FEEL BETTER ABOUT YOUR CHOICES

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1 2016 FEEL BETTER ABOUT YOUR CHOICES CHOOSE WELLCARE. CHOOSE A PLAN TO FIT YOUR NEEDS. Information on individual and family plans inside. Kentucky Boone, Bullitt, Campbell, Clay, Fayette, Harlan, Jefferson, Jessamine, Kenton, Laurel, Leslie, Warren

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3 FEEL BETTER ABOUT YOUR PLAN. WellCare Health Plans, Inc., provides plans with care for those that need it most, when they need it most. If you have trusted us before or if you are looking at our plans for the first time, let us help you feel better about your choices and your decision. At WellCare, our goal is to give our members quality care. We focus on government-sponsored health programs, like Medicare and Medicaid. Our mission is to help people who need it most. For 2016, WellCare has been certified as a Qualified Health Plan to offer plans on the Marketplace. As you read through this booklet, you ll see how many benefits you can get with a WellCare health plan. Feel better about your privacy. Keeping your protected health information (PHI) safe is very important to us. We have policies to protect it. Your PHI can only be seen by those who need it to do their work. For more detailed information, ask for a copy of the member policy. You can also get a copy of our privacy statement. It s on our website. Just visit us at www. wellcare.com/default/privacylegal. 1

4 WHAT IS THE MARKETPLACE? The Affordable Care Act created an easier way to compare, shop for and buy health insurance coverage with an online tool called the Marketplace. In your area, the Marketplace is called kynect. On the Marketplace, you can compare benefit packages and prices. You can learn if you are eligible for a government program, and you can find out if you qualify for help paying for the coverage you choose. You can apply online, or you can apply over the phone. You can also find out if your income makes you eligible for a tax credit and other financial help to make your health insurance more affordable. It s important to know that the tax credit is available to a wide range of income levels. So even if you think your income might be too high to qualify, you might be surprised. 2

5 THE MARKETPLACE OFFERS PLANS TO FIT ALL BUDGETS. The Affordable Care Act implemented four metal levels of coverage: BRONZE SILVER GOLD PLATINUM PLAN PAYS 60% FOR COVERED SERVICES PLAN PAYS 70% FOR COVERED SERVICES PLAN PAYS 80% FOR COVERED SERVICES PLAN PAYS 90% FOR COVERED SERVICES YOU PAY 40% YOU PAY 30% YOU PAY 20% YOU PAY 10% LOWEST PREMIUMS HIGHEST COST-SHARING MODERATE PREMIUMS MODERATE COST-SHARING HIGHER PREMIUMS LOWER COST-SHARING HIGHER PREMIUMS LOWEST COST-SHARING Bronze plans offer the lowest monthly premium, but typically have the highest deductibles, coinsurance and/or co-pays. Platinum plans generally have the highest monthly premium, but you have lower out-of-pocket costs when you receive health care services. In addition, Catastrophic (basic) coverage will be available at a lower cost for those under 30 years of age or for people facing financial hardship. To choose the plan that s right for you, you should consider each plan s co-pays, deductibles, coinsurance and maximum out-of-pocket costs. The differences in these amounts determine the monthly premium you will pay. The availability of plans may vary by state and by county. Visit us at to see which options are available in your area. Benefit grids are provided in the back of this brochure. 3

6 WELLCARE HAS THE RIGHT PLAN FOR YOU. WellCare works with you to help you manage your health care costs. We make it easy to compare plans so that you can select the plan that best fits your needs and budget. Our plans offer: Preventive and wellness services Outpatient (ambulatory) patient care Emergency services, like going to the ER or urgent care center Inpatient care (when you stay overnight in a hospital) Laboratory services Prescription drug coverage Rehabilitative and habilitative services (Habilitative services help a person learn, keep or improve skills that may not be developing normally.) Mental health and substance abuse services Maternity (pregnancy) and newborn care Pediatric services (health care for children) And much more! Financial assistance may be available to lower the cost of health insurance. You may be able to get lower costs on monthly medical insurance premiums or out-of-pocket costs like deductibles, coinsurance and co-pays, depending on your income and family size. When you apply for coverage through the Marketplace, you ll learn if you re eligible for these savings. You can see what your premium, deductible and out-of-pocket costs will be before you make a decision to enroll. Every situation is different. Call (TTY ) Monday Friday, 8 a.m. 8 p.m., to speak to a representative who can explain your options in detail and help you find the coverage that s right for you. 4

7 AS A WELLCARE MEMBER, YOU WILL ENJOY: Choice: We offer a variety of plans to choose from. Compare our plans to find the coverage you need at the cost that works best for you and your family. Cost Savings: Access to WellCare s network of doctors, pharmacies and hospitals. Network discounts provide greater savings for you. No matter which WellCare plan you select, you ll have many providers to choose from. With a large percentage of doctors and hospitals participating in our networks, chances are good that your current health care providers are included. Choose Your PCP: You will need to choose a primary care provider (PCP). After you choose, you can change at any time. This is an HMO product. For more information, ask for a copy of the member policy. Online Resources: Convenient website tools to help you manage your coverage. 24/7 Nurse Advice Line: Provides you access to registered nurses who will listen to your health concerns and give you health information and tips at no additional cost. More Value: Enjoy added value with programs and services that are included for each of our members at no additional cost. WellCare gives you choices to make sure your coverage is a great fit for you. Learn more about our plans by visiting or by contacting a licensed agent. Look over the plans and benefits WellCare offers in your area. Do you need help comparing plans? Call now. Speak to someone who can help. There is no obligation to enroll. Call (TTY ) Monday Friday, 8 a.m. 8 p.m. 5

8 HOW TO USE YOUR PLAN. SETTING UP CARE IS EASY WellCare makes it simple to get the care you need. CALL YOUR PCP AS SOON AS POSSIBLE In the first few months of joining our plan, you should see your PCP. This is even more important if you ve never seen your PCP. A new PCP needs to know as much of your medical history as possible. Be sure to tell your PCP about any problems you have now. Also tell him or her about any medications you take. Make sure to ask any questions you have. GETTING APPROVAL FOR SERVICES Some services must be approved by us before you can receive them or in order to keep getting them. This is called prior (or service) authorization. You or someone you trust can ask for this approval. Just call us toll-free at (TTY ). Here are some items that may need approval: Some specialist visits require authorization Surgical procedures, inpatient services, specialist services by non-participating providers Some tests require prior authorization by your PCP and WellCare s Medical Management For additional information on benefits that may not be covered, or potential network, service, or benefit restrictions, please go to to review the plan details. The summary of benefits contains specific plan information you may need. 6 The member policy has more details about prior approval. It has a complete list of services that need prior approval. It also tells you the process to follow. You may ask for a copy of the member policy. HOW TO USE THE PHARMACY You must use a pharmacy that is part of our plan. Co-payments apply for most covered drugs. To get drugs with your WellCare plan, you need your ID card. In some cases, your doctor may have to get prior approval from us before we cover your prescription. In cases like this, your doctor will work with WellCare. You can get a copy of our preferred drug list. You can view it at Or you can call us at (TTY ) Monday Friday, from 8 a.m. to 8 p.m.

9 STANDARD METAL LEVEL CATASTROPHIC BRONZE Individual Deductible $6,850 $6,500 Medical /$300 Rx Family Deductible $13,700 $13,000 Medical /$600 Rx - Individual Maximum Out of Pocket $6,850 $6,800 Family Maximum Out of Pocket $13,700 $13,600 MEDICAL Inpatient Hospital Care $0 after Ded $0 after Ded Emergency Care $0 after Ded $0 after Ded Urgent Care $0 after Ded $80 after Ded Outpatient Hospital Services $0 after Ded $0 after Ded X-rays/Labs $0 after Ded Basic Lab: $40 (Ded Waived) X-Ray: $0 after Ded Advanced Imaging $0 after Ded $0 after Ded PCP Office Visits $40 (Ded Waived) Visits 1 3: $0 (Ded Waived) Visits 4+: $0 after Ded Specialist Office Visits $0 after Ded $80 (Ded Waived) OTHER SERVICES Dental Pediatric Vision Pediatric PHARMACY Generic *$0 after Ded *$15 (Ded Waived) Preferred Brand *$0 after Ded *$75 (Ded Waived) Non-Preferred Brand *$0 after Ded *$125 after Ded Preferred Specialty **$0 after Ded **35% after Ded Non-Preferred Specialty **$0 after Ded **40% after Ded *Co-pays are for a 1-month supply. **Preferred and Non-Preferred Specialty drugs are only available through mail service. Some medical and pharmacy services must be approved by us before you can receive them. For more information, ask for a copy of the member policy. You must use a pharmacy that accepts our plan. Co-pays may apply for most medications. 7

10 METAL LEVEL *** CSR LEVEL C SILVER Individual Deductible $2,800 Family Deductible $5,600 Individual Maximum Out of Pocket $5,300 Family Maximum Out of Pocket $10,600 MEDICAL Inpatient Hospital Care 30% after Ded Emergency Care 30% after Ded Urgent Care $45 after Ded Outpatient Hospital Services X-rays/Labs Advanced Imaging PCP Office Visits $15 (Ded Waived) Specialist Office Visits $45 (Ded Waived) OTHER SERVICES Dental Pediatric Vision Pediatric PHARMACY Generic *$5 (Ded Waived) Preferred Brand *$40 after Ded Non-Preferred Brand *$100 after Ded Preferred Specialty **35% after Ded Non-Preferred Specialty **40% after Ded *Co-pays are for a 1-month supply. **Preferred and Non-Preferred Specialty drugs are only available through mail service. *** CSR stands for Cost Share Reduction. To be eligible for this plan, your income must be between 100% and 250% of the Federal Poverty Level (FPL). To determine eligibility, visit kynect.ky.gov. Some medical and pharmacy services must be approved by us before you can receive them. For more information, ask for a copy of the member policy. You must use a pharmacy that accepts our plan. Co-pays may apply for most medications. 8

11 METAL LEVEL *** CSR LEVEL B SILVER Individual Deductible $800 Family Deductible $1,600 Individual Maximum Out of Pocket $1,650 Family Maximum Out of Pocket $3,300 MEDICAL Inpatient Hospital Care $300 after Ded Emergency Care $200 after Ded Urgent Care $20 after Ded Outpatient Hospital Services 10% after Ded X-rays/Labs 10% after Ded Advanced Imaging 10% after Ded PCP Office Visits $5 (Ded Waived) Specialist Office Visits $20 (Ded Waived) OTHER SERVICES Dental Pediatric Vision Pediatric PHARMACY Generic *$5 (Ded Waived) Preferred Brand *$30 after Ded Non-Preferred Brand *$70 after Ded Preferred Specialty **35% after Ded Non-Preferred Specialty **40% after Ded *Co-pays are for a 1-month supply. **Preferred and Non-Preferred Specialty drugs are only available through mail service. *** CSR stands for Cost Share Reduction. To be eligible for this plan, your income must be between 100% and 250% of the Federal Poverty Level (FPL). To determine eligibility, visit kynect.ky.gov. Some medical and pharmacy services must be approved by us before you can receive them. For more information, ask for a copy of the member policy. You must use a pharmacy that accepts our plan. Co-pays may apply for most medications. 9

12 METAL LEVEL *** CSR LEVEL A SILVER Individual Deductible $0 Family Deductible $0 Individual Maximum Out of Pocket $975 Family Maximum Out of Pocket $1,950 MEDICAL Inpatient Hospital Care $175 Emergency Care $150 Urgent Care $15 Outpatient Hospital Services 10% X-rays/Labs 10% Advanced Imaging 10% PCP Office Visits $0 Specialist Office Visits $15 OTHER SERVICES Dental Pediatric Vision Pediatric PHARMACY Generic *$0 Preferred Brand *$20 Non-Preferred Brand *$45 Preferred Specialty **35% Non-Preferred Specialty **40% *Co-pays are for a 1-month supply. **Preferred and Non-Preferred Specialty drugs are only available through mail service. *** CSR stands for Cost Share Reduction. To be eligible for this plan, your income must be between 100% and 250% of the Federal Poverty Level (FPL). To determine eligibility, visit kynect.ky.gov. Some medical and pharmacy services must be approved by us before you can receive them. For more information, ask for a copy of the member policy. You must use a pharmacy that accepts our plan. Co-pays may apply for most medications. 10

13 METAL LEVEL STANDARD SILVER Individual Deductible $2,800 Family Deductible $5,600 Individual Maximum Out of Pocket $6,600 Family Maximum Out of Pocket $13,200 MEDICAL Inpatient Hospital Care 30% after Ded Emergency Care 30% after Ded Urgent Care $45 after Ded Outpatient Hospital Services X-rays/Labs Advanced Imaging PCP Office Visits $15 (Ded Waived) Specialist Office Visits $45 (Ded Waived) OTHER SERVICES Dental Pediatric Vision Pediatric PHARMACY Generic *$5 (Ded Waived) Preferred Brand *$40 after Ded Non-Preferred Brand *$100 after Ded Preferred Specialty **35% after Ded Non-Preferred Specialty **40% after Ded *Co-pays are for a 1-month supply. **Preferred and Non-Preferred Specialty drugs are only available through mail service. Some medical and pharmacy services must be approved by us before you can receive them. For more information, ask for a copy of the member policy. You must use a pharmacy that accepts our plan. Co-pays may apply for most medications. 11

14 METAL LEVEL GOLD Individual Deductible $1,500 Family Deductible $3,000 Individual Maximum Out of Pocket $3,000 Family Maximum Out of Pocket $6,000 MEDICAL Inpatient Hospital Care Emergency Care Urgent Care $35 after Ded Outpatient Hospital Services X-rays/Labs Advanced Imaging PCP Office Visits $20 (Ded Waived) Specialist Office Visits $35 (Ded Waived) OTHER SERVICES Dental Pediatric Vision Pediatric PHARMACY Generic *$0 (Ded Waived) Preferred Brand *$25 after Ded Non-Preferred Brand *$100 after Ded Preferred Specialty **35% after Ded Non-Preferred Specialty **40% after Ded *Co-pays are for a 1-month supply. **Preferred and Non-Preferred Specialty drugs are only available through mail service. Some medical and pharmacy services must be approved by us before you can receive them. For more information, ask for a copy of the member policy. You must use a pharmacy that accepts our plan. Co-pays may apply for most medications. 12

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16 THERE ARE MANY OPTIONS TO CHOOSE FROM. CHOOSE THE PLAN THAT CARES. WELLCARE IS PROUD TO BE YOUR PARTNER IN HEALTH CARE. CALL TTY MONDAY FRIDAY, 8 A.M. 8 P.M. Speak with a representative who can explain your options in detail and help you find the coverage that makes you feel better. Plan compare: Price your plan today. ENROLL NOW. kynect.ky.gov CUSTOMER SERVICE LINE kynect This document is available in alternate languages. Please call Customer Service at the number listed above for alternate languages available in your area. Este document se encuentra disponible en idiomas alternativos. Para obtener información sobre los idiomas alternativos disponibles en su área, por favor llame a Servicio al Cliente al número indicado más arriba KY033338_HIX_BRO_ENG Internal Approved WellCare 2016 KY_03_16 KY6V01BOV73987E_0316

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