2021 summary of benefits

We know how important it is to have a health plan you can count on.This is a summary of drug and health services covered by WellCare Dividend (HMO), WellCare Elite(HMO), WellCare Premier (PPO), WellCare Compass (HMO) from January 1, 2021 to December 31,2021.This information does not list every service, limitation or exclusion. A complete list of services is in theplan’s Evidence of Coverage. You can find the Evidence of Coverage on our website. Or you may call usto ask for a copy at the phone number listed on the back cover.Who can join?To join one of our plans, you must be entitled to Medicare Part A, be enrolled in Medicare Part B and livein our service area.Our plans and service area:H9730007000 WellCare Dividend (HMO) Allen, Anderson, Ballard, Barren, Bell, Boone, Bourbon, Boyd,Boyle, Breckinridge, Bullitt, Butler, Caldwell, Calloway, Campbell, Carlisle, Carroll, Carter, Christian,Clark, Clay, Daviess, Edmonson, Fayette, Floyd, Franklin, Fulton, Gallatin, Garrard, Grant, Graves,Grayson, Greenup, Hancock, Hardin, Harlan, Harrison, Hart, Henderson, Henry, Hickman, Hopkins,Jefferson, Jessamine, Johnson, Kenton, Knott, Knox, Laurel, Leslie, Letcher, Lincoln, Logan, Madison,Marshall, McCracken, McCreary, McLean, Meade, Mercer, Montgomery, Muhlenberg, Nelson, Ohio,Oldham, Owen, Pendleton, Perry, Pike, Pulaski, Scott, Shelby, Simpson, Spencer, Taylor, Todd, Trigg,Trimble, Warren, Washington, Wayne, Whitley, WoodfordH9730009000 WellCare Elite (HMO) Allen, Anderson, Ballard, Barren, Bell, Boone, Bourbon, Boyd,Boyle, Breckinridge, Bullitt, Butler, Caldwell, Calloway, Campbell, Carlisle, Carroll, Carter, Christian,Clark, Clay, Daviess, Edmonson, Fayette, Floyd, Franklin, Fulton, Gallatin, Garrard, Grant, Graves,Grayson, Greenup, Hancock, Hardin, Harlan, Harrison, Hart, Henderson, Henry, Hickman, Hopkins,Jefferson, Jessamine, Johnson, Kenton, Knott, Knox, Laurel, Leslie, Letcher, Lincoln, Logan, Madison,Marshall, McCracken, McCreary, McLean, Meade, Mercer, Montgomery, Muhlenberg, Nelson, Ohio,Oldham, Owen, Pendleton, Perry, Pike, Pulaski, Scott, Shelby, Simpson, Spencer, Taylor, Todd, Trigg,Trimble, Warren, Washington, Wayne, Whitley, WoodfordH3975001000 WellCare Premier (PPO) Allen, Anderson, Ballard, Barren, Bell, Boone, Bourbon, Boyd,Boyle, Breckinridge, Bullitt, Butler, Caldwell, Calloway, Campbell, Carlisle, Carroll, Carter, Christian,Clark, Clay, Daviess, Edmonson, Fayette, Floyd, Franklin, Fulton, Gallatin, Garrard, Grant, Graves,Grayson, Greenup, Hancock, Hardin, Harlan, Harrison, Hart, Henderson, Henry, Hickman, Hopkins,Jefferson, Jessamine, Johnson, Kenton, Knott, Knox, Laurel, Leslie, Letcher, Lincoln, Logan, Madison,Marshall, McCracken, McCreary, McLean, Meade, Mercer, Montgomery, Muhlenberg, Nelson, Ohio,Oldham, Owen, Pendleton, Perry, Pike, Pulaski, Scott, Shelby, Simpson, Spencer, Taylor, Todd, Trigg,Trimble, Warren, Washington, Wayne, Whitley, WoodfordH9730010000 WellCare Compass (HMO) Allen, Anderson, Ballard, Barren, Bell, Boone, Bourbon, Boyd,Boyle, Breckinridge, Bullitt, Butler, Caldwell, Calloway, Campbell, Carlisle, Carroll, Carter, Christian,Clark, Clay, Daviess, Edmonson, Fayette, Floyd, Franklin, Fulton, Gallatin, Garrard, Grant, Graves,Grayson, Greenup, Hancock, Hardin, Harlan, Harrison, Hart, Henderson, Henry, Hickman, Hopkins,Jefferson, Jessamine, Johnson, Kenton, Knott, Knox, Laurel, Leslie, Letcher, Lincoln, Logan, Madison,Marshall, McCracken, McCreary, McLean, Meade, Mercer, Montgomery, Muhlenberg, Nelson, Ohio,Oldham, Owen, Pendleton, Perry, Pike, Pulaski, Scott, Shelby, Simpson, Spencer, Taylor, Todd, Trigg,Trimble, Warren, Washington, Wayne, Whitley, Woodford

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Like all Medicare health plans, our plans also cover everything that Original Medicare covers with additionalbenefits to support your well-being.For coverage and costs of Original Medicare, look in your current “Medicare & You” handbook. View itonline at www.medicare.gov or get a copy by calling 1-800-MEDICARE (1-800-633-4227). TTY/TDDusers should call 1-877-486-2048. Available 24 hours, 7 days a week, including some federal holidays.

Preferred Provider Organization (PPOs)Medicare Advantage Prescription Drug (MAPD) offer coveragethrough a network of providers, but you are allowed to access out-of-network care for covered services,usually for a higher cost. You do not need to choose a primary care doctor with a PPO, and usually you donot need a referral to see a specialist. Some plans also include giveback of some or all of the Part B premium.Health Maintenance Organizations (HMOs) are health-care plans offered by an insurance provider witha network of contracted healthcare providers and facilities. HMOs generally require members to select aprimary care doctor to coordinate care. Some plans also include giveback of some or all of the Part Bpremium.

Which doctors, hospitals and pharmacies can I use?WellCare has a network of doctors, hospitals, pharmacies and other providers. You can save money by usingour preferred mail-order pharmacy and by using providers in the plan's network. With some plans if youuse providers that are not in our network, your share of the costs for covered services may be higher. Youcan see our plan's provider and pharmacy directory at our website: www.wellcare.com/medicare. Or, calland we'll send you a copy.How will I determine my drug costs?If your plan offers a drug benefit, you will generally have to use one of our network pharmacies to fill yourprescriptions covered by Part D. You will need to use our plan's formulary (list of covered drugs) to locatewhat tier your drug is on to determine how much it will cost you. Each medication will be grouped intoone of the five tiers. The amount you pay depends on the drug’s tier and what stage of the benefit you havereached. Later in this document we discuss the drug benefit stages that occur, if applicable: Deductible,Initial Coverage, Coverage Gap, and Catastrophic Coverage.

This document is available in other formats such as braille, large print or audio. This document is availablein languages other than English. For additional information, call us at 1-877-374-4056, (TTY/TDD 711).For more information, please call us at 1-833-444-9088 (TTY/TDD users should call 711) Between October1 and March 31, representatives are available Monday–Sunday, 8 a.m. to 8 p.m. Between April 1 andSeptember 30, representatives are available Monday–Friday, 8 a.m. to 8 p.m., or visit us atwww.wellcare.com/medicare.

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Summary of BenefitsJanuary 1, 2021 - December 31, 2021NOTE:

Services with PA may require prior authorizationServices with R may require a referral from your doctor

PPO plans do not require a prior authorization or referral for out-of-network services.

WellCare Elite (HMO)H9730009000KY

WellCare Dividend (HMO)H9730007000KY

Plan Name

Allen, Anderson, Ballard, Barren,Bell, Boone, Bourbon, Boyd, Boyle,Breckinridge, Bullitt, Butler,Caldwell, Calloway, Campbell,Carlisle, Carroll, Carter, Christian,Clark, Clay, Daviess, Edmonson,Fayette, Floyd, Franklin, Fulton,Gallatin, Garrard, Grant, Graves,Grayson, Greenup, Hancock,Hardin, Harlan, Harrison, Hart,Henderson, Henry, Hickman,Hopkins, Jefferson, Jessamine,Johnson, Kenton, Knott, Knox,Laurel, Leslie, Letcher, Lincoln,Logan, Madison, Marshall,McCracken, McCreary, McLean,Meade, Mercer, Montgomery,Muhlenberg, Nelson, Ohio,Oldham, Owen, Pendleton, Perry,Pike, Pulaski, Scott, Shelby,Simpson, Spencer, Taylor, Todd,Trigg, Trimble, Warren,Washington, Wayne, Whitley,Woodford

Allen, Anderson, Ballard, Barren,Bell, Boone, Bourbon, Boyd, Boyle,Breckinridge, Bullitt, Butler,Caldwell, Calloway, Campbell,Carlisle, Carroll, Carter, Christian,Clark, Clay, Daviess, Edmonson,Fayette, Floyd, Franklin, Fulton,Gallatin, Garrard, Grant, Graves,Grayson, Greenup, Hancock,Hardin, Harlan, Harrison, Hart,Henderson, Henry, Hickman,Hopkins, Jefferson, Jessamine,Johnson, Kenton, Knott, Knox,Laurel, Leslie, Letcher, Lincoln,Logan, Madison, Marshall,McCracken, McCreary, McLean,Meade, Mercer, Montgomery,Muhlenberg, Nelson, Ohio,Oldham, Owen, Pendleton, Perry,Pike, Pulaski, Scott, Shelby,Simpson, Spencer, Taylor, Todd,Trigg, Trimble, Warren,Washington, Wayne, Whitley,Woodford

Service Area

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WellCare Compass (HMO)H9730010000KY

WellCare Premier (PPO)H3975001000KY

Allen, Anderson, Ballard, Barren, Bell, Boone, Bourbon,Boyd, Boyle, Breckinridge, Bullitt, Butler, Caldwell,Calloway, Campbell, Carlisle, Carroll, Carter, Christian,Clark, Clay, Daviess, Edmonson, Fayette, Floyd,Franklin, Fulton, Gallatin, Garrard, Grant, Graves,Grayson, Greenup, Hancock, Hardin, Harlan, Harrison,Hart, Henderson, Henry, Hickman, Hopkins, Jefferson,Jessamine, Johnson, Kenton, Knott, Knox, Laurel,Leslie, Letcher, Lincoln, Logan, Madison, Marshall,McCracken, McCreary, McLean, Meade, Mercer,Montgomery, Muhlenberg, Nelson, Ohio, Oldham,Owen, Pendleton, Perry, Pike, Pulaski, Scott, Shelby,Simpson, Spencer, Taylor, Todd, Trigg, Trimble,Warren, Washington, Wayne, Whitley, Woodford

Allen, Anderson, Ballard, Barren, Bell, Boone, Bourbon,Boyd, Boyle, Breckinridge, Bullitt, Butler, Caldwell,Calloway, Campbell, Carlisle, Carroll, Carter, Christian,Clark, Clay, Daviess, Edmonson, Fayette, Floyd,Franklin, Fulton, Gallatin, Garrard, Grant, Graves,Grayson, Greenup, Hancock, Hardin, Harlan, Harrison,Hart, Henderson, Henry, Hickman, Hopkins, Jefferson,Jessamine, Johnson, Kenton, Knott, Knox, Laurel,Leslie, Letcher, Lincoln, Logan, Madison, Marshall,McCracken, McCreary, McLean, Meade, Mercer,Montgomery, Muhlenberg, Nelson, Ohio, Oldham,Owen, Pendleton, Perry, Pike, Pulaski, Scott, Shelby,Simpson, Spencer, Taylor, Todd, Trigg, Trimble,Warren, Washington, Wayne, Whitley, Woodford

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Monthly Premium, Deductible andLimits

$0.00$0.00Monthly Plan PremiumWhat you should knowYou must continue to pay yourMedicare Part B premium.

What you should knowYou must continue to pay yourMedicare Part B premium.

This plan does not offer a Part BPremium Reduction

$75.00Part B Premium Buy-Down

No Deductible$100 annuallyDeductibleWhat you should knowThe deductible is the amount youmust pay out-of-pocket for medicalservices before our plan begins to payits share.

In-NetworkIn-Network$6,700 annually

Maximum Out-of-PocketResponsibility(MOOP)

$5,000 annually

(does not include prescription drugs)Combined and/or Out-of-NetworkCombined and/or Out-of-Network

Not Applicable Not ApplicableWhat you should knowOur plan protects you by havingyearly limits on your out-of-pocketcosts for medical and hospital care.These limits are the most you pay forco-pays, coinsurance and other costsfor hospital and medical services. Formore information on out-of-pocketcosts for this plan, refer to theEvidence of Coverage.

What you should knowOur plan protects you by having yearlylimits on your out-of-pocket costs formedical and hospital care. These limitsare the most you pay for co-pays,coinsurance and other costs forhospital and medical services. Formore information on out-of-pocketcosts for this plan, refer to theEvidence of Coverage.



Medical and Hospital Benefits

In-Network$300 co-pay per day for days 1-6 anda$0 co-pay per day for days 7-90

In-Network$400 co-pay per day for days 1-5 anda$0 co-pay per day for days 6-90

Inpatient Hospital CoveragePA

Out-of-NetworkOut-of-NetworkNot Covered Not Covered

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$18.20$0.00What you should knowYou must continue to pay your Medicare Part B premium.

What you should knowYou must continue to pay your Medicare Part B premium.

This plan does not offer a Part B Premium ReductionThis plan does not offer a Part B Premium Reduction

No DeductibleNo DeductibleWhat you should knowSee the Prescription Drug Benefits section of thisdocument for Part D Prescription Drug Deductibleinformation.

What you should knowSee the Prescription Drug Benefits section of thisdocument for Part D Prescription Drug Deductibleinformation.

In-NetworkIn-Network$5,000 annually$5,500 annually

Combined and/or Out-of-NetworkCombined and/or Out-of-NetworkNot Applicable$10,000 annuallyWhat you should knowWhat you should know

Our plan protects you by having yearly limits on yourout-of-pocket costs for medical and hospital care. Theselimits are the most you pay for co-pays, coinsurance andother costs for hospital and medical services. For moreinformation on out-of-pocket costs for this plan, refer tothe Evidence of Coverage.

Our plan protects you by having yearly limits on yourout-of-pocket costs for medical and hospital care. Theselimits are the most you pay for co-pays, coinsurance andother costs for hospital and medical services. For moreinformation on out-of-pocket costs for this plan, refer tothe Evidence of Coverage.



In-Network$325 co-pay per day for days 1-6 and a$0 co-pay per day for days 7-90

In-Network$325 co-pay per day for days 1-6 and a$0 co-pay per day for days 7-90

Out-of-NetworkOut-of-NetworkNot Covered35% of the total cost for days 1-90

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What you should knowOur plan covers a specified numberof days for an inpatient hospital stay.Once discharged from an inpatienthospital stay, talk to one of our caremanagers. Our care managers canhelp make sure you stay healthy andout of the hospital. Refer to theEvidence of Coverage for more planspecific information.

What you should knowOur plan covers a specified number ofdays for an inpatient hospital stay.Once discharged from an inpatienthospital stay, talk to one of our caremanagers. Our care managers can helpmake sure you stay healthy and out ofthe hospital. Refer to the Evidence ofCoverage for more plan specificinformation.

In-NetworkIn-Network$250 co-pay per non-surgical service/ $350 co-pay per surgical service

Outpatient Hospital CoveragePA

$225 co-pay per non-surgical service/ $275 co-pay per surgical serviceOut-of-NetworkOut-of-Network

Not Covered Not CoveredWhat you should knowCovered services include surgery,heart catheterizations, oncologyrelated services, respiratory services,wound care, infusion therapies andother therapeutic procedures done inan outpatient setting.

What you should knowCovered services include surgery, heartcatheterizations, oncology relatedservices, respiratory services, woundcare, infusion therapies and othertherapeutic procedures done in anoutpatient setting.

In-NetworkIn-Network$90 co-pay Emergency Room (ER) /

Outpatient Hospital ObservationServicesPA $90 co-pay Emergency Room (ER) /

$350 co-pay (Outpatient) $275 co-pay (Outpatient)Out-of-NetworkOut-of-Network

Not Covered Not CoveredWhat you should knowYour cost for Outpatient HospitalObservation Services when you enterthrough ER or when you enterobservation status through anoutpatient setting.

What you should knowYour cost for Outpatient HospitalObservation Services when you enterthrough ER or when you enterobservation status through anoutpatient setting.

In-NetworkIn-Network$200 co-pay

Ambulatory Surgery Center (ASC)PA

$175 co-payOut-of-NetworkOut-of-Network

Not Covered Not Covered

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What you should knowWhat you should knowOur plan covers a specified number of days for an inpatienthospital stay. Once discharged from an inpatient hospitalstay, talk to one of our care managers. Our care managerscan help make sure you stay healthy and out of thehospital. Refer to the Evidence of Coverage for more planspecific information.

Our plan covers a specified number of days for an inpatienthospital stay. Once discharged from an inpatient hospitalstay, talk to one of our care managers. Our care managerscan help make sure you stay healthy and out of thehospital. Refer to the Evidence of Coverage for more planspecific information.

In-NetworkIn-Network$225 co-pay per non-surgical service / $275 co-pay persurgical service

$250 co-pay per non-surgical service / $300 co-pay persurgical service

Out-of-NetworkOut-of-NetworkNot Covered35% coinsurance for surgical and non-surgical servicesWhat you should knowWhat you should know

Covered services include surgery, heart catheterizations,oncology related services, respiratory services, wound care,infusion therapies and other therapeutic procedures donein an outpatient setting.

Covered services include surgery, heart catheterizations,oncology related services, respiratory services, wound care,infusion therapies and other therapeutic procedures donein an outpatient setting.

In-NetworkIn-Network$90 co-pay Emergency Room (ER) /$90 co-pay Emergency Room (ER) /$275 co-pay (Outpatient)$300 co-pay (Outpatient)Out-of-NetworkOut-of-NetworkNot Covered35% coinsurance per stayWhat you should knowWhat you should know

Your cost for Outpatient Hospital Observation Serviceswhen you enter through ER or when you enter observationstatus through an outpatient setting.

Your cost for Outpatient Hospital Observation Serviceswhen you enter through ER or when you enter observationstatus through an outpatient setting.

In-NetworkIn-Network$175 co-pay$250 co-payOut-of-NetworkOut-of-NetworkNot Covered35% coinsurance

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Doctor VisitsIn-NetworkIn-Network

$0 co-payPrimary Care Provider (PCP)


Not Covered Not CoveredWhat you should knowYour PCP is the doctor who willhandle most of your health careservices. For telemedicine servicesrendered by your Primary CarePhysician, Specialist, Urgent NeededServices, Outpatient Mental HealthCare (Individual Session),Occupational Therapy, PhysicalTherapy and/or Speech-LanguageTherapy, Outpatient Substance Abuse(Individual Session), Podiatry Services(Medicare Covered ), Home HealthAgency Care, DiabetesSelf-Management Training, OtherHealthcare Professional, Walk-in andPharmacy Clinics, you will pay thecost share for that provider listedthroughout this document.

What you should knowYour PCP is the doctor who willhandle most of your health careservices. For telemedicine servicesrendered by your Primary CarePhysician, Specialist, Urgent NeededServices, Outpatient Mental HealthCare (Individual Session),Occupational Therapy, PhysicalTherapy and/or Speech-LanguageTherapy, Outpatient Substance Abuse(Individual Session), Podiatry Services(Medicare Covered ), Home HealthAgency Care, DiabetesSelf-Management Training, OtherHealthcare Professional, Walk-in andPharmacy Clinics, you will pay thecost share for that provider listedthroughout this document.

In-NetworkIn-NetworkSpecialistPA

$35 co-pay$40 co-payOut-of-NetworkOut-of-Network

Not Covered Not CoveredIn-Network$0 co-pay (PCP office)

In-Network$0 co-pay (PCP office)

Other Healthcare ProfessionalsPA

(e.g. Physician Assistant or NursePractitioner) $35 co-pay (specialist office)$40 co-pay (specialist office)

$35 co-pay (clinic/pharmacy setting)$40 co-pay (clinic/pharmacy setting)Out-of-NetworkOut-of-Network


You pay a $0 co-pay per callYou pay a $0 co-pay per callTeladoc

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In-NetworkIn-Network$0 co-pay$0 co-payOut-of-NetworkOut-of-NetworkNot Covered$25 co-payWhat you should knowYour PCP is the doctor who will handle most of yourhealth care services. For telemedicine services rendered byyour Primary Care Physician, Specialist, Urgent NeededServices, Outpatient Mental Health Care (IndividualSession), Occupational Therapy, Physical Therapy and/or Speech-Language Therapy, Outpatient SubstanceAbuse (Individual Session), Podiatry Services (MedicareCovered ), Home Health Agency Care, DiabetesSelf-Management Training, Other HealthcareProfessional, Walk-in and Pharmacy Clinics, you will paythe cost share for that provider listed throughout thisdocument.

What you should knowYour PCP is the doctor who will handle most of yourhealth care services. For telemedicine services rendered byyour Primary Care Physician, Specialist, Urgent NeededServices, Outpatient Mental Health Care (IndividualSession), Occupational Therapy, Physical Therapy and/or Speech-Language Therapy, Outpatient SubstanceAbuse (Individual Session), Podiatry Services (MedicareCovered ), Home Health Agency Care, DiabetesSelf-Management Training, Other HealthcareProfessional, Walk-in and Pharmacy Clinics, you will paythe cost share for that provider listed throughout thisdocument.

In-NetworkIn-Network$40 co-pay$35 co-payOut-of-NetworkOut-of-NetworkNot Covered$50 co-payIn-Network$0 co-pay (PCP office)

In-Network$0 co-pay (PCP office)

$40 co-pay (specialist office)$35 co-pay (specialist office)$40 co-pay (clinic/pharmacy setting)$35 co-pay (clinic/pharmacy setting)Out-of-NetworkOut-of-NetworkNot Covered$25 co-pay (PCP Office)

$50 co-pay (specialist office)$50 co-pay (clinic/pharmacy setting)

You pay a $0 co-pay per callYou pay a $0 co-pay per call

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What you should knowParticipating providers may diagnoseand treat some medical conditions viareal-time interactive audio and videotechnologies.

What you should knowParticipating providers may diagnoseand treat some medical conditions viareal-time interactive audio and videotechnologies.

In-Network$0 co-pay

In-Network$0 co-pay

Preventive CareAbdominal aortic aneurysm screening;Alcohol misuse counseling; Bone massmeasurement; Breast cancer screening(mammogram); Cardiovascular disease(behavioral therapy); Cardiovascularscreenings; Cervical and vaginal cancerscreening; Colorectal cancer screenings(colonoscopy, fecal occult blood test,flexible sigmoidoscopy); Depressionscreening; Diabetes screenings; HIVscreening; Medical nutrition therapyservices; Obesity screening andcounseling; Prostate cancer screenings(PSA); Sexually transmitted infectionsscreening and counseling; Tobacco usecessation counseling (counseling forpeople with no sign of tobacco-relateddisease); Vaccines, including Flu shots,Hepatitis B shots, Pneumococcalshots; "Welcome to Medicare"preventive visit (one-time); AnnualWellness visit; Hepatitis B VirusScreening; Lung Cancer Screeningand Medicare Diabetes PreventionProgram (MDPP).

Out-of-Network Out-of-Network Not Covered Not Covered

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What you should knowWhat you should knowParticipating providers may diagnose and treat somemedical conditions via real-time interactive audio andvideo technologies.

Participating providers may diagnose and treat somemedical conditions via real-time interactive audio andvideo technologies.

In-Network$0 co-pay

In-Network$0 co-pay

Out-of-NetworkOut-of-NetworkNot Covered$0 co-pay

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What you should knowWhat you should knowOther preventive services are available.There are some covered services thathave a cost.

Other preventive services are available.There are some covered services thathave a cost.Stay healthy by getting your AnnualWellness Visit. During the visit, youcan work with your PCP to scheduleall preventive screenings and care.

Stay healthy by getting your AnnualWellness Visit. During the visit, youcan work with your PCP to scheduleall preventive screenings and care.

Any additional preventive servicesapproved by Medicare during thecontract year will be covered.

Any additional preventive servicesapproved by Medicare during thecontract year will be covered.



Emergency Care / Urgently NeededServices

$90 co-pay$90 co-payEmergency CareWhat you should knowWhat you should know

If you are admitted to the hospitalwithin 24 hours, you do not have topay your share of the cost foremergency care.

If you are admitted to the hospitalwithin 24 hours, you do not have topay your share of the cost foremergency care. $90 co-pay$90 co-payWorldwide Emergency CoverageWhat you should knowWorldwide Emergency andworldwide urgently needed servicesare subject to a $50,000 maximumplan coverage. There is no worldwidecoverage for care outside of theemergency room or emergencyhospital admission. The copay is notwaived if admitted to the hospital forWW Emergency Services.

What you should knowWorldwide Emergency and worldwideurgently needed services are subject toa $50,000 maximum plancoverage. There is no worldwidecoverage for care outside of theemergency room or emergencyhospital admission. The copay is notwaived if admitted to the hospital forWW Emergency Services.

$25 co-pay$25 co-payUrgently Needed ServicesWhat you should knowIf you are admitted to the hospitalwithin 24 hours, you do not have topay your share of the cost for urgentlyneeded services.

What you should knowIf you are admitted to the hospitalwithin 24 hours, you do not have topay your share of the cost for urgentlyneeded services.

$90 co-pay $90 co-payWorldwide Urgent Coverage

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What you should knowWhat you should knowOther preventive services are available. There are somecovered services that have a cost.Stay healthy by getting your Annual Wellness Visit.During the visit, you can work with your PCP to scheduleall preventive screenings and care.

Other preventive services are available. There are somecovered services that have a cost.Stay healthy by getting your Annual Wellness Visit.During the visit, you can work with your PCP to scheduleall preventive screenings and care.

Any additional preventive services approved by Medicareduring the contract year will be covered.

Any additional preventive services approved by Medicareduring the contract year will be covered.



$90 co-pay$90 co-payWhat you should knowWhat you should knowIf you are admitted to the hospital within 24 hours, youdo not have to pay your share of the cost for emergencycare.

If you are admitted to the hospital within 24 hours, youdo not have to pay your share of the cost for emergencycare.

$90 co-pay$90 co-payWhat you should knowWorldwide Emergency and worldwide urgently neededservices are subject to a $50,000 maximum plan coverage. There is no worldwide coverage for care outside of theemergency room or emergency hospital admission. Thecopay is not waived if admitted to the hospital for WWEmergency Services.

What you should knowWorldwide Emergency and worldwide urgently neededservices are subject to a $50,000 maximum plancoverage. There is no worldwide coverage for care outsideof the emergency room or emergency hospitaladmission. The copay is not waived if admitted to thehospital for WW Emergency Services.

$25 co-pay$30 co-payWhat you should knowWhat you should know

If you are admitted to the hospital within 24 hours, youdo not have to pay your share of the cost for urgentlyneeded services.

If you are admitted to the hospital within 24 hours, youdo not have to pay your share of the cost for urgentlyneeded services.

$90 co-pay $90 co-pay

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Emergency Care / Urgently NeededServices

What you should knowWhat you should knowWorldwide Emergency and worldwideurgently needed services are subject toa $50,000 maximum plancoverage. The copay is not waived ifadmitted to the hospital for WWUrgently Needed Services.

Worldwide Emergency andworldwide urgently needed servicesare subject to a $50,000 maximumplan coverage. The copay is notwaived if admitted to the hospital forWW Urgently Needed Services.



Diagnostic Services / Labs / Imaging


Lab ServicesPA

(Medicare approved lab work) $0 co-payOut-of-NetworkOut-of-Network

Not Covered Not CoveredIn-Network$100 co-pay /

In-Network$100 co-pay /

Diagnostic Radiology ServicesPA

(MRI/CT/PET scans in specialistoffice or free standing facility /outpatient setting)

$225 co-pay$250 co-pay


What you should knowYou pay $0 for mammograms andDEXA scans.

What you should knowYou pay $0 for mammograms andDEXA scans.

In-NetworkIn-NetworkDiagnostic Tests and ProceduresPA

$0 co-pay$0 co-pay(Basic / Advanced)$20 co-pay$20 co-payOut-of-NetworkNot Covered

Out-of-NetworkNot covered

In-NetworkIn-Network20% coinsurance

Therapeutic Radiology ServicesPA

(radiation treatment for cancer in aspecialist office or free standing facility/ outpatient setting)

20% coinsurance


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What you should knowWhat you should knowWorldwide Emergency and worldwide urgently neededservices are subject to a $50,000 maximum plancoverage. The copay is not waived if admitted to thehospital for WW Urgently Needed Services.

Worldwide Emergency and worldwide urgently neededservices are subject to a $50,000 maximum plancoverage. The copay is not waived if admitted to thehospital for WW Urgently Needed Services.



In-NetworkIn-Network$0 co-pay$0 co-payOut-of-NetworkOut-of-NetworkNot Covered35% coinsuranceIn-Network$100 co-pay /

In-Network$100 co-pay / $250 co-pay

$225 co-pay

Out-of-NetworkOut-of-NetworkNot Covered35% coinsuranceWhat you should knowWhat you should know

You pay $0 for mammograms and DEXA scans. You pay $0 for mammograms and DEXA scans.

In-NetworkIn-Network$0 co-pay$0 co-pay$20 co-pay$35 co-payOut-of-NetworkOut-of-NetworkNot Covered35%coinsuranceIn-NetworkIn-Network20% coinsurance20% coinsurance

Out-of-NetworkOut-of-NetworkNot Covered35% coinsurance

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Diagnostic Services / Labs / Imaging


Outpatient X-RayPA





Hearing Services


Hearing ExamPA,R

(Medicare Covered) $35 co-payOut-of-NetworkOut-of-Network

Not Covered Not CoveredIn-NetworkIn-Network

$0 co-payRoutine Hearing ExamPA,R

$0 co-pay1 exam every year 1 exam every year


In-Network$0 co-pay

In-Network$0 co-pay

Hearing Aid Fitting/EvaluationsPA,R

1 fitting(s)/evaluation(s) every year1 fitting(s)/evaluation(s) every yearOut-of-NetworkOut-of-Network



Annual Hearing Aid AllowancePA,R

$0 co-pay2 hearing aids per year 2 hearing aids per year$1,000 value $2,000 value


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In-NetworkIn-Network$0 co-pay$0 co-payOut-of-NetworkOut-of-NetworkNot Covered35% coinsurance



In-NetworkIn-Network$40 co-pay$35 co-payOut-of-NetworkOut-of-NetworkNot Covered$50 co-payIn-NetworkIn-Network$0 co-pay$0 co-pay1 exam every year 1 exam every year Out-of-NetworkOut-of-NetworkNot Covered40% coinsurance

1 exam every yearIn-Network$0 co-pay

In-Network$0 co-pay

1 fitting(s)/evaluation(s) every year1 fitting(s)/evaluation(s) every yearOut-of-NetworkOut-of-NetworkNot Covered40% coinsurance

1 fitting(s)/evaluation(s) every yearIn-NetworkIn-Network$0 co-pay$0 co-pay2 hearing aids per year2 hearing aids per year$1,500 value $2,000 valueOut-of-NetworkOut-of-NetworkNot Covered40% coinsurance

2 hearing aids per year$2,000 value

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Hearing Services

What you should knowMedicare covers diagnostic hearingand balance exams if your doctor orother health care provider orders thesetests to see if you need medicaltreatment.

What you should knowMedicare covers diagnostic hearingand balance exams if your doctor orother health care provider orders thesetests to see if you need medicaltreatment.



Dental Services

In-Network$0 co-pay for:


Preventive ServicesPA,R

Cleanings (1 every 6 months)Cleanings (1 every 6 months)Dental x-rays (1 every 12 to 36months)

Dental x-rays (1 every 12 to 36months)

Oral exams (1 every 6 months)Oral exams (1 every 6 months)Out-of-NetworkOut-of-Network



FluoridePA,R

$0 co-pay(1 every year) (1 every year)



Comprehensive ServicesPA,R

(Medicare-Covered) $35 co-payOut-of-NetworkOut-of-NetworkNot CoveredNot Covered

Comprehensive ServicesPA,R


Routine Services$0 co-payOut-of-NetworkOut-of-NetworkNot CoveredNot Covered1 every three years 1 every three years Restorative

20



What you should knowWhat you should knowMedicare covers diagnostic hearing and balance exams ifyour doctor or other health care provider orders these teststo see if you need medical treatment.

Medicare covers diagnostic hearing and balance exams ifyour doctor or other health care provider orders these teststo see if you need medical treatment.





Cleanings (1 every 6 months)Cleanings (1 every 6 months)Dental x-rays (1 every 12 to 36 months)Dental x-rays (1 every 12 to 36 months)Oral exams (1 every 6 months)Oral exams (1 every 6 months)

Out-of-NetworkOut-of-NetworkNot Covered50% coinsurance for

Cleanings (1 every 6 months)Dental x-rays 1 (Every 12 to 36 months)Oral exams (1 every 6 months)

In-NetworkIn-Network$0 co-pay$0 co-pay(1 every year)(1 every year)Out-of-NetworkOut-of-NetworkNot Covered50% coinsurance

(1 every year)In-NetworkIn-Network$40 co-pay$35 co-payOut-of-NetworkOut-of-NetworkNot Covered$50 co-pay

In-NetworkIn-Network$0 co-pay$0 co-payOut-of-NetworkOut-of-NetworkNot Covered50% coinsurance1 every three years 1 every three years

21



Dental Services

1 Endodontic procedure per tooth Not CoveredEndodontics1 Periodontic procedure every 6 to 36months

1 Periodontic procedure every 6 to 36months

Periodontics

1 Extraction per tooth 1 Extraction per tooth Extractions1 Non-Routine Services every 6 to 24months

1 Non-Routine Services every 6 to 24months

Non-Routine Services

1 Prosthodontic procedure every 12to 60 months1 Oral Maxillofacial procedure every60 months or per lifetimeOther services every 6 to 24 months

1 Prosthodontic procedure every 12 to60 months1 Oral Maxillofacial procedure every60 months or per lifetime

Prosthodontics, Other Oral/Maxillofacial Surgery

What you should knowWhat you should knowThis plan includes coverage ofpreventive and comprehensive servicesup to $500 including but not limitedto cleanings, x-ray(s), oral exams,fluoride treatments, fillings anddentures or a bridge.

This plan includes coverage ofpreventive and comprehensive servicesup to $1,000, including but notlimited to cleanings, x-ray(s), oralexams, fluoride treatments, fillings,dentures or a bridge or a crown and aroot canal.



Vision Services

In-NetworkIn-Network$0 co-pay (Medicare-covered diabetesretinopathy screening)

Eye ExamsPA,R

(Medicare Covered) $0 co-pay (Medicare-covered diabetesretinopathy screening)

$40 co-pay (all otherMedicare-covered eye exams)

$35 co-pay (all otherMedicare-covered eye exams)Out-of-NetworkOut-of-Network



Routine Eye Exams (Refraction)PA,R

$0 co-pay1 exam per year 1 exam per year


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1 Endodontic procedure per tooth 1 Endodontic procedure per tooth 1 Periodontic procedure every 6 to 36 months 1 Periodontic procedure every 6 to 36 months

1 Extraction per tooth 1 Extraction per tooth 1 Non-Routine Services every 6 to 24 months1 Non-Routine Services every 6 to 24 months

1 Prosthodontic procedure every 12 to 60 months1 Oral Maxillofacial procedure every 60 months or perlifetimeOther services every 6 to 24 months

1 Prosthodontic procedure every 12 to 60 months1 Oral Maxillofacial procedure every 60 months or perlifetimeOther services every 6 to 24 months

What you should knowWhat you should knowThis plan includes coverage of preventive andcomprehensive services up to $1,500, including but notlimited to cleanings, x-ray(s), oral exams, fluoridetreatments, fillings, dentures or a bridge or a crown and aroot canal.

This plan includes coverage of preventive andcomprehensive services up to $1,000, including but notlimited to cleanings, x-ray(s), oral exams, fluoridetreatments, fillings, dentures or a bridge or a crown and aroot canal.



In-NetworkIn-Network$0 co-pay (Medicare-covered diabetes retinopathyscreening)

$0 co-pay (Medicare-covered diabetes retinopathyscreening)

$40 co-pay (all other Medicare-covered eye exams)$35 co-pay (all other Medicare-covered eye exams)

Out-of-NetworkOut-of-NetworkNot Covered$0 co-pay (Medicare-covered diabetes retinopathy

screening) $50 co-pay (all other Medicare-covered eye exams)

In-NetworkIn-Network$0 co-pay$0 co-pay1 exam per year1 exam per yearOut-of-NetworkOut-of-NetworkNot Covered40% coinsurance

1 exam per year

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Vision Services


Glaucoma Screening$0 co-payOut-of-NetworkOut-of-Network

Not Covered Not CoveredIn-Network$0 co-pay

In-Network$0 co-pay

EyewearPA,R

(Medicare Covered)

Out-of-NetworkNot Covered



Contact Lenses, Eye Glasses, EyeGlass Lenses,Eye Glass FramesPA,R

$0 co-payUnlimited contactsUnlimited contactsUnlimited glasses (lenses and/orframes) per year

Unlimited glasses (lenses and/orframes) per year

Up to $300Up to $100Out-of-NetworkOut-of-Network




Mental Health Services

In-NetworkIn-Network$350 co-pay per day for days 1-5 anda$0 co-pay per day for days 6-90

Inpatient Mental Health ServicesPA

$485 co-pay per day for days 1-3 anda$0 co-pay per day for days 4-90Out-of-NetworkOut-of-Network

Not Covered Not CoveredWhat you should knowOur plan covers up to 190 days in alifetime for inpatient mental healthcare in a psychiatric hospital. Theinpatient hospital care limit does notapply to inpatient mental healthservices provided in a general hospital.

What you should knowOur plan covers up to 190 days in alifetime for inpatient mental healthcare in a psychiatric hospital. Theinpatient hospital care limit does notapply to inpatient mental healthservices provided in a general hospital.

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In-NetworkIn-Network$0 co-pay$0 co-payOut-of-NetworkOut-of-NetworkNot Covered$0 co-payIn-NetworkIn-Network$0 co-pay$0 co-payOut-of-NetworkNot Covered

Out-of-Network$50 co-pay

In-NetworkIn-Network$0 co-payUnlimited contacts

$0 co-payUnlimited contacts

Unlimited glasses (lenses and/or frames) per yearUnlimited glasses (lenses and/or frames) per yearUp to $300Up to $200


Unlimited contactsUnlimited glasses (lenses and/or frames) per yearUp to $200



In-NetworkIn-Network$475 co-pay per day for days 1-3 and a$0 co-pay per day for days 4-90

$350 co-pay per day for days 1-5 and a$0 co-pay per day for days 6-90

Out-of-NetworkOut-of-NetworkNot Covered35% of the total cost for days 1-90What you should knowWhat you should know

Our plan covers up to 190 days in a lifetime for inpatientmental health care in a psychiatric hospital. The inpatienthospital care limit does not apply to inpatient mentalhealth services provided in a general hospital.

Our plan covers up to 190 days in a lifetime for inpatientmental health care in a psychiatric hospital. The inpatienthospital care limit does not apply to inpatient mentalhealth services provided in a general hospital.

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Mental Health Services

Outpatient Mental Health ServicesPA


Per session for individual therapy$40 co-payOut-of-NetworkOut-of-Network


$40 co-payPer session for group therapy


Not Covered Not CoveredIn-Network$55 co-pay

In-Network$55 co-pay

Partial HospitalizationPA




Skilled Nursing Facility (SNF)

In-NetworkIn-Network$0 co-pay per day for days 1-20 and a$184.00 co-pay per day for days21-100

Skilled Nursing Facility (SNF)PA

$0 co-pay per day for days 1-20 anda$184.00 co-pay per day for days21-100Out-of-NetworkOut-of-Network


What you should knowOur plan covers up to 100 days perbenefit period in a SNF. A BenefitPeriod begins the first day you go intoa SNF and ends when you haven’treceived any SNF care for 60consecutive days. There is no limit tothe number of benefit periods youmay have.

What you should knowOur plan covers up to 100 days perbenefit period in a SNF. A BenefitPeriod begins the first day you go intoa SNF and ends when you haven’treceived any SNF care for 60consecutive days. There is no limit tothe number of benefit periods you mayhave.

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In-NetworkIn-Network$40 co-pay$40 co-payOut-of-NetworkOut-of-NetworkNot Covered35% coinsuranceIn-NetworkIn-Network$40 co-pay$40 co-payOut-of-NetworkOut-of-NetworkNot Covered35% coinsuranceIn-Network$55 co-pay





In-NetworkIn-Network$0 co-pay per day for days 1-20 and a$184.00 co-pay per day for days 21-100

$0 co-pay per day for days 1-20 and a$184.00 co-pay per day for days 21-100

Out-of-NetworkOut-of-NetworkNot Covered$0 co-pay per day for days 1-20 and a

$184.00 co-pay per day for days 21-100 What you should knowWhat you should know

Our plan covers up to 100 days per benefit period in aSNF. A Benefit Period begins the first day you go into aSNF and ends when you haven’t received any SNF carefor 60 consecutive days. There is no limit to the numberof benefit periods you may have.

Our plan covers up to 100 days per benefit period in aSNF. A Benefit Period begins the first day you go into aSNF and ends when you haven’t received any SNF carefor 60 consecutive days. There is no limit to the numberof benefit periods you may have.

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Therapy and Rehabilitation Services


Physical Therapy andSpeech-Language TherapyPA $40 co-pay

Out-of-NetworkOut-of-NetworkNot CoveredNot CoveredIn-NetworkIn-Network

$40 co-payOccupational TherapyPA



$40 co-payCardiac RehabilitationPA



$30 co-payPulmonary RehabilitationPA


Not Covered Not CoveredIn-NetworkIn-NetworkSupervised Exercise Therapy

(SET) for Symptomatic PeripheralArtery Disease (PAD)PA

$10 co-pay$30 co-pay




Ambulance and Transportation

(ground / air)(ground / air)$240 co-pay

AmbulancePA

$275 co-payIn-Network Not Covered

In-NetworkNot Covered

TransportationPA



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In-NetworkIn-Network$30 co-pay$40 co-payOut-of-NetworkOut-of-NetworkNot Covered35% coinsuranceIn-NetworkIn-Network$30 co-pay$40 co-payOut-of-NetworkOut-of-NetworkNot Covered35% coinsuranceIn-NetworkIn-Network$10 co-pay$45 co-payOut-of-NetworkOut-of-NetworkNot Covered35% coinsuranceIn-NetworkIn-Network$10 co-pay$30 co-payOut-of-NetworkOut-of-NetworkNot Covered35% coinsuranceIn-NetworkIn-Network$10 co-pay$30 co-pay




(ground / air)(ground / air)$300 co-pay$300 co-payIn-Network$0 co-pay for 24 one-way trips every year

In-Network$0 co-pay for 12 one-way trips every year


Out-of-Network75% coinsurance 12 one-way trips every year

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Ambulance and Transportation



Medicare Part B Drugs

In-Network20% coinsurance


Medicare Part B DrugsPA



What you should knowIncludes chemotherapy and other PartB drugs

What you should knowIncludes chemotherapy and otherPart B drugs



Prescription Drug Coverage

$0$0Part D Deductible

You pay these co-pays or coinsuranceamounts until your total yearly drugcost reaches $4,130. Total yearly drugcosts are the total drug costs paid byboth you and our Part D plan atnetwork retail pharmacies and mailorder pharmacies.

You pay these co-pays or coinsuranceamounts until your total yearly drugcost reaches $4,130. Total yearly drugcosts are the total drug costs paid byboth you and our Part D plan atnetwork retail pharmacies and mailorder pharmacies.

Initial Coverage Stage(after you pay your deductible ifapplicable)

Standard Retail, Mail and Preferred Mail Cost-Share (In-Network)

Tier 1: Preferred Generic Drugs$0.00$0.00Standard Retail and Mail - 30 day

supply$0.00$0.00Standard Retail and Mail - 90 day

supply$0.00$0.00Preferred Mail - 30 day supply$0.00$0.00Preferred Mail - 90 day supply

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What you should knowWhat you should knowThe first step to staying healthy is getting to your doctor.That’s why we cover these shared trips to plan approvedhealth care providers. We want to make sure you get thecare you need, when you need it. Call Customer Service72 hours in advance to reserve a ride for your appointment.

The first step to staying healthy is getting to your doctor.That’s why we cover these shared trips to plan approvedhealth care providers. We want to make sure you get thecare you need, when you need it. Call Customer Service72 hours in advance to reserve a ride for your appointment.






Out-of-Network35% coinsurance

What you should knowIncludes chemotherapy and other Part B drugs

What you should knowIncludes chemotherapy and other Part B drugs



$445$100Tiers 2 to 5Tiers 3 to 5After you pay your deductible, You pay these co-pays orcoinsurance amounts until your total yearly drug costreaches $4,130. Total yearly drug costs are the total drugcosts paid by both you and our Part D plan at networkretail pharmacies and mail order pharmacies.

After you pay your deductible, You pay these co-pays orcoinsurance amounts until your total yearly drug costreaches $4,130. Total yearly drug costs are the total drugcosts paid by both you and our Part D plan at networkretail pharmacies and mail order pharmacies.

$0.00$0.00

$0.00$0.00

$0.00$0.00$0.00$0.00

31




Tier 2: Generic Drugs$10.00$10.00Standard Retail and Mail - 30 day



Tier 3: Preferred Brand Drugs$47.00$47.00Standard Retail and Mail - 30 day



Tier 4: Non-Preferred Drugs43%48%Standard Retail and Mail - 30 day

supply43%48%Standard Retail and Mail - 90 day

supply43%48%Preferred Mail - 30 day supply43%48%Preferred Mail - 90 day supply

Tier 5: Specialty Tier Drugs33%33%Standard Retail and Mail - 30 day

supply33%33%Preferred Mail - 30 day supply

32



$20.00$8.00

$60.00$24.00

$20.00$8.00$0.00$0.00

$47.00$47.00

$141.00$141.00

$47.00$47.00$94.00$94.00

50%49%

50%49%

50%49%50%49%

25%31%

25%31%

33




Preferred Mail:90-day supply of Tier 1 and Tier 2prescription drugs for a $0 co-pay;90-day supply of Tier 3 and Tier 4prescription drugs for two 30-dayco-pays, if applicable. Available onlyfrom a preferred mail servicepharmacy and filled during the initialcoverage stage. See the Formulary andEvidence of Coverage (EOC) foravailability and co-pays.

Preferred Mail:90-day supply of Tier 1 and Tier 2prescription drugs for a $0 co-pay;90-day supply of Tier 3 and Tier 4prescription drugs for two 30-dayco-pays, if applicable. Available onlyfrom a preferred mail service pharmacyand filled during the initial coveragestage. See the Formulary and Evidenceof Coverage (EOC) for availability andco-pays.

What you should know

Standard Retail and Mail:You may get your drugs at networkretail pharmacies and mail orderpharmacies. If you reside in along-term care facility, you pay thesame as at a retail pharmacy. You mayget drugs from an out-of-networkpharmacy at the same cost as anin-network pharmacy. You will bereimbursed up to the plan’s cost of thedrug minus the co-pay or coinsurancefor drugs purchased out-of-networkuntil your total yearly drug costs reach$4,130. You will likely have to pay thepharmacy’s full charge for the drugsand submit documentation to receivereimbursement. Cost-sharing maychange depending on the pharmacyyou use and when you move from onephase of the Part D benefit toanother, your cost-sharing maychange as well. For more informationon the additional pharmacy specificcost-sharing and the phases of thebenefit, please call us or access ourEvidence of Coverage online.

Standard Retail and Mail:You may get your drugs at networkretail pharmacies and mail orderpharmacies. If you reside in along-term care facility, you pay thesame as at a retail pharmacy. You mayget drugs from an out-of-networkpharmacy at the same cost as anin-network pharmacy. You will bereimbursed up to the plan’s cost of thedrug minus the co-pay or coinsurancefor drugs purchased out-of-networkuntil your total yearly drug costs reach$4,130. You will likely have to pay thepharmacy’s full charge for the drugsand submit documentation to receivereimbursement. Cost-sharing maychange depending on the pharmacyyou use and when you move from onephase of the Part D benefit to another,your cost-sharing may change as well.For more information on theadditional pharmacy specificcost-sharing and the phases of thebenefit, please call us or access ourEvidence of Coverage online.

Excluded Drugs:Excluded Drugs:This plan includes enhanced drugcoverage of certain excludeddrugs. Generic only Sildenafil andVardenafil on Tier 1 have a quantitylimit of four pills every 30 days.

This plan includes enhanced drugcoverage of certain excluded drugs.Generic only Sildenafil and Vardenafilon Tier 1 have a quantity limit of fourpills every 30 days.

34



Preferred Mail:90-day supply of Tier 1 and Tier 2 prescription drugs fora $0 co-pay; 90-day supply of Tier 3 and Tier 4prescription drugs for two 30-day co-pays, if applicable.Available only from a preferred mail service pharmacy andfilled during the initial coverage stage. See the Formularyand Evidence of Coverage (EOC) for availability andco-pays.

Preferred Mail:90-day supply of Tier 1 and Tier 2 prescription drugs fora $0 co-pay; 90-day supply of Tier 3 and Tier 4prescription drugs for two 30-day co-pays, if applicable.Available only from a preferred mail service pharmacy andfilled during the initial coverage stage. See the Formularyand Evidence of Coverage (EOC) for availability andco-pays.

Standard Retail and Mail:You may get your drugs at network retail pharmacies andmail order pharmacies. If you reside in a long-term carefacility, you pay the same as at a retail pharmacy. You mayget drugs from an out-of-network pharmacy at the samecost as an in-network pharmacy. You will be reimbursedup to the plan’s cost of the drug minus the co-pay orcoinsurance for drugs purchased out-of-network until yourtotal yearly drug costs reach $4,130. You will likely haveto pay the pharmacy’s full charge for the drugs and submitdocumentation to receive reimbursement. Cost-sharingmay change depending on the pharmacy you use and whenyou move from one phase of the Part D benefit to another,your cost-sharing may change as well. For moreinformation on the additional pharmacy specificcost-sharing and the phases of the benefit, please call usor access our Evidence of Coverage online.

Standard Retail and Mail:You may get your drugs at network retail pharmacies andmail order pharmacies. If you reside in a long-term carefacility, you pay the same as at a retail pharmacy. You mayget drugs from an out-of-network pharmacy at the samecost as an in-network pharmacy. You will be reimbursedup to the plan’s cost of the drug minus the co-pay orcoinsurance for drugs purchased out-of-network until yourtotal yearly drug costs reach $4,130. You will likely haveto pay the pharmacy’s full charge for the drugs and submitdocumentation to receive reimbursement. Cost-sharingmay change depending on the pharmacy you use and whenyou move from one phase of the Part D benefit to another,your cost-sharing may change as well. For moreinformation on the additional pharmacy specificcost-sharing and the phases of the benefit, please call usor access our Evidence of Coverage online.

Excluded Drugs:This plan includes enhanced drug coverage of certainexcluded drugs. Generic only Sildenafil and Vardenafil onTier 1 have a quantity limit of four pills every 30 days.Because these drug are excluded from Part D coverageunder Medicare, they are not covered by Extra Help. Also,the amount you pay when you fill a prescription for thesedrugs does not count toward qualifying you for theCatastrophic Coverage Stage.Please see your Formulary and Evidence of Coverage fordetails regarding this drug coverage.

Excluded Drugs:This plan includes enhanced drug coverage of certainexcluded drugs. Generic only Sildenafil and Vardenafil onTier 1 have a quantity limit of four pills every 30 days.Because these drug are excluded from Part D coverageunder Medicare, they are not covered by Extra Help. Also,the amount you pay when you fill a prescription for thesedrugs does not count toward qualifying you for theCatastrophic Coverage Stage.Please see your Formulary and Evidence of Coverage fordetails regarding this drug coverage.

35




Because these drug are excluded fromPart D coverage under Medicare, theyare not covered by Extra Help. Also,the amount you pay when you fill aprescription for these drugs does notcount toward qualifying you for theCatastrophic Coverage Stage.

Because these drug are excluded fromPart D coverage under Medicare, theyare not covered by Extra Help. Also,the amount you pay when you fill aprescription for these drugs does notcount toward qualifying you for theCatastrophic Coverage Stage.

Please see your Formulary andEvidence of Coverage for detailsregarding this drug coverage.

Please see your Formulary andEvidence of Coverage for detailsregarding this drug coverage.Most Medicare drug plans have acoverage gap (also called the “donuthole”). This means that there’s atemporary change in what you willpay for your drugs. The coverage gapbegins after the total yearly drug cost(including what our plan has paid andwhat you have paid) reaches $4,130.

Most Medicare drug plans have acoverage gap (also called the “donuthole”). This means that there’s atemporary change in what you will payfor your drugs. The coverage gapbegins after the total yearly drug cost(including what our plan has paid andwhat you have paid) reaches $4,130.

Coverage Gap

After you enter the coverage gap, youpay 25% of the plan’s cost for coveredbrand name drugs and 25% of theplan’s cost for covered generic drugsuntil your out-of-pocket costs total$6,550 which is the end of thecoverage gap.

After you enter the coverage gap, youpay 25% of the plan’s cost for coveredbrand name drugs and 25% of theplan’s cost for covered generic drugsuntil your out-of-pocket costs total$6,550 which is the end of thecoverage gap.

You will pay $0.00 for 30-dayStandard Retail, $0.00 for 90-dayStandard Retail and $0.00 for 90-dayPreferred Mail for select drugs onTier 1. The standard gap cost-share of25% will apply for all other brandname drugs and 25% for genericdrugs. Please call us or access your planEvidence of Coverage and Formularyfor details of which drugs are coveredthrough the Coverage Gap Stage.

36



Most Medicare drug plans have a coverage gap (also calledthe “donut hole”). This means that there’s a temporarychange in what you will pay for your drugs. The coveragegap begins after the total yearly drug cost (including whatour plan has paid and what you have paid) reaches $4,130.

Most Medicare drug plans have a coverage gap (also calledthe “donut hole”). This means that there’s a temporarychange in what you will pay for your drugs. The coveragegap begins after the total yearly drug cost (including whatour plan has paid and what you have paid) reaches $4,130.

After you enter the coverage gap, you pay 25% of the plan’scost for covered brand name drugs and 25% of the plan’scost for covered generic drugs until your out-of-pocketcosts total $6,550 which is the end of the coverage gap.

After you enter the coverage gap, you pay 25% of the plan’scost for covered brand name drugs and 25% of the plan’scost for covered generic drugs until your out-of-pocketcosts total $6,550 which is the end of the coverage gap.

37




After your yearly out-of-pocket drugcosts (including drugs purchasedthrough your retail pharmacy andthrough mail order) reach $6,550, youpay the greater of:• 5% of the cost; or• $3.70 co-pay for generics (includingbrand drugs treated as generic) or• $9.20 co-pay for all other drugs.

After your yearly out-of-pocket drugcosts (including drugs purchasedthrough your retail pharmacy andthrough mail order) reach $6,550, youpay the greater of:• 5% of the cost; or• $3.70 co-pay for generics (includingbrand drugs treated as generic) or• $9.20 co-pay for all other drugs.

Catastrophic Coverage



Additional Covered Benefits

Chiropractic CarePA



(Medicare-Covered)





Routine Services



In-Network$0 co-pay

In-Network$0 co-pay

Home Health Agency CarePA



What you should knowCovered services include part-time orintermittent Skilled Nursing andhome health-aide services includingphysical therapy, occupationaltherapy, and speech therapy, medicaland social services, medical supplies.

What you should knowCovered services include part-time orintermittent Skilled Nursing and homehealth-aide services including physicaltherapy, occupational therapy, andspeech therapy, medical and socialservices, medical supplies.

Outpatient Substance AbusePA



Individual Therapy

38



After your yearly out-of-pocket drug costs (including drugspurchased through your retail pharmacy and through mailorder) reach $6,550, you pay the greater of:• 5% of the cost; or• $3.70 co-pay for generics (including brand drugs treatedas generic) or• $9.20 co-pay for all other drugs.

After your yearly out-of-pocket drug costs (including drugspurchased through your retail pharmacy and through mailorder) reach $6,550, you pay the greater of:• 5% of the cost; or• $3.70 co-pay for generics (including brand drugs treatedas generic) or• $9.20 co-pay for all other drugs.









12 visits every year Out-of-NetworkNot Covered


In-Network$0 co-pay

In-Network$0 co-pay



What you should knowCovered services include part-time or intermittent SkilledNursing and home health-aide services including physicaltherapy, occupational therapy, and speech therapy, medicaland social services, medical supplies.

What you should knowCovered services include part-time or intermittent SkilledNursing and home health-aide services including physicaltherapy, occupational therapy, and speech therapy, medicaland social services, medical supplies.



39








Group Therapy





Opioid Treatment ServicesPA



What you should knowOpioid treatment services includeFDA-approved opioid agonist andantagonist treatment medications,substance counseling and individualand/or group therapy.

What you should knowOpioid treatment services includeFDA-approved opioid agonist andantagonist treatment medications,substance counseling and individualand/or group therapy.



Renal Dialysis



The maximum total annual benefit is$460.

The maximum total annual benefit is$460.

Over-The-Counter (OTC) HealthItems

What you should knowMembers may purchase eligible itemsfrom participating locations orthrough the plan's catalog for deliveryto their home.

What you should knowMembers may purchase eligible itemsfrom participating locations or throughthe plan's catalog for delivery to theirhome.

Not CoveredNot CoveredIn-Home Support ServicesPA

Meals$0 co-pay for each post-acute meal$0 co-pay for each post-acute mealPost-Acute MealsPA

40













What you should knowOpioid treatment services include FDA-approved opioidagonist and antagonist treatment medications, substancecounseling and individual and/or group therapy.

What you should knowOpioid treatment services include FDA-approved opioidagonist and antagonist treatment medications, substancecounseling and individual and/or group therapy.





The maximum total annual benefit is $800.The maximum total annual benefit is $240.

What you should knowMembers may purchase eligible items from participatinglocations or through the plan's catalog for delivery to theirhome.

What you should knowMembers may purchase eligible items from participatinglocations or through the plan's catalog for delivery to theirhome.

$0 co-payNot CoveredUp to 6 visits every year.What you should knowYou can receive Chore Services if you meet certain clinicalcriteria. Services must be recommended or requested by alicensed plan clinician or a licensed plan provider. Servicesare provided in two hour increments.

$0 co-pay for each post-acute meal$0 co-pay for each post-acute meal

41




What you should knowYou pay nothing for post-acute mealsimmediately following an Inpatienthospital stay to aid in recovery with amaximum of 3 meals per day for upto 14 days.

What you should knowYou pay nothing for post-acute mealsimmediately following an Inpatienthospital stay to aid in recovery with amaximum of 3 meals per day for up to14 days.

$0 co-pay for each chronic meal$0 co-pay for each chronic mealChronic MealsPA

What you should knowYou pay nothing for home deliveredmeals as part of a supervised programdesigned to transition members withchronic conditions to lifestylemodification. Members receive 3meals per day for up to 28 days permonth, for a maximum of 84 meals.The benefit can be received for up to3 months.

What you should knowYou pay nothing for home deliveredmeals as part of a supervised programdesigned to transition members withchronic conditions to lifestylemodification. Members receive 3meals per day for up to 28 days permonth, for a maximum of 84 meals.The benefit can be received for up to3 months



Medical Equipment / Supplies /Services



Durable Medical Equipment(DME)PA(e.g., wheelchairs, oxygen)





ProstheticsPA(e.g., braces, artificiallimbs)



In-Network$0 co-pay

In-Network$0 co-pay

Diabetic Monitoring SuppliesPA



What you should knowCovered diabetes supplies include:blood glucose monitor, blood glucosetest strips, lancet devices and lancets,and glucose-control solutions.

What you should knowCovered diabetes supplies include:blood glucose monitor, blood glucosetest strips, lancet devices and lancets,and glucose-control solutions.

42



What you should knowYou pay nothing for post-acute meals immediatelyfollowing an Inpatient hospital stay to aid in recovery witha maximum of 3 meals per day for up to 14 days.

What you should knowYou pay nothing for post-acute meals immediatelyfollowing an Inpatient hospital stay to aid in recovery witha maximum of 3 meals per day for up to 14 days.

$0 co-pay for each chronic meal$0 co-pay for each chronic meal

What you should knowYou pay nothing for home delivered meals as part of asupervised program designed to transition members withchronic conditions to lifestyle modification. Membersreceive 3 meals per day for up to 28 days per month, fora maximum of 84 meals. The benefit can be received forup to 3 months.

What you should knowYou pay nothing for home delivered meals as part of asupervised program designed to transition members withchronic conditions to lifestyle modification. Membersreceive 3 meals per day for up to 28 days per month, fora maximum of 84 meals. The benefit can be received forup to 3 months.











In-Network$0 co-pay

In-Network$0 co-pay



What you should knowCovered diabetes supplies include: blood glucose monitor,blood glucose test strips, lancet devices and lancets, andglucose-control solutions.

What you should knowCovered diabetes supplies include: blood glucose monitor,blood glucose test strips, lancet devices and lancets, andglucose-control solutions.

43



Medical Equipment / Supplies /Services



Medical SuppliesPA





Diabetic Therapeutic Shoes andInsertsPA



In-Network$0 co-pay

In-Network$0 co-pay

Diabetic Self-Management Training





Foot Care


Podiatry ServicesPA

(Medicare Covered) $35 co-payOut-of-NetworkOut-of-Network




Wellness Programs

$0 co-pay$0 co-payFitnessWhat you should knowThis benefit covers an annualmembership at a participating healthclub or fitness center. For memberswho do not live near a participatingfitness center and/or prefer to exerciseat home, members can choose fromavailable exercise programs to beshipped to them at no cost.

What you should knowThis benefit covers an annualmembership at a participating healthclub or fitness center. For memberswho do not live near a participatingfitness center and/or prefer to exerciseat home, members can choose fromavailable exercise programs to beshipped to them at no cost.

A Fitbit fitness tracker is included inthe home kit.

A Fitbit fitness tracker is included inthe home kit.

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In-Network$0 co-pay

In-Network$0 co-pay





In-NetworkIn-Network$40 co-pay$35 co-payOut-of-NetworkOut-of-NetworkNot Covered$50 co-pay



$0 co-pay$0 co-payWhat you should knowThis benefit covers an annual membership at aparticipating health club or fitness center. For memberswho do not live near a participating fitness center and/orprefer to exercise at home, members can choose fromavailable exercise programs to be shipped to them at nocost.

What you should knowThis benefit covers an annual membership at aparticipating health club or fitness center. For memberswho do not live near a participating fitness center and/orprefer to exercise at home, members can choose fromavailable exercise programs to be shipped to them at nocost.

A Fitbit fitness tracker is included in the home kit.A Fitbit fitness tracker is included in the home kit.

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Wellness Programs

$0 co-pay$0 co-payPersonal Emergency ResponseSystem (PERS)PA

In-Network$0 co-pay

In-Network$0 co-pay

Additional Routine Annual Physical



What you should knowWellness programs are a great way tomaintain your health. Whether it’s anextra checkup during the year or youjust have a simple health question, weare here as your partner in health.

What you should knowWellness programs are a great way tomaintain your health. Whether it’s anextra checkup during the year or youjust have a simple health question, weare here as your partner in health.

$0 co-pay$0 co-pay24-Hour Nurse Advice Line



Additional Supplemental Benefits

$750 yearly benefitNot CoveredFlex CardWhat you should knowThe Flex Card benefit is a debit cardthat may be used to reduce out ofpocket costs at a dental, vision orhearing providers that accepts the cardcarrier.

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$0 co-pay$0 co-pay

In-Network$0 co-pay

In-Network$0 co-pay



What you should knowWellness programs are a great way to maintain your health.Whether it’s an extra checkup during the year or you justhave a simple health question, we are here as your partnerin health.

What you should knowWellness programs are a great way to maintain your health.Whether it’s an extra checkup during the year or you justhave a simple health question, we are here as your partnerin health.

$0 co-pay$0 co-pay



$750 yearly benefit$300 yearly benefitWhat you should knowWhat you should know

The Flex Card benefit is a debit card that may be used toreduce out of pocket costs at a dental, vision or hearingproviders that accepts the card carrier.

The Flex Card benefit is a debit card that may be used toreduce out of pocket costs at a dental, vision or hearingproviders that accepts the card carrier.

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WellCare Health Plans, Inc., is an HMO, PPO, PFFS plan with a Medicare contract. Enrollment in the plans dependon contract renewal. The formulary, pharmacy network and/or provider network may change at any time. You will receivenotice when necessary. Our plans use a formulary.You have the choice to sign up for automated mail service delivery. You can get prescription drugs shipped to your homethrough our network mail service delivery program. You should expect to receive your prescription drugs within 10–14calendar days from the time that the mail service pharmacy receives the order. If you do not receive your prescriptiondrugs within this time, please contact us at 1-866-808-7471 (TTY/TDD 711), 24 hours a day, seven days a week, or visitmailrx.wellcare.com.Out-of-network/non-contracted providers are under no obligation to treat WellCare members, except in emergencysituations. Please call our customer service number or see your Evidence of Coverage for more information, including thecost-sharing that applies to out-of-network services. Please contact your plan for details.

ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available toyou. Call 1-877-374-4056 (TTY/TDD: 711).

ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al1-877-374-4056 (TTY/TDD: 711).

注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-877-374-4056 (TTY/TDD: 711) 。

CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-877-374-4056(TTY/TDD: 711).

주의:한국어를사용하시는경우,언어지원서비스를무료로이용하실수있습니다. 1-877-374-4056 (TTY/TDD:711)번으로전화해주십시오.

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nangwalang bayad. Tumawag sa 1-877-374-4056 (TTY/TDD: 711).

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Pre-Enrollment ChecklistBefore making an enrollment decision, it is important that you fully understand our benefits and rules.If you have any questions, you can call and speak to a customer service representative at 1-866-527-0056(TTY/TDD 711).

Understanding the Benefits

Review the full list of benefits found in the Evidence of Coverage (EOC), especially for those servicesfor which you routinely see a doctor. Visit www.wellcare.com/medicare or call 1-866-527-0056to view a copy of the EOC.

Review the provider directory (or ask your doctor) to make sure the doctors you see now are in thenetwork. If they are not listed, it means you will likely have to select a new doctor.

Review the pharmacy directory to make sure the pharmacy you use for any prescription medicinesis in the network. If the pharmacy is not listed, you will likely have to select a new pharmacy foryour prescriptions.

Understanding Important Rules

In addition to your monthly plan premium, you must continue to pay your Medicare Part B premium.This premium is normally taken out of your Social Security check each month.

Benefits, premiums and/or co-payments/coinsurance may change on January 1, 2022.

Except in emergency or urgent situations, we do not cover services by out-of-network providers(doctors who are not listed in the provider directory).

Our plan allows you to see providers outside of our network (non-contracted providers). However,while we will pay for covered services provided by a non-contracted provider, the provider mustagree to treat you. Except in an emergency or urgent situations, non-contracted providers may denycare. In addition, you will pay a higher co-pay for services received by non-contracted providers.

Contact Us

For more information, please call us at the phone number below or visit us atwww.wellcare.com/medicare.

Not yet a member? Please call us toll-free at 1-866-527-0056 (TTY/TDD 711). Your callmay be answered by a licensed agent.Already a member? Please call us toll-free at 1-833-444-9088 (TTY/TDD 711).

Hours of OperationBetween October 1 and March 31, representatives are available Monday–Sunday, 8 a.m. to 8p.m.Between April 1 and September 30, representatives are available Monday–Friday, 8 a.m. to 8p.m.

Formularies and DirectoriesYou can see our plan's Provider/Pharmacy Directory and our complete plan formulary (list of Part Dprescription drugs) at our website: www.wellcare.com/medicare. Or, call us and we'll send you acopy. We're with our members every step of the way.

2021 summary of benefits

Documents