WellCare

Wellcare is the Medicare brand for Centene Corporation, an HMO, PPO, PFFS, PDP plan with a Medicare contract and is an approved Part D Sponsor. Our D-SNP plans have a contract with the state Medicaid program. Enrollment in our plans depends on contract renewal.

'Ohana Health Plan, a plan offered by WellCare Health Insurance of Arizona, Inc. .

Our plans use a formulary.

WellCare’s pharmacy network includes limited lower-cost, preferred pharmacies in rural areas of MO and NE. The lower costs advertised in our plan materials for these pharmacies may not be available at the pharmacy you use. For up-to-date information about our network pharmacies, including whether there are any lower-cost preferred pharmacies in your area, please call 1-833-444-9088 (TTY 711) for Wellcare No Premium (HMO) and Wellcare Giveback (HMO) in MO or consult the online pharmacy directory at www.wellcare.com/medicare, and 1-833-542-0693 (TTY 711) for Wellcare No Premium (HMO), Wellcare Giveback (HMO), and Wellcare No Premium Open (PPO) in NE or consult the online pharmacy directory at www.wellcare.com/NE.

For Allwell Arizona D-SNP plans: Contract services are funded in part under contract with the State of Arizona.

For Allwell New Mexico D-SNP plans: Such services are funded in part with the state of New Mexico.

For Louisiana D-SNP members: As a WellCare HMO D-SNP member, you have coverage from both Medicare and Medicaid. You receive your Medicare health care and prescription drug coverage through WellCare and are also eligible to receive additional health care services and coverage through Louisiana Medicaid. Learn more about providers who participate in Louisiana Medicaid by visiting https://www.myplan.healthy.la.gov/myaccount/choose/find-provider. For detailed information about Louisiana Medicaid benefits, please visit the Medicaid website at https://ldh.la.gov/medicaid and select the 'Learn about Medicaid Services' link.

For Louisiana D-SNP prospective enrollees: For detailed information about Louisiana Medicaid benefits, please visit the Medicaid website at https://ldh.la.gov/medicaid.

For Tennessee D-SNP plans: Notice: TennCare is not responsible for payment for these benefits, except for appropriate cost sharing amounts. TennCare is not responsible for guaranteeing the availability or quality of these benefits.

†Other <Pharmacies/Physicians/Providers> are available in our network.

If we determine that you owe a late enrollment penalty (or if you currently have a late enrollment penalty), we need to know how you would prefer to pay it. You can pay by mail, credit card, pay by phone, or Electronic Funds Transfer (EFT) each month. You can also choose to pay your premium by automatic deduction from your Social Security or Railroad Retirement Board (RRB) benefit check each month, if eligible.

If you are assessed a Part D-Income Related Monthly Adjustment Amount (Part D-IRMAA), you will be notified by the Social Security Administration. You will be responsible for paying this extra amount in addition to your plan premium. You will either have the amount withheld from your Social Security benefit check or be billed directly by Medicare or the RRB. DO NOT pay <Wellcare> the Part D-IRMAA.

You can pay your monthly plan premium (including any late enrollment penalty that you currently have or may owe) by mail, credit card, pay by phone, or through Electronic Funds Transfer (EFT) each month. You can also choose to pay your premium by automatic deduction from your Social Security or Railroad Retirement Board (RRB) benefit check each month, if eligible. If you are assessed a Part D-Income Related Monthly Adjustment Amount (Part D-IRMAA), you will be notified by the Social Security Administration. You will be responsible for paying this extra amount in addition to your plan premium. You will either have the amount withheld from your Social Security benefit check or be billed directly by Medicare or RRB. DO NOT pay <Wellcare> the Part D-IRMAA. People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If eligible, Medicare could pay for 75% or more of your drug costs, including monthly prescription drug premiums, annual deductibles and coinsurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and do not even know it. For more information about this Extra Help, contact your local Social Security office, or call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. You can also apply for Extra Help online at www.socialsecurity.gov/prescriptionhelp. If you qualify for Extra Help with your Medicare prescription drug coverage costs, Medicare will pay all or part of your plan premium. Even if you have Extra Help now, you may need to reapply for it later. If Medicare pays only a portion of this premium, we will bill you for the amount that Medicare doesn’t cover. If you don’t select a payment option, you will get a coupon book to pay your monthly premiums.

If you currently have health coverage from an employer or union, joining a Wellcare plan could affect your employer or union health benefits. You could lose your employer or union health coverage if you join Wellcare. Read the communications your employer or union sends you. If you have questions, visit their website, or contact the office listed in their communications. If there isn't any information on whom to contact, your benefits administrator or the office that answers questions about your coverage can help.

‘Ohana Health Plan, a plan offered by WellCare Health Insurance of Arizona, Inc. Wellcare is the Medicare brand for Centene Corporation, an HMO, PPO, PFFS, PDP plan with a Medicare contract and is an approved Part D Sponsor. Our D-SNP plans have a contract with the state Medicaid program. Enrollment in our plans depends on contract renewal.

I must keep both Hospital (Part A) and Medical (Part B) to stay in Wellcare.

By joining this Medicare Advantage Plan, I acknowledge that Wellcare will share my information with Medicare, who may use it to track my enrollment, to make payments, and for other purposes allowed by Federal law that authorize the collection of this information (see Privacy Act Statement below). Your response to this form is voluntary. However, failure to respond may affect enrollment in the plan. The information on this enrollment form is correct to the best of my knowledge. I understand that if I intentionally provide false information on this form, I will be disenrolled from the plan. I understand that people with Medicare are generally not covered under Medicare while out of the country, except for limited coverage near the U.S. border.

I understand that when my Wellcare coverage begins, I must get all of my medical and prescription drug benefits from Wellcare. Benefits and services provided by Wellcare and contained in my Wellcare "Evidence of Coverage" document (also known as a member contract or subscriber agreement) will be covered. Neither Medicare nor Wellcare will pay for benefits or services that are not covered.

I understand that my signature (or the signature of the person legally authorized to act on my behalf) on this application means that I have read and understand the contents of this application. If signed by an authorized representative (as described above), this signature certifies that: 1) This person is authorized under State law to complete this enrollment, and 2) Documentation of this authority is available upon request by Medicare.

Please contact your plan for details.

ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call <1-877-374-4056> (TTY: 711). ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al <1-877-374-4056+D3> (TTY: 711). 注愠：如果您使用繠體中文，您堯以兠費砲得語言栴助朠務。請致電<1-877-374-4056> (TTY：711）。