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Conditions and Limitations

There are conditions that apply to enrolling (and being enrolled) in our Medicare Advantage plans. Please make sure to read this section carefully to learn more about your Medicare Advantage coverage and the rules that apply.

  • WellCare Health Plans, Inc., is an HMO, PPO, PFFS plan with a Medicare contract. Our D-SNP Plans have a contract with the state Medicaid program. Enrollment in our plans depends on contract renewal.
  • To be eligible, you must be entitled to Medicare Part A and enrolled in Medicare Part B and live in the plan's service area, with limited exceptions.
  • Network pharmacies include retail, mail service, specialty, long-term care, home infusion and Indian Health Service/Tribal/Urban Indian Health Program (I/T/U) pharmacies. To obtain names and addresses of WellCare's network pharmacies, use the pharmacy search tool or contact us.
  • You must use network pharmacies to access your prescription drug benefit, except under non-routine circumstances (e.g., emergencies) when you cannot reasonably use network pharmacies. Quantity limits and restrictions may apply.
  • Non-Point-of-Service Plans: You must use plan providers except in emergency or urgent care situations, for out-of-area renal dialysis, or if you are enrolled in a PPO plan. If you obtain routine care from out-of-network providers, neither Medicare nor WellCare will be responsible for the costs, except in the case you are enrolled in a PPO plan.
  • Point-of-Service Plans: With the exception of emergencies, urgent care and out-of-area renal dialysis, it may cost more to get care from out-of-network providers.
  • Medicare Advantage Plans: Out-of-network/non-contracted providers are under no obligation to treat WellCare members, except in emergency situations. Please call our Customer Service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.
  • You can only be in one Medicare Advantage plan at a time. If you are currently in a Medicare Advantage or Prescription Drug plan, your enrollment in WellCare will end that enrollment. Enrollment in this plan is generally for the entire year. Once you enroll, you may leave this plan or make changes only at certain times of the year when an enrollment period is available (Example: you may make changes Oct. 15-Dec. 7 of every year), or under certain special circumstances.
  • If you qualify for additional assistance with your Medicare Prescription Drug plan costs, the amount of your premium and cost at the pharmacy will be less. Once you have enrolled in WellCare, Medicare will tell us how much assistance you are receiving, and we will send you information on the amounts you will pay.
  • If you decide to switch to premium withhold or move from premium withhold to direct bill, it could take up to three months to take effect and you will remain responsible for payment of those premiums during that time.
  • By law, WellCare can choose not to renew our contract with CMS. CMS may also refuse to renew the contract, resulting in a termination or non-renewal. This may result in termination of your enrollment in the plan. Additionally, WellCare may reduce its service area and no longer offer services in the area where you reside.
  • Medicare beneficiaries may also enroll in a plan through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov.

For a complete list of drugs covered by our plan, please call Customer Service.

The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

For full information on WellCare Medicare Advantage plan benefits, please contact us.

This information is available free in other languages. Please contact Customer Service for more information.



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Y0070_WCM_42183E Last Updated On: 10/1/2018