Wellcare Dual Access (HMO D-SNP)

Annual Notice of Change

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

• English
  Last Updated
  October 01, 2023

Evidence of Coverage

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

• English
  Last Updated
  October 01, 2023

Plan Enrollment Form

Use this form to enroll in a Medicare Advantage Plan

• English
  Last Updated
  October 01, 2023

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.

• Multi Language

Medical Direct Member Reimbursement Form

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

• English
• Spanish

Appointment of Representative Form

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

• English
• Spanish

Late Enrollment Penalty (LEP) Reconsideration Form

Part D Late Enrollment Penalty (LEP) Reconsideration Request Form

• English

2024 Medicare Step Therapy Part B Drugs

The drugs on this list require step therapy. Step therapy means you must try one drug before we will cover another drug.

• English