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Common Healthcare Terms
Common Medicare Questions
Preferred Provider Organization (PPO) Questions
How to Search my Provider Network and Pharmacies
Specialist & Referral Questions
Questions about Member Materials or Documents
Transition & Continuation of Care Questions
Wellcare+ App Questions Pharmacy Questions
Over the Counter (OTC) Catalog Questions

Still have questions? Visit our liên hệ với chúng tôi page, select your state and give us a call at the number provided. We are happy to help!

Common Healthcare Terms

What is an Authorized Representative?
Someone you allow to act for you, such as a friend or family member.

What is Coinsurance?
A percentage of the total cost of the service. These payments may be paid at the doctor's office or after billing.

What is a Co-pay?
A fixed amount that's your portion to pay for a covered healthcare service, usually paid at the time you get the service.

What is Cost-sharing?
Cost-sharing is what you pay when you get medications or healthcare services.

What is a Deductible?
The amount you owe for covered healthcare services before your health insurance plan begins to pay. For example, if your deductible is $200 your plan won't pay anything until you've paid $200 for covered services.

What is Durable medical equipment (DME)?
Special equipment your doctor may order for you for medical reasons. It can be things like walkers or wheelchairs.

What is an Evidence of Coverage (EOC)?
A document you receive as a new member that gives you details about what the plan covers, how much you pay and more.

What is an Explanation of Benefits (EOB)?
A statement explaining any treatments or services that you recently received. The EOB usually includes the date(s) of service, provider(s), fees, amounts you may be responsible for and any adjustments.

What is a Formulary?
The list of brand name and generic prescription drugs that a health plan covers for its members.

What is a Network Pharmacy?
A drug store that works with the plan to provide services to members at lower rates.

What is an Over-the-Counter (OTC)?
Medications, vitamins and other healthcare items that are available without a prescription.

What is a Point-of-Service (POS) plan?
A health plan option that lets you use doctors and hospitals outside the plan for an additional cost.

What is a Power of Attorney?
A legal form that allows someone else to act for you. You can create a power of attorney for times when you may be unable to make your own health care decisions.

What is a Premium?
A premium is the amount you pay for your health plan, in order to receive all of your benefits.

What is a Primary Care Provider (PCP)?
A doctor or other healthcare provider who gives, coordinates or helps you access the range of healthcare services you need.

What is a Prior Authorization?
An OK from the plan before a member gets a healthcare service. Your Medicare drug plan may require prior authorization for certain drugs.

What is a Registered Nurse (RN)?
Registered Nurses have completed specialized education and training, plus meet licensing requirements for the state that they practice in.

What is a Specialist?
A doctor trained in a specific area of medicine. Your primary doctor might refer you to a specialist.

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Common Medicare Questions

What is a Medicare Advantage HMO plan?
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. That 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.

What is a Medicare Advantage HMO POS plan?
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.

What is a network?
A network is a group of 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.

Where can I get information about basic Medicare terms?
We want you to make an informed decision about your Medicare health plan. That's why we created a glossary located in your state's Medicare Basics page.

Should I still keep my red, white and blue Medicare card?
Yes. However, as long as you are a member of our plan you must use your Wellcare Member ID Medicare card to get covered medical services (with the exception of clinical research studies and hospice services). Keep Wellcare Member ID Medicare card in a safe place in case you need it later. If your Wellcare ID card is damaged, lost or stolen, liên hệ với chúng tôi right away and we will send you a new card.

If I do not like my Wellcare plan, can I go back to original Medicare?
Of course. You do not 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.

I'm signed up to get my medications via mail service. How do I order refills?
There are three ways to refill:

  1. Online. Ordering refills at CVS Caremark.com is convenient, fast and easy! Register online to receive refill reminders and other important updates. Have your Wellcare ID card handy to register.
  2. By Phone. Call the toll-free Customer Care number on your prescription label for fully automated refill service. Have your benefit ID number (BIN) ready. This number can be found on your Wellcare ID card.
  3. By Mail. You will receive an order form with every mail service order. Simply fill in the ovals for the refills you want to order. If you need a refill for a prescription not listed on the form, write the prescription number in the space provided. Send the form to CVS Caremark along with your payment.

Allow up to 10 days from the day you submit your order for delivery of your medicine. Regular delivery is at no cost to you. Overnight or second-day delivery is available for an additional charge.

How do I get permission to receive services?
You can get service authorizations from you primary care provider (PCP) or from specialists you're referred to.

Will I have the same coverage as I do with original Medicare?
Our plans are required to cover all services and procedures that are covered by original Medicare. However, our plans also offer extra benefits not covered by original Medicare, which may include routine dental, routine hearing, routine vision and prescription drug coverage. Please note that, as a member of our plan, your use/participation in a limited number of services, such as clinical research studies and hospice services, will be paid for directly by Medicare. Becoming a member of our plan does not make you ineligible to receive these services.

Can I receive emergency care?
You have the right to emergency care, when needed, anywhere in the United States and without pre-approval from us.

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

What do I need to do to get care?
Our plans work just like a 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.

What happens if my doctor is not familiar with Wellcare Medicare Advantage Plans?
If your doctor or health care provider would like more information about Wellcare, ask him or her to contact us. Our Customer Service representatives are ready to answer questions.

Can Wellcare ever drop my coverage?
Once you are 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. 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 other options for Medicare coverage in your area.

What if I need to talk to a nurse?
One of the perks of being a Wellcare member is our 24-hour Nurse Advice Line at 1-800-581-9952. (TTY 711 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. You can also find the number on the back of your Member ID card.

Do I still have to pay my Medicare Part B premium?
When you join a Wellcare plan, you must continue to pay your Medicare Part B premium unless it's paid for you 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 help by reducing your 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.

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Preferred Provider Organization (PPO) Questions

I have a PPO plan. What is the benefit of seeing an in network provider?
Our plans are designed to save you money by offering lower copays and coinsurances when you seek care within our network of providers. An in network PCP will be able to work more directly with your plan to coordinate your care.

Network providers will also save you time by billing our plan for your services. You pay your copays, coinsurance, or deductibles, if applicable, for covered services when you arrive for a visit.

Network PCPs and specialists will work with our plan directly to determine if services are covered, or if they need authorization before you have the service. You can go in for treatment knowing your care is covered.

I have a PPO plan. Can I go to a doctor, specialist or hospital that is not in the plan's network list?
Yes, a Preferred Provider Organization (PPO) allows members the flexibility to go to doctors, specialists or hospitals that are not in the plan's network list, however they will usually pay a higher cost share. However, out of network providers must be eligible to participate in Medicare and providers that are not in network with your plan are under no obligation to treat our members, except in emergencies.

I have a PPO plan. What do I need to know before seeing an out of network provider?

If your provider charges higher for a service than what Medicare allows, you will be responsible for paying that extra amount in addition to the applicable cost-share amounts.

Out-of-network providers are under no obligation to see our members. When you schedule your appointment, make sure they know the insurance you have and are willing to see you.

Some providers have opted out of the Medicare Program. If you receive services from these providers you may be responsible for the full cost of the service or visit, with the exception of emergency care.

Your out-of-network provider may choose not to bill our plan for you and may ask you to pay for services up front. If this happens, you can fill out a claim form and submit it to us with a copy of the bill and any documentation you have about payments you have made. Information on how to file a claim can be found in the Evidence of Coverage online.

Out-of-network providers are not required to get authorization from the plan for your services ahead of time. If you have a service or a visit with an out-of-network provider that is reviewed by the plan after the fact and that service does not meet medical-necessity guidelines, you may be responsible for the full cost of the service. You can ask for a pre-visit coverage decision to confirm the services you are getting are covered and are medically necessary.

Are ALL services covered by a PPO plan?
PPOs plans provide reimbursement for medically necessary services, regardless if the benefits/services are provided in or out of network. Medical necessity must be established whether the member chooses an in network or out of network provider.

I have a PPO plan. Am I required to be assigned to a PCP?
You are not required to choose a PCP on the PPO plan, but we highly recommend you select a primary care physician when you enroll to get the most out of your healthcare. You can pick an in-network or out-of-network PCP, but an in-network PCP will be able to work more directly with your plan to coordinate your care.

I have a PPO plan. Are referrals and pre-authorizations for out of network providers required?
Referrals and pre-authorizations for out of network providers are not required, although it is highly encouraged. This applies to services obtained from providers in and out of the member's state.

I have a PPO plan. Can I see any Medicare provider?
PPO members can see any Medicare provider within the US and territories.

I have a PPO plan. What is my out of pocket limit for covered medical services?
Under PPO plans there are two different limits on what you have to pay out-of-pocket for covered medical services:

  1. In Network Maximum out of pocket: Amount you pay during calendar year for covered Medicare Part A/B services received from in-network providers
  2. Combined Maximum out of pocket: Amount you pay during calendar year for covered Medicare Part A/B services received from both in-network and out-of-network providers

I have a PPO plan. What is my out of network cost share?
This will apply if a member goes to an out-of-network provider, regardless if it is within or outside the member's state. If the doctor/provider they visited is a Wellcare participating provider who is outside their state, Out-of-Network cost share will still apply. Additionally, authorization and referral rules do not change whether in or out of state.

I have a PPO plan. My Provider is out of network and is asking me to pay for services up front?
Ask your Provider to bill your plan first. However, if you have already paid, you can request reimbursement by filling out a claim form and submitting it to us with a copy of the bill and any documentation you have about payments you have made. Information on how to file a claim can be found in the Evidence of Coverage online.

Can you call my preferred provider and explain that I can see him/her?
Yes! Visit our Contact Us page, select your state and give us a call at the number provided. We are happy to help!

I have a PPO plan. How long do I have to request reimbursement on a claim?
365 days from date of service.

I have a PPO plan. I requested a reimbursement on a claim. What is the turn-around time to process the claim?
30 days (once all required information has been received)

I have a PPO plan. Before seeing my out of network provider, I want to confirm the services I will receive are covered and medically necessary.
Out of network providers are not required to obtain authorization from the plan prior for your services ahead of time. If you have a service or a visit with an out of network provider that is reviewed by the plan after the fact and that service does not meet medical-necessity guidelines, you may be responsible for the full cost of the service. You can ask for a pre visit coverage decision to confirm the services you are getting are covered and are medically necessary.

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How to Search my Provider Network and Pharmacies

How do I look up my in network provider or pharmacy on your website?
Visit our Find a Provider page.

  • Enter your Zip Code
  • Enter Coverage Type
  • Select Corresponding Plan
  • Select "Where you want to search"
  • Enter "What you are looking for" (ex. Pharmacy) or Choose a Specialty
  • Click "Go to results"

How do I look up pharmacies near me?
Use our Find a Provider tool or download our Wellcare+ Mobile App to access these feature at your fingertips!

Pharmacy Finder

  • Members can search by zip code or allow the app to use their current location.
  • Once location is determined, you can select "Map View" in the top right-hand corner to get a visual of the actual location.
  • Tap on a pin location to view Pharmacy Details.
  • You also have the option to access our "Drug Cost Lookup" feature to determine the cost of your prescription and identified if it is a covered prescription.

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Specialist and Referral Questions

I have a PPO plan. I would like assistance with confirming if a referral is preferred by my new specialist.
With your PPO plan, you have the freedom to choose doctors, specialist and hospitals that are not in network. Your plan does not require a referral to see specialists, but please keep in mind that some specialists may request one. If you would like assistance in confirming if a referral is preferred by your new specialist, please give us a call and we can contact their office to confirm that they are willing to accept our plan for you and to advise them that your plan will not require a referral.

I have a PPO plan. My new specialist is insisting on a referral. What should I do?
With your PPO plan, you have the freedom to choose doctors, specialist and hospitals that are not in network. Your plan does not require a referral to see specialists, but please keep in mind that some specialists may request one. You can call your PCP office and advise them that even though you have a PPO plan, your specialist is requesting that your PCP fax over a referral order. Alternatively, you can call us and we can assist you with this process.

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Questions about Member Materials or Documents

I am a new member. When will I receive my ID card?
You will receive your ID card in the mail within 10 calendar days from receipt of CMS confirmation of enrollment or by last day of month prior to effective date, whichever is later.
You can also download our Wellcare+ Mobile App to have your ID card at your fingertips.  It's free to download in the
App Store® and Google Play™. Create your account to get started.

I am a new member. When will I receive my Welcome Kit?
You will receive your Welcome Kit in the mail within 10 calendar days from receipt of CMS confirmation of enrollment or by last day of month prior to effective date, whichever is later.

I am a new member. I have recently selected a new PCP and submitted a PCP change. When will I receive a new Member ID card in the mail with my updated Primary Care Physician?
Upon submitting your request for a PCP update, you will be receiving a new Member ID card in the mail with your updated Primary Care Physician within 7-10 business days at the address on file. Should you need your card sooner, you may log on to the member portal to print a temporary ID Card.

You can also download our Wellcare+ Mobile App to have your ID card at your fingertips. Visit the app store on your mobile device and search Wellcare+. Create your account to get started.

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Transition and Continuation of Care Questions

I am a new member and I have an existing relationship with a provider who is not part of the Wellcare provider network. What should I do?
If you have written documentation of prior authorization, Wellcare will honor ongoing covered services by the non-participating provider for a period after the effective date of enrollment. A non participating provider can submit a previously approved authorization to Wellcare Authorization Intake for continuity of care during the member's Transition of Care period.

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Wellcare+ App Questions

What does the Wellcare+ mobile app allow me to do?
Wellcare members can keep up with health benefits and ID Cards, find a provider and more. If you are a Medicare or Prescription Drug Plan member, you can download the Wellcare+ app to get all the same helpful tools and more. This includes drug claim history and drug cost lookup.

I have a Wellcare Medicare Advantage plan. What features can I access through the Wellcare+ App?
The following features are available to you through the Wellcare+ App:

  • Tìm Nhà Cung Cấp
  • Pay Your Premium
  • Quick Care (search for Urgent Care facilities)
  • Appointments (future and past appointments scheduled for you by Wellcare)
  • Wellness Services (listing of your open care gaps)
  • Change PCP (if applicable)
  • Update Contact Information
  • Care Plan (if applicable)
  • ID Card
  • Messages
  • About Us
  • Liên Hệ Với Chúng Tôi

Features available for members who have prescription drug coverage through Wellcare:

  • Drug Cost Lookup
  • Drug Claims History

Am I able to view my Member ID card through the Wellcare+ App?
Yes. Members can view, download, print and fax the front and back of their ID Card.

What information do I need to have on hand to register for the Wellcare+ App?
You will need to have the following information on hand to register for the Wellcare+ App:

  • Member/ Subscriber ID or Medicare ID
  • First Name and Last Name
  • Date of Birth

I already registered online through the Member Portal? Do I need to create a new login for the Wellcare+ App?
Members who have already registered from within the online Member Portal will be able to use their existing Member Portal ID and password to login to their Wellcare+ App.

I previously registered for the Wellcare+ App but forgot my password. What should I do?
To reset your password you will need to follow the following steps:

  • Select "Forgot Password" and you will be navigated to the Forgot Password screen.
  • You will then need to answer the questions you previously selected during your registration process
  • Upon correctly answering all questions, a message will then display indicating that a temporary password has been sent to your email. Your new temporary password will then be emailed to the email address we have in our records, and you will be required to change it when you log into the application
  • One your temporary password is retrieved from your email, you will need to return to the Wellcare+ App and click OK on the message.
  • After selecting "Ok", you will be navigated to the "Reset Password" screen to input your temporary password as well as create a new password
  • Passwords must include at least 3 of the following:
    • Uppercase letter
    • Lowercase letter
    • Number or special character
  • Once you have set up your new password, a message will display indicating that your password has been updated

Can I complete my Health Questionnaire through the Wellcare+ App?
Yes. The questionnaire will open outside of the app, displaying within your default browser.

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Pharmacy Questions

Can I submit a reimbursement request on a covered drug?
Yes. Reimbursement requests must include the following:

  • Cash Register Receipt
  • Prescription Receipt Including:
    • Patient Name
    • Date of Fill
    • Day of Supply
    • Prescription Number
    • Quantity Dispensed
    • Pharmacy Name and Address
    • Drug NDC Number
    • Total Amount Paid

Where do I submit a reimbursement request on a covered drug?
Requests can be submitted to the address & fax number below:

  • Member Reimbursement Fax Number: 1-888-481-7921
  • Member Reimbursement Mailing Address:
    • Medicare Part D Pharmacy Claims
      Attn: Member Reimbursement Departments
      P.O. Box 31577
      Tampa, FL 33631-3577

How do I look up Pharmacies near me?
Download our Wellcare+ Mobile App to access these features at your fingertips! It's free to download in the App Store® and Google Play™.

Pharmacy Finder

  • Members can search by zip code or allow the app to use their current location.
  • Once location is determined, you can select "Map View" in the top right-hand corner to get a visual of the actual location.
  • Tap on a pin location to view Pharmacy Details.
  • You also have the option to access our "Drug Cost Lookup" feature to determine the cost of your prescription and identified if it is a covered prescription.

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Over the Counter (OTC) Catalog Questions

I was told I have an OTC benefit, what is that?
An OTC benefit is an Over-the-Counter Benefit. This valuable benefit provides a monthly or quarterly allowance for personal care items like toothpaste, vitamins, and pain relievers.

CVS OTC

I have a CVS OTC benefit. How can I obtain my items?
You can easily obtain your OTC items in several different ways:

  1. Browse our paper and online catalogs and place an order online or call us at 1-866-528-4679.
    • Catalog, online, phone mail orders will be limited to 3 per quarter
    • Members will need to log into the CVS OTC Health Solutions portal to place an online
  2. Visit a participating retail location and use your Wellcare member ID card to get your items.
    • Members can place unlimited number of in-store orders up to benefit maximum
    • Members cannot exceed their allowance when placing order for home delivery (online/phone) but can pay the difference in-store if they exceed the benefit amount

I have a CVS OTC benefit. How do I place an order? The easiest and fastest way to order OTC items is by placing your order online at Cvs.com/otchs/wellcare.
Just follow the instructions on the website to create a username and password. This will make reordering a seamless process. Once the order is placed, the amount will be automatically deducted from the OTC allowance. You may also place your order by calling the number listed in the OTC catalog that is included in your New Member Kit.

I have a CVS OTC benefit, where can I find the catalog?
Here is a link to the CVS OTC Catalogs:

I have a CVS OTC benefit. If I don't use all of my allowance, will it roll over?
Benefits do not roll over into the following quarter.

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Y0020_WCM_100876E Được Cập Nhật Lần Cuối Vào: 01/10/2022