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Conditions and Limitations

There are conditions that apply to enrolling (and being enrolled) in our Medicare Advantage plans. Please make sure to read this section carefully to learn more about your Medicare Advantage coverage and the rules that apply.

  • ‘Ohana Health Plan, a plan offered by WellCare Health Insurance of Arizona, Inc.
  • Centene, Inc. is 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.
  • To be eligible, you must be entitled to Medicare Part A and enrolled in Medicare Part Band live in the plan's service area, with limited exceptions.
  • Network pharmacies include retail, mail service, specialty, long-term care, home infusion and Indian Health Service/Tribal/Urban Indian Health Program (I/T/U) pharmacies. To obtain names and addresses of Wellcare's network pharmacies, use the pharmacy search tool or contact us.
  • You must use network pharmacies to access your prescription drug benefit, except under non-routine circumstances (e.g., emergencies) when you cannot reasonably use network pharmacies. Quantity limits and restrictions may apply.
  • Non-Point-of-Service Plans: You must use plan providers except in emergency or urgent care situations, for out-of-area renal dialysis, or if you are enrolled in a PPO plan. If you obtain routine care from out-of-network providers, neither Medicare nor Wellcare will be responsible for the costs, except in the case you are enrolled in a PPO plan.
  • Point-of-Service Plans: With the exception of emergencies, urgent care and out-of-area renal dialysis, it may cost more to get care from out-of-network providers.
  • You can only be in one Medicare Advantage plan at a time. If you are currently in a Medicare Advantage or Prescription Drug plan, your enrollment in Wellcare will end that enrollment. Enrollment in this plan is generally for the entire year. Once you enroll, you may leave this plan or make changes only at certain times of the year when an enrollment period is available (Example: you may make changes Oct. 15-Dec. 7 of every year), or under certain special circumstances.
  • If you qualify for additional assistance with your Medicare Prescription Drug plan costs, the amount of your premium and cost at the pharmacy will be less. Once you have enrolled in Wellcare, Medicare will tell us how much assistance you are receiving, and we will send you information on the amounts you will pay.
  • If you decide to switch to premium withhold or move from premium withhold to direct bill, it could take up to three months to take effect and you will remain responsible for payment of those premiums during that time.
  • By law, Wellcare can choose not to renew our contract with CMS. CMS may also refuse to renew the contract, resulting in a termination or non-renewal. This may result in termination of your enrollment in the plan. Additionally, Wellcare may reduce its service area and no longer offer services in the area where you reside.
  • Medicare beneficiaries may also enroll in a plan through the CMS Medicare Online Enrollment Center located at http://www.medicare.gov.
  • Out-of-network/non-contracted providers are under no obligation to treat Wellcare members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.
  • For Louisiana D-SNP plans:
    • 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 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.
  • For WellCare Liberty (HMO-D-SNP) in New Jersey:

    • WellCare Liberty (HMO D-SNP) is a Fully Integrated Dual Eligible Special Needs Plan with a Medicare contract and a contract with the New Jersey Medicaid program. Enrollment in WellCare Liberty depends on contract renewal.

    • Your Part B premium is covered by Medicaid.

    • This plan is available to those who have both Medicare and full Medicaid benefits.

  • Value-Added Items and Services (VAIS) are not plan benefits and are not covered by the plan. Plan enrollees are responsible for all costs.

  • Wellcare’s pharmacy network includes limited lower-cost, preferred pharmacies in rural areas of MO. 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) or consult the online pharmacy directory at www.wellcare.com/medicare.

This information is not a complete description of benefits. Contact the plan for more information. Limitations, co-payments and restrictions may apply. Benefits, premiums and/or copayments/coinsurance may change on January 1 of each year.

For a complete list of drugs covered by our plan, please call Customer Service.

Our plans use a formulary.

The formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary.

Some plans are available to those who have medical assistance from both the state and Medicare. Premiums, co-pays, coinsurance and deductibles may vary based on the level of Extra Help you receive. Please contact the plan for further details.

For full information on Wellcare Medicare Advantage plan benefits, please contact us.

This information is available free in other languages. Please contact Customer Service for more information.


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Y0070_WCM_64252E Last Updated On: 10/1/2020