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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 which includes pharmacies with preferred cost-sharing, which may offer lower cost-sharing than standard network pharmacies. Preferred cost share pharmacies include CVS, Target, most independent, and many regional chains.

WellCare Classic is best suited to those who take only a few medications and seek a low monthly premium. Enrollees who qualify for Extra Help may not have any premium if enrolled in this plan.

Annual Notice of Change (ANOC)

This document (the "Annual Notice of Change") includes any changes in coverage, costs, or service area between your 2017 and 2018 plan.

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

Evidence of Coverage (EOC)

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

Plan Specific Documents

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

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 is a listing of the changes that have occurred in our formulary in the past month.

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_WCM_06390E CMS Approved 10/23/2017 Last Updated On: 10/1/2017