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Here you can quickly get to the documents and forms that are specific to your plan.

This plan provides coverage for outpatient prescription drugs covered under Medicare Part D. It features a nationwide network of pharmacies. WellCare Extra is best suited to those who take several medications regularly and desire low copays and no deductibles.

Annual Notice of Change (ANOC)

This document (the "Annual Notice of Change") includes any changes in coverage, costs, or service area between your 2016 and 2017 plan.

This document includes any changes in coverage, costs or service area between your previous and current plan year.

Plan Specific Documents

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

This document includes a legal, detailed description of your benefits and costs as a member.

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.

Use this form to enroll in a Prescription Drug Plan.

Formulary

This document shows you what drugs are covered by a specific plan.

This document includes any changes in coverage, costs or service area that will be effective in January. All Annual Notice of Change (ANOC) documents are organized by state, plan name and county of residence.

Related Materials

Complete this form to request reimbursement for covered prescription drugs that you paid full price for.

Use this form to authorize us to withdraw your monthly premiums from your bank.

This is a sample of what an Explanation of Benefits looks like. It details any prescriptions covered in a specific month, what your plan paid and what you paid.

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.

This form confirms your request for a particular person to act as your representative in connection with a claim.

This form confirms you are the court-appointed legal guardian, have power of attorney or are able to make medical decisions on another person’s behalf.

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

This form revokes your permission for WellCare to discuss or disclose Protected Health Information (PHI) with a particular person.


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Y0070_NA035556_WCM_WEB_ENG CMS Approved 10/04/2016 Last Updated On: 9/30/2016