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Medicare : Frequently Asked Questions

Frequently Asked Questions & Answers

Have questions about your health plan? WellCare wants to make it easy for you to find answers. Below are some commonly asked questions from our members along with the respective answers. If you have a question that isn’t listed here, or if you need any information regarding your WellCare health plan coverage, please contact us.


Q: What is a Medicare Advantage HMO plan?

A: A Medicare Advantage HMO plan is offered by a private company that contracts with Medicare to provide you with all your Medicare Part A (hospital) and Part B (medical) benefits. It is a health maintenance organization, or HMO. The means it provides care through a network of providers. Care is coordinated through the primary care physician (PCP), who may refer people to specialists as needed. Referrals are generally required to see specialists.


Q: What is a Medicare Advantage HMO POS plan?

A: A Medicare Advantage HMO POS also provides care through a network of providers. However, it includes a point of service (POS) feature, which allows members to receive health care services outside of the network with authorization from the plan, although use of providers within the network is encouraged.


Q: What is a network?

A: Network providers are the doctors and other health care professionals, medical groups, hospitals and other health care facilities that have an agreement with us to deliver covered services to members in our plan. The providers in our network generally bill us directly for care they give you. When you see a network provider, you usually pay only your share of the cost for their services.



Q: Where can I get information about basic Medicare terms?

A: We want you to make an informed decision about your Medicare health plan. That’s why we created a glossary to help you understand many commonly used Medicare terms.


Q: Should I still keep my red, white and blue Medicare Card?

A: Yes. However, as long as you are a member of our plan you must not use your red, white and blue Medicare card to get covered medical services (with the exception of clinical research studies and hospice services). Keep your red, white, and blue Medicare card in a safe place in case you need it later. Here’s why this is so important: If you get covered services using your red, white and blue Medicare card instead of using our membership card while you are a plan member, you may have to pay the full cost yourself. If your WellCare ID card is damaged, lost or stolen, contact us right away and we will send you a new card.


Q: If I don't like my WellCare plan, can I go back to Original Medicare?

A: Of course. You don't lose your Medicare benefits when you join our plan. However, there are limits on when and how often you can change your Medicare Advantage plan. Contact us to find out more.


Q: When can I enroll or make a plan change into a WellCare Medicare Advantage Plan?

A: You can enroll or make a plan change into a WellCare Plan three months before to three months after the month you turn 65. This is your Initial Coverage Election Period. You can also enroll during the Annual Election Period (October 15 - December 7 of every year), in which your new coverage would be effective January 1st. There are also exceptions throughout the year that may allow you to make plan changes outside of the Annual Election Period.  Contact us for more information.


What's Covered

Q: Will I have the same coverage as I do with Original Medicare?

A: Our plans are in place of Original Medicare (except clinical research studies and hospice services) and may some offer extra benefits such as routine dental, routine hearing, routine vision and prescription drug coverage. If you have questions about whether your plan will pay for specific services, please read our Evidence of Coverage.


Q: Can I receive emergency care?

A: You have the right to emergency care, when needed, anywhere in the United States and without pre-approval from us. Please read the Evidence of Coverage or contact us for details.


Q: Do HMO or HMO POS plans cover services that Medicare does not consider medically necessary?

A: An HMO or HMO POS plan is not required to pay for services that are not medically necessary under Medicare. However, WellCare plans do pay for additional benefits not covered by Original Medicare. If you receive a service that is not covered by our plan, you are responsible for the cost of that service. If you are not sure whether a service is covered, you have the right to call us and ask for an advance decision.


Q: What do I need to do to get care?

A: Our plans work just like traditional health insurance. Just show your WellCare Member ID card (instead of your Medicare card) at the doctor's office. You may have a co-payment due at that time.


Q: What happens if my doctor is not familiar with WellCare Plans?

A: If your doctor or health care provider would like more information about WellCare, ask them to contact us. Our Customer Service representatives are ready to answer questions.


Q: Can WellCare ever drop my coverage?

A: Once you're enrolled, you cannot be disqualified for any medical condition. However, if you move out of our service area or commit fraud, WellCare reserves the right to disenroll you. Please read the Evidence of Coverage for complete details. All Medicare Advantage plans commit to their members for a full year. Each year, WellCare decides whether to continue a plan for another year. Even if a Medicare Advantage Plan is discontinued at the end of a benefit year, you will not lose Medicare coverage. If your plan is discontinued, WellCare must notify you in writing at least 60 days before your coverage ends. The letter will explain your options for other Medicare coverage in your area.


Q: What if I need to talk to a nurse?

A: One of the perks of being a WellCare member is our 24-hour Nurse Advice Line. Our nurses will give you answers to your medical questions and help you decide whether or not to see your doctor or go to the emergency room. Nurses are available 24 hours a day, 7 days a week.  Just call the number on the back of your member identification (ID) card.




Q: Do I still have to pay my Medicare Part B premium?

A: Yes. When you join a WellCare plan, you must continue to pay your Medicare Part B premium if not otherwise paid for by Medicaid or another third party. If you meet certain eligibility requirements for both Medicare and Medicaid, your Part B premium may be covered in full. Some of WellCare's Plans reduce the Medicare Part B premium. The reduction is set up by Medicare and administered through the Social Security Administration (SSA). Depending on how you pay your Medicare Part B premium, your reduction may be credited to your Social Security check or credited on your Medicare Part B premium statement. Reductions may take several months to be issued. However, you will receive a full credit.


Prescription Drug Coverage

Q: One of the prescriptions I usually take isn't on the WellCare formulary. What should I do?

A: Contact us and we can look up your prescription to see if it's part of our formulary. When you call, one of our representatives may suggest an alternative medication.  Please check with your doctor to see if that alternative would work for you.  If your doctor feels that you need to take a certain brand name prescription drug that isn't covered, we have a review process in place that may allow you to do this. Read our Part D Transition Policy for what to do if your medication isn't covered by the plan. 


Q: What if I have to pay cash for my prescription because I do not have my WellCare ID card?

A: You will need to request a reimbursement from WellCare by completing a Direct Member Reimbursement Formpdf and mailing it to us. Please keep a copy of the form and receipts for your records.


Q: How will I know if WellCare is going to pay me for the prescriptions when I did not have my WellCare ID card?

A: We will send you a letter that informs you of our decision concerning the request for payment of your prescriptions. You can expect to receive this letter within 7 to 10 business days.


Q: What if I mailed my request for WellCare to pay for my prescriptions, but I have not received any information?

A: Please contact us. We will provide you information, including whether or not we received your request.


Q: What prescriptions are covered by WellCare?

A: WellCare covers both brand-name and generic prescription drugs. The federal government has created guidelines for the types of drugs that must be covered, along with setting a minimum standard of benefits. You can review our full list of our covered prescription drugs either by using our search tool or you can download a comprehensive formulary.


Q: Can I use my WellCare ID card at a lot of different pharmacies?

A: You can use your WellCare ID card at any of our 60,000 network pharmacies. WellCare also has preferred pharmacies.  By filling your prescription at a preferred pharmacy (retail or mail-service), your co-pay could be lower.  Preferred pharmacies includes Exactus Pharmacy Solutions, Duane Reade, Kmart, Sam’s Club, Walgreens, and Wal-Mart. Use our pharmacy search tool to find both preferred and network pharmacies in your area.


Q: Does my WellCare Prescription Drug Plan cover medications filled by an out-of-network pharmacy?

A: A network pharmacy is a pharmacy that has a contract with the plan to provide your covered prescription drugs.

Generally, we only cover drugs filled at an out-of-network pharmacy in limited, non-routine circumstances when a network pharmacy is not available. There are certain circumstances we could cover prescriptions filled at an out-of-network pharmacy such as traveling or a medical emergency.  Review our Evidence of Coverage for more information about filling your prescriptions at an out-of-network pharmacy.  If you must use an out-of-network pharmacy, you generally have to pay the full cost (rather than your normal share of the cost) when you fill your prescription. You can ask us to reimburse you for our share of the cost by completing a Direct Member Reimbursement  form.


Q: Can I get prescriptions through a mail service?

A: Yes. Exactus Pharmacy Solutions is WellCare's preferred mail-service pharmacy. Exactus allows you to safely and securely request a transfer of your maintenance medications from your local retail pharmacy to our mail service.

Other pharmacies are available in our network. You can have your prescription filled at any network pharmacy, however, by using a preferred network pharmacy, your co-pay could be less.


Q: I'd like to get a 3-month supply of my drugs. Is that possible?

A: You can get a 3-month supply of most drugs when you use a pharmacy that contracts to offer 3-month supplies. Please call your pharmacy beforehand to confirm they offer a 3-month supply. If you use WellCare's preferred mail-service provider, Exactus Pharmacy Solutions*,  you can save even more. Pay $0 for a 3-month supply for Tier 1 medications or for all other drugs (excluding our Specialty tier), you can still get a 3-month supply for only a 2-month co-pay when using Exactus. Best of all, standard shipping is always free. 

*These savings occur when you use Exactus Pharmacy Solutions, WellCare's preferred mail-service pharmacy, instead of a non-preferred mail-service pharmacy. Other pharmacies are available in our network.

Q: What is Exactus Pharmacy Solutions?
Exactus (formerly known as WellCare Specialty Pharmacy) is a licensed pharmacy registered in all 50 states. Exactus delivers medications and supplies to our members living throughout the country, according to their mail service and specialty pharmacy needs.


Q: Can I get drugs from another country through WellCare?

A: No. Please read the Evidence of Coverage for more information.


Q: Can your plan refuse me coverage if I take a lot of prescriptions?

A: As long as you are eligible, WellCare cannot refuse to offer you coverage. To lower your prescription drug costs, you should also consider using our preferred generic drugs, which are usually less expensive than brand drugs.


Q: I get some of my prescriptions through Medicare Part B. Now what?

A: You'll continue to receive them through Part B. Prescriptions received as part of a physician's services, due to surgery, along with certain Part B prescription drugs, are covered through Part B. Please contact us if you need more information.


Q: What if I'm on a limited income or cannot afford my prescription drugs?

A: You may qualify for extra help from the federal government—and if you're eligible, this assistance could really reduce the cost of your drugs. Learn more about Extra Help.


Q: I was at the pharmacy and was told I do not have coverage. What should I do?

A: Please contact us.


Y0070_NA025190_WCM_WEB_ENG CMS Approved

Last modified: 01/01/2014

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