Wellcare Giveback Open (PPO)

Summary of Benefits

This document provides some of the features of this plan. For a complete list of benefits, see your Evidence of Coverage.

• English
  Last Updated
  October 01, 2023

Dental Benefit Details

This document provides additional details about the dental benefits, including a list of services and benefit limits.

• English
  Last Updated
  October 01, 2023

Star Ratings

Star Ratings judge how well Medicare health and drug plans perform in different categories. They are distributed by Medicare. Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.

• English
  Last Updated
  October 31, 2023

Electronic Funds Transfer Request Form

Use this form to authorize us to withdraw your monthly premiums from your bank.

• English
• Spanish

Prescription Drug Claim Form

Complete this form to request reimbursement/refund for covered prescription drugs that you paid full price for.

• English
• Spanish

Member Disenrollment Form

Each member requesting to be disenrolled must complete their own form.

• English
• Spanish

Primary Care Provider (PCP) Change Request Form

Please complete this form with your provider if you want to change your PCP. Your provider will then send this form to your health plan, letting them know about the change.

• English

Preventive Health Screenings by Age

Wellcare Preventive Health Screenings Flyer: Vaccinations, disease screenings and cancer screenings, by age and frequency to administer.

• English