WellCare and You - HealthPlanOneweb1.healthplanone.com/HP1_Vendor_Docs/Medicare/... · Medicare and Medicaid. We have more than 25 years of experience delivering benefits value to

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


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.



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.



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.


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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








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








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








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








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

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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

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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

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ttin

g O

f Pr

efor

med

D

owel

Or

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$01 p

er li

fetim

e pe

r to

oth

✓

D39

99U

nspe

cifie

d En

dodo

ntic

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oced

ure,

By

Repo

rt$0

1 per

life

time

per

toot

h✓

Perio

dont

ics

D42

10

Gin

give

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y O

r G

ingi

vopl

asty

– F

our

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e C

ontig

uous

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eth

Or

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ded

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h Sp

aces

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Q

uadr

ant

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very

24

mos

. per

qu

adra

nt✓

D42

11

Gin

give

ctom

y O

r G

ingi

vopl

asty

– O

ne

To T

hree

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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








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

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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

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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

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sorb

able

Bar

rier,

Per

Site

$01 e

very

24

mos

. per

too

th✓

D42

67

Gui

ded

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ue

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nera

tion

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onre

sorb

able

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rier,

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Site

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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








Perio

dont

ics

D42

71Fr

ee S

oft

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ue G

raft

Pr

oced

ure

(Incl

udin

g D

onor

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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

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cedu

res,

Per

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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

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Surg

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Pro

cedu

res

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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

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very

24

mos

. per

too

th✓

D42

76

Com

bine

d C

onne

ctiv

e Ti

ssue

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ble

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cle

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ft, P

er

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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

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$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

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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

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iver

y O

f A

ntim

icro

bial

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d Re

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e V

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le In

to

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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

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ting

Den

tist)

$01 e

very

12 m

os. p

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proc

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D49

99U

nspe

cifie

d Pe

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ntal

Pr

oced

ure,

By

Repo

rt$0

1 eve

ry 12

mos

. per

pr

oced

ure

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Extr

actio

ns

D71

40Ex

trac

tion,

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pted

To

oth

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sed

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$01 p

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fetim

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Cro

wns

D27

10C

row

n –

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posi

te (I

ndire

ct)

$01 e

very

60

mos

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th✓

D27

12C

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(Indi

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)$0

1 eve

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0 m

os. p

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✓

2012

Den

tal C

over

age

| 14

AD

A C

ode

Des

crip

tion

of S

ervi

ceC

o-pa

yLi

mita

tions








Cro

wns

D27

21C

row

n –

Resi

n W

ith

Pred

omin

antly

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e M

etal

$01 e

very

60

mos

. per

too

th✓

D27

22C

row

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With

N

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al$0

1 eve

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0 m

os. p

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✓

D27

40C

row

n –

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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

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edom

inan

tly B

ase

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$01 e

very

60

mos

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too

th✓

D27

52C

row

n –

Porc

elai

n Fu

sed

To N

oble

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al$0

1 eve

ry 6

0 m

os. p

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✓

D27

81C

row

n –

3/4

Cas

t Pr

edom

inan

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ase

Met

al$0

1 eve

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0 m

os. p

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✓

D27

82C

row

n –

3/4

Cas

t N

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al$0

1 eve

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0 m

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ooth

✓

D27

83C

row

n –

3/4

Porc

elai

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eram

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1 eve

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0 m

os. p

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✓

D27

91C

row

n –

Full

Cas

t Pr

edom

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al$0

1 eve

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0 m

os. p

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✓

D27

92C

row

n –

Full

Cas

t N

oble

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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

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rtia

l Cov

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e Re

stor

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n$0

1 eve

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mos

. per

too

th✓

D29

15Re

cem

ent

Cas

t O

r Pr

efab

ricat

ed P

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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

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$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

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n$0

1 eve

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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

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✓

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








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

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th✓

D29

71

Add

ition

al P

roce

dure

s To

Con

stru

ct N

ew

Cro

wn

Und

er E

xist

ing

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ial D

entu

re

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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

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tinen

t D

ocum

enta

tion

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uate

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ical

A

ppro

pria

tene

ss

Shou

ld B

e In

clud

ed

Whe

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is C

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rted

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$01 e

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60

mos

. per

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th✓

Ad

dit

ion

al

Com

pre

hen

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Ser

vice

s

2012

Den

tal C

over

age

| 17

D29

99

Uns

peci

fied

Rest

orat

ive

Proc

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By R

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t (D

eter

min

e If

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HC

PCS

Leve

l II O

r A

CPT

Cod

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tter

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escr

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ing

Repo

rted

. Th

is C

ode

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ld

Be U

sed

Onl

y If

A

Mor

e Sp

ecifi

c C

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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

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0 m

os. p

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ooth

✓

D62

10Po

ntic

– C

ast

Hig

h N

oble

Met

al$0

1 eve

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0 m

os. p

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✓

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

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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

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ooth

✓

D62

45Po

ntic

– P

orce

lain

/C

eram

ic$0

1 eve

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0 m

os. p

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ooth

✓

D62

51Po

ntic

– R

esin

With

Pr

edom

inan

tly B

ase

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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








Cro

wns

D65

48

Reta

iner

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orce

lain

/C

eram

ic F

or R

esin

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nded

Fix

ed

Pros

thes

is

$01 e

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60

mos

. per

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th✓

D66

00In

lay

– Po

rcel

ain/

Cer

amic

, Tw

o Su

rfac

es$0

1 eve

ry 6

0 m

os. p

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ooth

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D66

01In

lay

– Po

rcel

ain/

Cer

amic

, Thr

ee O

r M

ore

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aces

$01 e

very

60

mos

. per

too

th✓

D66

02In

lay

– C

ast

Hig

h N

oble

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al, T

wo

Surf

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$01 e

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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

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th✓

D66

06In

lay

– C

ast

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le

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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








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








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








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








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

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✓

D26

62O

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✓

D26

63O

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$01 e

very

60

mos

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too

th✓

D26

64O

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0 m

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Oth

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urge

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D72

10Su

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✓✓

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D72

20Re

mov

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Soft

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1 per

life

time

per

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D72

30Re

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ed

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Part

ially

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1 per

life

time

per

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✓✓

D72

40Re

mov

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$01 p

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D72

41

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oval

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cted

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– C

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ny, W

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plic

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$01 p

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✓

2012

Den

tal C

over

age

| 2

8

AD

A C

ode

Des

crip

tion

of S

ervi

ceC

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Oth

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D72

50Su

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1 per

life

time

per

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h✓

✓✓

D72

60O

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$01 e

very

60

mos

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pr

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✓✓

✓

D72

61Pr

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losu

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f A

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$01 e

very

60

mos

. per

pr

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✓

D72

70

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impl

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And

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Of

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d O

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ispla

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$01 e

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60

mos

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oced

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✓

D72

72

Toot

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mos

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D72

80Su

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proc

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D72

82

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To A

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$01 e

very

60

mos

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✓

D72

83Pl

acem

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ptio

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$01 e

very

60

mos

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pr

oced

ure

✓

Ad

dit

ion

al

Com

pre

hen

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Ser

vice

s

2012

Den

tal C

over

age

| 2

9

D72

85Bi

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Of

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l Tis

sue

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)$0

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proc

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D72

86Bi

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l Tis

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– So

ft$0

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0 m

os. p

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proc

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e✓

D72

87Ex

folia

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Cyt

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Sa

mpl

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proc

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e✓

D72

88Br

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Biop

sy –

Tr

anse

pith

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l Sam

ple

Col

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ion

$01 e

very

60

mos

. per

pr

oced

ure

✓

D72

90Su

rgic

al R

epos

ition

ing

Of

Teet

h$0

1 eve

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0 m

os. p

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proc

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D72

91

Tran

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my/

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rest

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$01 e

very

60

mos

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pr

oced

ure

✓

D72

92

Surg

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cem

ent:

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pora

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D

evic

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late

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quiri

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60

mos

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pr

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✓

D72

93

Surg

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ent:

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pora

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mos

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pr

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✓

D72

94

Surg

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Pla

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pora

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ncho

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D

evic

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lap

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mos

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pr

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D73

10

Alv

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plas

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C

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mos

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qu

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D73

11

Alv

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plas

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C

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nctio

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actio

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eth

Or

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h Sp

aces

, Per

Qua

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$01 e

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60

mos

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nt✓

2012

Den

tal C

over

age

| 3

0

AD

A C

ode

Des

crip

tion

of S

ervi

ceC

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Oth

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D73

20

Alv

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plas

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actio

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mos

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D73

21

Alv

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mos

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D73

40

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50

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D74

10Ex

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2012

Den

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over

age

| 3

1

D74

11Ex

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f Be

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D74

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D74

14Ex

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unlim

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per

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D74

15Ex

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50

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D74

51

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eter

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an 1.

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D74

60

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eter

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CM

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limite

d pe

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2012

Den

tal C

over

age

| 3

2

AD

A C

ode

Des

crip

tion

of S

ervi

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Oth

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D74

61

Rem

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an 1.

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d pe

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D74

65

Des

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O

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By

Rep

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D74

71Re

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andi

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D74

72Re

mov

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f To

rus

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D74

73Re

mov

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f To

rus

Man

dibu

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✓

D74

85Su

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al R

educ

tion

Of

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eous

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eros

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life

time

per

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D74

90Ra

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D75

10In

cisi

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d pe

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dit

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pre

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2012

Den

tal C

over

age

| 3

3

D75

11

Inci

sion

And

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f A

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Fa

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D75

20In

cisi

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rain

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D75

21

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Soft

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ultip

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pace

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D75

30

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40

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D79

60

Fren

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rate

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cedu

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60

mos

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D79

63Fr

enul

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$01 e

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60

mos

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D79

70Ex

cisio

n O

f H

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plas

tic T

issue

–

Per

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h$0

1 eve

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0 m

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proc

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D79

71Ex

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f Pe

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D79

72Su

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educ

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Of

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Tube

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y$0

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life

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e✓

2012

Den

tal C

over

age

| 3

4

AD

A C

ode

Des

crip

tion

of S

ervi

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mita

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D79

97

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D79

99U

nspe

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Surg

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Proc

edur

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y Re

port

$01 e

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60

mos

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pr

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Oth

er S

ervi

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D92

10

Loca

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sthe

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D92

11Re

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lock

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nest

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D92

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15Lo

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nest

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D92

20D

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21

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datio

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Ad

dit

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pre

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2012

Den

tal C

over

age

| 3

5

D92

30A

nalg

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Inha

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f N

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D92

41In

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datio

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nalg

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D92

42

Intr

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D92

48N

onin

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D91

20Fi

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entu

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D96

10Th

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D96

12

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D96

30O

ther

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D99

10A

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D99

11

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D99

20Be

havi

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agem

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Repo

rt$0

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2012

Den

tal C

over

age

| 3

6

AD

A C

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Des

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tion

of S

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D99

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D99

40O

cclu

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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.


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.


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


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



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


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





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



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



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



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


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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Cough Syrup $10.00

Candy $6.00

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Grand Total:$ 20.00

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(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


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





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

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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


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





3870

4

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

Documents

WellCare and You - HealthPlanOneweb1.healthplanone.com/HP1_Vendor_Docs/Medicare/... · Medicare and Medicaid. We have more than 25 years of experience delivering benefits value to