys o
f rec
eipt
dat
e an
d ar
e pr
oces
sed
with
in 3
0 da
ys o
f rec
eipt
.
Mem
ber’s
Sig
natu
re: _
____
____
____
____
____
____
____
____
__ D
ate:
___
____
____
____
_
#09396Green Pharm
acy
08/13/10
Pain Reliever $10.00
Cough Syrup $10.00
Candy $6.00
SUBTOTAL $26.00
TAX (7%)
$1.82TOTAL
$27.82
SA
MP
LE
RE
CE
IPT*
SA
MP
LE
CLA
IM S
UB
MIS
SIO
N
Date Purchased
Name
of RetailerNam
e/Description of Item
(s) Purchased
Item
Amount
(A)
Tax Amount
(If Applicable) (B)
Total Claim
Amount
(Add Amount
A and B)
1. 8/13/10Green Pharm
acyPain Reliever
$ 10.00$ 0.70
$ 10.70
2. 8/13/10Green Pharm
acyCough Syrup
$ 10.00$ 0.70
$ 10.70
Grand Total:$ 20.00
$ 1.40$ 21.40
(A)(A)
(B)
Remem
ber:
Com
plete the claim form
on the other side of this page.
Also include receipt for item
(s) purchased.
Your receipt must include the date of purchase and item
(s) purchased.
You may fax or m
ail your claim form
and receipt, but faxing provides faster customer service.
Fax your form and receipt to: W
ellCare OTC D
MR Center at 1-877-849-5068
OR
Mail your form
and receipt to: WellCare O
TC DM
R Center • P.O. Box 31396 • Tam
pa, FL 33631-3396
To get more inform
ation or to request additional claim form
s, please contact Custom
er Service at one of the toll-free numbers
listed in your HealthStuff™ catalog.
Connecticut: WellCare Access (HMO SNP) .................................................... 1-866-635-7047All other plans .................................................................................. 1-866-579-8006
Florida:WellCare Access (HMO SNP) .................................................... 1-866-637-8041
WellCare Select (HMO SNP/HMO-POS SNP) .................. 1-866-637-8041All other plans .................................................................................. 1-888-888-9355
Georgia: WellCare Access (HMO SNP) .................................................... 1-866-482-3361All other plans .................................................................................. 1-866-334-7730
Illinois: WellCare Access (HMO SNP) .................................................... 1-866-439-1190All other plans .................................................................................. 1-866-334-6876
Louisiana:WellCare Access (HMO SNP) .................................................... 1-866-530-9488All other plans .................................................................................. 1-866-804-5926
Missouri: WellCare Access (HMO SNP) .................................................... 1-866-635-7049All other plans .................................................................................. 1-866-687-8994
New Jersey:WellCare Access (HMO SNP) .................................................... 1-866-530-9496
All other plans .................................................................................. 1-866-687-8570
New York: WellCare Access (HMO SNP) .................................................... 1-866-482-3363All other plans .................................................................................. 1-800-278-5155
Ohio: WellCare Access (HMO SNP) .................................................... 1-866-530-9487All other plans .................................................................................. 1-866-687-8815
Texas: WellCare Access (HMO SNP) .................................................... 1-866-530-9495All other plans .................................................................................. 1-866-687-8878
TTY for all states: ................................................................................................................. 1-877-247-6272
We’re always just a phone call away!If you’re ready to enroll or have questions about enrolling, call 1-877-818-8739.
If you’re already a member, find the number for your state/plan in the list below.
Hours of operation are Monday–Sunday, 8 a.m. to 9 p.m. Eastern. Between 2/15/12 and 10/14/12, representatives are available Monday–Friday, 8 a.m. to 9 p.m. Eastern. Or visit us anytime at www.wellcare.com.
3970
0
WellCare is a Coordinated Care Plan with a Medicare Advantage contract. Benefits, formulary, pharmacy network, premium and/or co-payments/coinsurance may change on January 1, 2013. Benefits, limitations, co-payments and
restrictions may vary by plan and by county/parish. You must continue to pay your Medicare Part B premium. If you meet certain eligibility requirements for both Medicare and Medicaid, your Part B premiums may be covered in full. Members may enroll in the plan only during specific times of the year, unless you qualify for a special needs plan.
Contact WellCare for more information. Please contact WellCare for details.
P.O. Box 31389 | Tampa, FL 33631-33891-877-818-8739 | TTY 1-877-247-6272
Hours of operation are Monday–Sunday, 8 a.m. to 9 p.m. Eastern. Between 2/15/12 and 10/14/12, representatives are available Monday–Friday, 8 a.m. to 9 p.m. Eastern.
Or visit us anytime at www.wellcare.com.
WellCare Extras
Why join a WellCare health plan? One reason is we offer some things that Original Medicare doesn’t. Among them are valuable discounts on alternative medicines and therapies, vitamins, and medical alert systems. Read this section to find out more about the extra values we offer you at no additional cost.
Section 6
Health & Wellness EducationWholeHealthMD.com is an online education tool developed by board-certified physicians and specialists. The site provides a wealth of information and resources to guide members on the path to health, wellness and longevity. It includes Healing Centers, which provide members with a balanced approach to integrative medicine, and The Healing Kitchen, which focuses on food as therapy and provides an extensive recipe database developed by in-house nutritionists. To access services, visit http://wellcare.wholehealthmd.com.
Complementary & Alternative MedicineA variety of therapies may help you increase wellness, prevent illness and address existing symptoms and conditions. Members are eligible to receive up to 30% off standard fees through a network of more than 37,000 practitioners, including:
• Massage & Bodywork • Diet & Supplement Advisors
• Mind/Body & Relaxation • Exercise/Movement Techniques
Find practitioners online through the http://wellcare.wholehealthmd.com website or by calling WellCare Customer Service at the number provided on your WellCare member ID card. Members must show their WellCare ID card to the practitioner at the time of service.
Vitamins & Natural SupplementsMembers of WellCare Health Plan receive 25% off their purchase of vitamins and natural health supplements manufactured by Enzymatic Therapy Inc. Members who order online receive free shipping. Order online through the http://wellcare.wholehealthmd.com website or over the phone by calling 1-888-847-3068 (TTY 711) Monday through Friday, 7 a.m. to 6 p.m. Central. When ordering by phone, members must provide WellCare’s unique code, AWH-8400, in order to receive their discount.
WellCare ExtrasSM
Coordinated Care Plans
NA015223_WCM_FLY_ENG NAVAISFLY39272E_0611©WellCare2011NA_06_11_WC
Jenny Craig Weight Loss ProgramJoin Jenny Craig® and receive a free 30-day program.* Together with one-on-one support, Jenny Craig will design a personalized, comprehensive weight-loss plan that fits your lifestyle. You can also enjoy up to 25% off the 6-month VIP Program* or 20% off the 1-year Premium Success Program.* Access special offer coupon via the http://wellcare.wholehealthmd.com website. Members must identify themselves as WellCare enrollees when they sign up with Jenny Craig.
*Plus the cost of food and shipping when applicable. Discounts apply to membership fee only. Offer good at participating Local Centers and Jenny Direct® in the United States, Canada and Puerto Rico.
Healthy Reading ProgramSave up to 90% off the cover price on magazine subscriptions through MagazineLine. Choose from health and fitness, sports and other great magazine topics. Order online through the http://wellcare.wholehealthmd.com website or over the phone by calling 1-800-959-1676 (TTY 711) Monday through Friday, 8 a.m. to 11 p.m. Eastern. When ordering by phone, members must identify themselves as WellCare enrollees.
Medical Alert SystemSave up to 17% off the retail price for the LifeStation® Medical Alert Service. LifeStation lets you get immediate emergency assistance in your home at the push of a button. It is simple to use and low in cost. The LifeStation system lets you maintain your independence and gives you peace of mind. There are no activation, enrollment or equipment costs. Customers may cancel at any time without penalty. The LifeStation System & Monitoring Center are UL Listed. Order online at www.lifestation.com or over the phone by calling 1-866-255-4549 (TTY 1-800-323-9121), 24 hours a day, 7 days a week. When ordering, members must provide the WellCare Product Code, WE20, to get the special WellCare member pricing.
WellCareisaCoordinatedCareplanwithaMedicareAdvantagecontract.TheproductsandservicesdescribedaboveareneitherofferednorguaranteedunderourcontractwiththeMedicareprogram.Inaddition,theyarenotsubjecttotheMedicareappealsprocess.AnydisputesregardingtheseproductsandservicesmaybesubjecttotheWellCaregrievanceprocess.Brandnamesaretrademarksoftheirrespectiveowners.
For more information about these discounts, please call Customer Service at the number listed on the back of your member ID card.
3927
2
Each year, the Centers for Medicare & Medicaid Services (CMS) releases ratings for all Medicare Advantage plans. This section contains the most recent overall ratings for WellCare. It’s good information to have when you’re considering a plan because it comes from an independent, objective source.
Plan RatingSection 7
Imag
e de
scrip
tion.
5 s
tars
End
of i
mag
e de
scrip
tion.
Imag
e de
scrip
tion.
4 s
tars
End
of i
mag
e de
scrip
tion.
Imag
e de
scrip
tion.
3 s
tars
End
of i
mag
e de
scrip
tion.
Imag
e de
scrip
tion.
2 s
tars
End
of i
mag
e de
scrip
tion.
Imag
e de
scrip
tion.
1 s
tar E
nd o
f im
age
desc
riptio
n.
The
num
ber
of st
ars
show
s how
wel
l our
pla
n p
erfo
rms.
m
eans
exce
llent
m
eans
above
ave
rage
m
eans
aver
age
m
eans
bel
ow
ave
rage
m
eans
poor
Imag
e de
scrip
tion.
3 S
tars
End
of i
mag
e de
scrip
tion.
WellC
are
- H
10
32
Overa
llP
lan
Rati
ng
3 S
tars
The
Ove
rall
Plan
Rat
ing c
om
bin
es s
core
s fo
r th
e ty
pes
of se
rvic
es e
ach p
lan o
ffer
s:
Wh
at
is b
ein
g m
easu
red
?
•Fo
r p
lan
s co
veri
ng
healt
h s
erv
ices,
the
ove
rall
score
for
qual
ity
of th
ose
ser
vice
s co
vers
36
dif
fere
nt
top
ics
in 5
cate
go
ries:
◦S
tayin
g h
ealt
hy:
scre
enin
gs,
tes
ts,
and v
acci
nes
: In
cludes
how
oft
en m
ember
s got
various
scre
enin
g t
ests
,va
ccin
es,
and o
ther
chec
k-ups
that
hel
p t
hem
sta
y hea
lthy.
◦M
an
ag
ing
ch
ron
ic (
lon
g-t
erm
) co
nd
itio
ns:
Incl
udes
how
oft
en m
ember
s w
ith d
iffe
rent
conditio
ns
got
cert
ain
test
s an
d t
reat
men
ts t
hat
hel
p t
hem
man
age
thei
r co
nditio
n.
◦R
ati
ng
s o
f h
ealt
h p
lan
resp
on
siven
ess
an
d c
are
: In
cludes
rat
ings
of m
ember
sat
isfa
ctio
n w
ith t
he
pla
n.
◦H
ealt
h p
lan
mem
ber
com
pla
ints
an
d a
pp
eals
: In
cludes
how
oft
en m
ember
s file
d a
com
pla
int
agai
nst
the
pla
n.
◦H
ealt
h p
lan
tele
ph
on
e c
ust
om
er
serv
ice:
Incl
udes
how
wel
l th
e pla
n h
andle
s ca
lls fro
m m
ember
s.
•Fo
r p
lan
s co
veri
ng
dru
g s
erv
ices,
the
ove
rall
score
for
qual
ity
of th
ose
ser
vice
s co
vers
17
dif
fere
nt
top
ics
in 4
cate
go
ries:
WellC
are
- H
10
32
Med
icare
Pla
n R
ati
ng
s
The
Med
icar
e Pr
ogra
m r
ates
how
wel
l M
edic
are
hea
lth a
nd d
rug p
lans
per
form
in d
iffe
rent
cate
gories
(fo
r ex
ample
, det
ecting a
nd p
reve
nting illn
ess,
ratings
from
pat
ients
, pat
ient
safe
ty,
dru
g p
rici
ng a
nd c
ust
om
er s
ervi
ce).
The
info
rmat
ion p
rovi
ded
bel
ow
is
an o
vera
ll pla
n r
atin
g o
f our
pla
n's
per
form
ance
. This
info
rmat
ion is
avai
lable
to h
elp y
ou m
ake
the
bes
t ch
oic
e. I
f yo
u w
ould
lik
e to
get
additio
nal
info
rmat
ion o
n o
ur
pla
n's
per
form
ance
ple
ase
conta
ct u
s at
877-2
32-7
119 (
toll-
free
) or
877-2
47-6
272 (
TTY/T
DD
) fo
r pro
spec
tive
mem
ber
s, 8
88-8
88-9
355 (
toll-
free
) or
877-2
47-6
272
(TTY/T
DD
) fo
r cu
rren
t m
ember
s, o
r yo
u m
ay v
isit w
ww
.med
icar
e.gov.
Bel
ow
is
a su
mm
ary
of how
our
pla
n r
ated
in q
ual
ity
and p
erfo
rman
ce.
H103
2_FL
0130
09_W
CM_I
NS_
ENG
File
& Us
e 07
/25/
2010
FL
_11_
10
FLM
AINS
3414
6E_1
110
36003
WellC
are
- H
10
32
◦D
rug
pla
n c
ust
om
er
serv
ice:
Incl
udes
how
wel
l th
e dru
g p
lan h
andle
s ca
lls a
nd m
akes
dec
isio
ns
about
mem
ber
appea
ls.
◦D
rug
pla
n m
em
ber
com
pla
ints
an
d M
ed
icare
au
dit
fin
din
gs:
Incl
udes
how
oft
en m
ember
s file
d a
com
pla
int
about
the
dru
g p
lan.
◦M
em
ber
exp
eri
en
ce w
ith
dru
g p
lan
: In
cludes
mem
ber
sat
isfa
ctio
n info
rmat
ion.
◦D
rug
pri
cin
g a
nd
pati
en
t sa
fety
: In
cludes
how
wel
l th
e dru
g p
lan p
rice
s pre
scriptions
and p
rovi
des
updat
edin
form
atio
n o
n t
he
Med
icar
e w
ebsi
te.
Incl
udes
info
rmat
ion o
n h
ow
oft
en m
ember
s w
ith c
erta
in m
edic
alco
nditio
ns
get
pre
scription d
rugs
that
are
consi
der
ed s
afer
and c
linic
ally
rec
om
men
ded
for
thei
r co
nditio
n.
•Fo
r p
lan
s co
veri
ng
bo
th h
ealt
h &
dru
g s
erv
ices,
the
ove
rall
score
for
qual
ity
of th
ose
ser
vice
s co
vers
all o
f th
e 5
3to
pic
s list
ed
ab
ove.
Wh
ere
do
es
the in
form
ati
on
fo
r th
e O
vera
ll P
lan
Rati
ng
co
me f
rom
?
•Fo
r qual
ity
of
healt
h s
erv
ices,
the
info
rmat
ion c
om
es fro
m s
ourc
es t
hat
incl
ude:
◦M
ember
surv
eys
done
by
Med
icar
e◦
Info
rmat
ion fro
m c
linic
ians
◦In
form
atio
n s
ubm
itte
d b
y th
e pla
ns
◦Res
ults
from
Med
icar
e's
regula
r m
onitoring a
ctiv
itie
s
•Fo
r qual
ity
of
dru
g s
erv
ices,
the
info
rmat
ion c
om
es fro
m s
ourc
es t
hat
incl
ude:
◦Res
ults
from
Med
icar
e's
regula
r m
onitoring a
ctiv
itie
s◦
Rev
iew
s of bill
ing a
nd o
ther
info
rmat
ion t
hat
pla
ns
subm
it t
o M
edic
are
◦M
ember
surv
eys
done
by
Med
icar
e
Wh
y is
the O
vera
ll P
lan
Rati
ng
im
po
rtan
t?
The
Ove
rall
Plan
Rat
ing g
ives
you a
sin
gle
sum
mar
y sc
ore
that
mak
es it
easy
for
you t
o c
om
par
e pla
ns
bas
ed o
n q
ual
ity
and
per
form
ance
. Le
arn m
ore
about
diffe
rence
s am
ong p
lans
by
looki
ng a
t th
e det
aile
d r
atin
gs.
Choosing a health plan is important. After all, it involves your health. And there are a lot of details to weigh. We want to make sure you fully understand those details. This section contains a checklist of key points about our plans, premiums and coverage. It gives you a chance to review them, to ask questions when something isn’t clear and to ensure you’re confident that you’re making a decision that’s right for you.
Statement of Understanding
Section 8
1. Ifyourplanhasamonthlyplanpremium,youcanpayyourmonthlyplanpremiumand/orlateenrollmentpenalty(ifwedetermineyouowealateenrollmentpenaltythatyoucurrentlyhaveormayowe)bymailorelectronicfundstransfer(EFT)eachmonth.Youcanalsochoosetopayyourpremiumand/orlateenrollmentpenaltybyautomaticdeductionfromyourSocialSecurity/RailroadRetirementBoardbenefitcheckeachmonth.Ifyoudon’tselectapaymentoption,youwillreceiveacouponbook/paymentbook.
2. If you are enrolling in a plan that has prescription drug coverage:IfyouqualifyforExtraHelpwithyourMedicareprescriptiondrugcosts,Medicarewillpayallorpartofyourplanpremiums.IfMedicarepaysonlyaportionofthispremium,wewillbillyoufortheamountthatMedicaredoesnotcover.
3. If you are enrolling in a plan that has prescription drug coverage:PeoplewithlimitedincomesmayqualifyforExtraHelptopayfortheirprescriptiondrugcosts.Ifyouqualify,Medicarecouldpayforuptoseventy-five(75)percentormoreofyourdrugcosts,includingmonthlyprescriptiondrugpremiums,annualdeductiblesandcoinsurance.Additionally,thosewhoqualifywillnotbesubjecttothecoveragegaporalateenrollmentpenalty.Manypeopleareeligibleforthesesavingsanddon’tevenknowit.FormoreinformationaboutthisExtraHelp,contactyourlocalSocialSecurityoffice,orcall1-800-MEDICARE(1-800-633-4227),24hoursperday,7daysperweek.TTYusersshouldcall1-877-486-2048.YoucanalsoapplyforExtraHelponlineatwww.socialsecurity.gov/prescriptionhelp.
4. If you are enrolling in a plan that has prescription drug coverage:Ifyoucurrentlyhavehealthcoveragefromanemployerorunion,joiningWellCarecouldaffectyouremployerorunionhealthbenefits.YoucouldloseyouremployerorunionhealthcoverageifyoujoinWellCare.Readthecommunicationsyouremployerorunionsendsyou.Ifyouhavequestions,visittheirwebsiteorcontacttheofficelistedintheircommunications.Ifthereisn’tanyinformationonwhomtocontact,yourbenefitsadministratorortheofficethatanswersquestionsaboutyourcoveragecanhelp.
When completing your enrollment in a WellCare plan, you understand and
acknowledge the following:
Y0070_NA015424_WCM_FLY_ENG CMS Approved 07192011 NACCPSOU38704E_0611©WellCare 2011 NA_06_11_WC
5. TheagentreviewedtheplaninformationincludingtheSummaryofBenefits.If you are enrolling in a plan that has prescription drug coverage:Theagentalsoreviewedourformulary,whichisalistofthedrugscoveredbyWellCareandanyothersummaryofyourout-of-pocketexpensesthatarelistedintheinformationalkit.Ifyouneedadditionalinformation,pleasereviewyourEvidenceofCoveragewhenyoureceiveitinthemail.
6. If you are enrolling in a plan that does not offer prescription drug coverage:Youunderstandthatifyouleavethisplananddon’thaveorgetotherMedicareprescriptiondrugcoverageorcreditableprescriptiondrugcoverage(asgoodasMedicare’s)foracontinuousperiodof63daysormore,youmayhavetopayalateenrollmentpenaltyinadditiontoyourpremiumforMedicareprescriptiondrugcoverageinthefuture.IfyouqualifyforcertainexceptionssuchasreceivingExtraHelp,youmaynotberequiredtopaythispenalty.
7. If you are enrolling in a plan that has a reimbursement for your Part B coverage:ItisimportantforyoutoknowthereimbursementissetupbyMedicareandadministeredbytheSocialSecurityAdministration(SSA).IfyoupayyourPartBpremiumthroughyourSocialSecuritybenefitcheck,youwillseeanincreaseinyourbenefitcheck.IfyourpremiumispaidbyMedicare,youwillgetacreditonyourMedicarePartBstatement.Reimbursementstypicallytakeuptothreemonthstobeissued.However,ifthisisthecase,youwillreceivefullcreditonceitissetup.IfyouhaveMedicaid,yourPartBpremiumispaidforyoubythestate.Therefore,youwillnotreceiveareimbursementforthepremium.
8. WellCareisaMedicareAdvantageplanandhasacontractwiththefederalgovernment.YouwillneedtokeepyourMedicarePartsAandB.
9. Whenyouenrollinoneofourplans,WellCarepaysforservicescoveredbyMedicare.However,youstillneedtopayforyourPartBpremium,unlessit’spaidonyourbehalfbysomeoneelse.YouwillberesponsiblefortheamountsthatWellCaredoesnotcover,suchasco-paysorcoinsurances,ifapplicable.
10. YoucanbeinonlyoneMedicareAdvantageplanatatime.OnceyourenrollmentinWellCareisapprovedbyMedicare,youwillbeautomaticallydisenrolledfromyourcurrentplan.Youdon’tneedtotakeanyactiontobedisenrolledfromyourcurrentplan.ItisyourresponsibilitytoinformWellCareofanyprescriptiondrugcoveragethatyouhaveormaygetinthefuture.
11. Enrollmentinthisplanisgenerallyfortheentireyear.Onceyouenroll,youmayleavethisplanormakechangesonlyatcertaintimesoftheyearwhenanenrollmentperiodisavailable(example:youmaymakechangesOctober15–December7ofeveryyear),orundercertainspecialcircumstances.
12. WellCareservesspecificserviceareas.IfyoumoveoutoftheareathatWellCareserves,youneedtonotifytheplansoyoucandisenrollandfindanewplaninyournewarea.
13. OnceyouareamemberofWellCare,youhavetherighttoappealplandecisionsaboutpaymentorservicesifyoudisagree.YouwillreadtheEvidenceofCoveragedocumentfromWellCarewhenyougetittoknowwhichrulesyoumustfollowtogetcoveragewiththisMedicareAdvantageplan.YouunderstandthatpeoplewithMedicarearen’tusuallycoveredunderMedicarewhileoutofthecountry,exceptforlimitedcoverageneartheU.S.border.
14. WhenyourcoveragewithWellCarebegins,youmustgetallyourhealthcarefromWellCare,exceptforemergencyorurgentlyneededservicesorout-of-areadialysisservices.
15. ServicesauthorizedbyWellCareandotherservicescontainedinyourWellCareEvidenceofCoveragedocument(alsoknownasamembercontractorsubscriberagreement)willbecovered.Without authorization, NEITHER MEDICARE NOR WELLCARE WILL PAY FOR THE SERVICES.
16. ThepersonwhoisdiscussingplanoptionswithyouiseitheremployedbyorcontractedwithWellCare.ThispersonmaybepaidbasedonyourenrollmentinaWellCareplan.
17. CounselingservicesmaybeavailableinyourstatetoprovideadviceconcerningMedicareSupplementInsuranceorotherMedicareAdvantageorPrescriptionDrugPlanoptionsaswellasmedicalassistancethroughthestateMedicaidprogramandtheMedicareSavingsProgram.
18. ByjoiningthisMedicarehealthplan,youacknowledgethatWellCarewillreleaseyourinformationtoMedicareandotherplansasisnecessaryfortreatment,paymentandhealthcareoperations.YoualsoacknowledgethatWellCarewillreleaseyourinformation,includingyourprescriptiondrugeventdata,toMedicare,thatmayreleaseitforresearchandotherpurposesthatfollowallapplicablefederalstatutesandregulations.Theinformationyouhaveprovidediscorrecttothebestofyourknowledge.Youunderstandthatifyouintentionallyprovidefalseinformationonthisform,youwillbedisenrolledfromtheplan.
19. Bycompletingthisenrollmentrequest,youacknowledgeunderstandingtheenrollmentapplicationprocess.Ifyouarenottheenrollee,onlyauthorizedindividualscanenrollonbehalfofanenrollee.Youragreementmeansyoucertifythat:1)youareauthorizedunderstatelawtocompletethisenrollment,and2)documentationofthisauthorityisavailableuponrequestbyWellCareorbyMedicare.
Usethisspacetonoteyourconfirmationnumberafteryou’veenrolled.
Confirmationnumber:______________________________________
Foradditionalinformation,visitwww.wellcare.comorcallCustomerServiceatthetoll-freenumberforyourplaninyourstate.
Connecticut:WellCare Access (HMO SNP) .................................................... 1-866-635-7047All other plans .................................................................................. 1-866-579-8006
Florida:WellCare Access (HMO SNP) .................................................... 1-866-637-8041WellCare Select (HMO SNP/HMO-POS SNP) .................. 1-866-637-8041All other plans .................................................................................. 1-888-888-9355
Georgia:WellCare Access (HMO SNP) .................................................... 1-866-482-3361All other plans .................................................................................. 1-866-334-7730
Illinois:WellCare Access (HMO SNP) .................................................... 1-866-439-1190All other plans .................................................................................. 1-866-334-6876
Louisiana:WellCare Access (HMO SNP) .................................................... 1-866-530-9488All other plans .................................................................................. 1-866-804-5926
Missouri:WellCare Access (HMO SNP) .................................................... 1-866-635-7049All other plans .................................................................................. 1-866-687-8994
New Jersey:WellCare Access (HMO SNP) .................................................... 1-866-530-9496All other plans .................................................................................. 1-866-687-8570
New York:
WellCare Access (HMO SNP) .................................................... 1-866-482-3363WellCare Advocate Complete (HMO SNP) ....................... 1-866-661-1232WellCare Liberty (HMO SNP) ................................................... 1-866-491-5746All other plans .................................................................................. 1-800-278-5155
Ohio:WellCare Access (HMO SNP) .................................................... 1-866-530-9487All other plans .................................................................................. 1-866-687-8815
Texas:WellCare Access (HMO SNP) .................................................... 1-866-530-9495
All other plans .................................................................................. 1-866-687-8878
TTY for all states: ................................................................................................................. 1-877-247-6272
We’re always just a phone call away!If you’re ready to enroll or have questions about enrolling, call 1-877-817-5793.
If you’re already a member, find the number for your state/plan in the list below.
Hours of operation are Monday–Sunday, 8 a.m. to 9 p.m. Eastern. Between 2/15/12 and 10/14/12, representatives are available Monday–Friday, 8 a.m. to 9 p.m. Eastern. Or visit us anytime at www.wellcare.com.
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WellCare is a Coordinated Care Plan with a Medicare Advantage contract.
Thisinformationisavailableforfreeinotherlanguages.PleasecontactourCustomerServicenumberat1-877-374-4056foradditionalinformation.
Estainformaciónestádisponiblegratisenotrosidiomas.Parainformaciónadicional,porfavorcomuníqueseconServicioalClienteal1-877-374-4056.
1-877-374-4056
1-877-374-4056
At WellCare, we want you to be satisfied with your coverage. If there’s ever a time you’re not, we have processes to address your concerns. This section explains how you can file an appeal if you’re not happy with a decision we make about your coverage. It also explains how you can file a complaint (called a “grievance”) if you’re not satisfied with the plan, a provider or the quality of services you get.
Appeals and Grievances
Section 9
What Are Your Protections in This Plan? If you should ever have a problem or concern, you have rights as a member of WellCare Health Plans. We will work with you to find a satisfactory solution. However, if an issue isn’t settled to your satisfaction, there are formal steps you can take.
There are two types of formal, Medicare-approved processes for handling problems: the process for coverage decisions and making an appeal, and the process for making a complaint (filing a grievance). Each process has a set of rules, procedures and deadlines that must be followed by us and by you. We pledge to honor your rights, take your concerns seriously and treat you with respect at all times.
Coverage decisions: WellCare makes coverage decisions about your benefits and coverage and about the amount we will pay for your medical services or drugs. You can ask us for a coverage decision whenever you go to a doctor for medical care if you want to know whether we will cover a medical service before you receive it. In some cases, we might decide the services are not covered for you. Or we may decide it is time to stop covering services you have been receiving. If you disagree with this coverage decision, you can make an appeal.
Depending on your situation, you may ask for a medical (Part C) coverage decision or a coverage decision for drugs (Part D). Or if a drug is not covered in the way you would like it to be covered, you can ask WellCare to make an exception to our coverage rules.
Y0070_NA015854_WCM_INS_ENG CMS Approved 08112011 ©WellCare 2011 NA_08_11_WC
WellCare’s Grievance, Coverage Determination and Appeal Processes
continued on next page
Exception requests: When you ask for an exception to our Part D drug coverage rules, your doctor will need to explain the medical reasons. We will then consider your request. For example, you or your doctor can ask us to cover a Part D drug that is not on our plan’s List of Covered Drugs (also known as a formulary or “drug list”). You can also ask us to remove a restriction on WellCare’s coverage for a covered drug. Or you can ask us to cover a drug in a lower cost group. Following a coverage decision, if our plan denies coverage or payment for Part D drugs you think should be covered, you have the right to appeal.
Appeals: If WellCare makes a coverage decision and you are not satisfied with this decision, you can appeal the decision. An appeal is a formal way of asking our plan to review and change a coverage decision we have made. When you make an appeal, our plan reviews the coverage decision we have made to determine if we were being fair and following all of the rules properly. When we have completed the review, we give you our decision.
If WellCare says no to your Part C (medical) appeal, your case will automatically be sent to the next level of the appeals process to make sure that we were being fair. We are required to send your appeal to the Independent Review Organization, also known as the Independent Review Entity (IRE), for your state. The IRE is an outside independent organization that is hired by Medicare. This organization will review your appeal and decide whether the decision our plan made should be changed.
If WellCare says no to your Part D appeal, you, your appointed representative or a provider can request a new appeal at the next level. The next-level Part D appeals are processed by an outside independent organization that is hired by Medicare. This organization will review your appeal and decide whether the decision our plan made should be changed.
If you prefer, you can also make complaints about quality of care to the Quality Improvement Organizations (QIO) in your state, without making the complaint to WellCare. If you make a complaint to this organization, we will work together with them to resolve it.
Grievances (making a complaint): You have the right to file a grievance (make a complaint) when unsatisfied with WellCare, a provider or health care services you have received. If you have any questions about WellCare’s process for coverage determinations, exception requests, appeals and/or grievances, please contact WellCare.
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WellCare is a Coordinated Care Plan with a Medicare Advantage contract. Benefits, limitations, co-payments and restrictions may vary by plan and by county/parish. Benefits, formulary, pharmacy network, premium and/or
co-payments/coinsurance may change on January 1, 2013. You must continue to pay your Medicare Part B premium. If you meet certain eligibility requirements for both Medicare and Medicaid, your Part B premiums may be covered in full. Members may enroll in the plan only during specific times of the year, unless you qualify for a special needs plan. You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for Extra Help, call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/7 days a
week; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call 1-800-325-0778; or your state Medicaid office. Beneficiaries must use network pharmacies to access their
prescription drug benefit, except in non-routine circumstances, and quantity limitations and restrictions may apply. Contact WellCare for more information.
This information is available for free in other languages. Please contact our Customer Service number at 1-877-374-4056 for additional information.
Esta información está disponible gratis en otros idiomas. Para información adicional, por favor comuníquese con Servicio al Cliente al 1-877-374-4056.
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P.O. Box 31389 | Tampa, FL 33631-3389
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