Wellcare Dual Access (HMO D-SNP)

Summary of Benefits

This document provides some of the features of this plan. For a complete list of benefits, see your Evidence of Coverage.

• English
  Last Updated
  October 01, 2022

Dental Benefit Details

This document provides additional details about the dental benefits, including a list of services and benefit limits.

• English
  Last Updated
  October 01, 2022

Star Ratings

Star Ratings judge how well Medicare health and drug plans perform in different categories. They are distributed by Medicare. Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.

• English
  Last Updated
  October 25, 2022

Original Medicare Defined Cost Share Amounts and Premiums

Original Medicare Defined Cost Share Amounts and Premiums

• English

Medical Direct Member Reimbursement Form

Complete this form to request reimbursement for covered medical services that you paid for out of pocket.

• English
• Spanish

Multi-Language Interpreter Services and Phone Contact Information

This document includes information about multi-language interpreter services for speakers of Arabic, Chinese Cantonese, Chinese Mandarin, French Creole, French, German, Hindi, Italian, Japanese, Korean, Polish, Portuguese, Russian, Spanish, Tagalog, and Vietnamese.

• English
• Spanish
• Chinese
• Arabic
• Armenian
• Farsi
• KhmerCambodian
• Korean
• Russian
• Tagalog
• Vietnamese

Member Disenrollment Form

Each member requesting to be disenrolled must complete their own form.

• English
• Spanish

HIPAA Release of Information

This form confirms your permission that WellCare may discuss or disclose Protected Health Information (PHI) with a particular person.

• English
• Spanish

Primary Care Provider (PCP) Change Request Form

Please complete this form with your provider if you want to change your PCP. Your provider will then send this form to your health plan, letting them know about the change.

• English