WellCare/ʽOhana/Easy Choice Monthly Plan Premium for People Who Get Extra Help from Medicare to Help Pay for Their Prescription Drug Costs If you get

Transcription

1 WellCare/ʽOhana/Easy Choice Monthly Plan Premium for People Who Get Extra Help from Medicare to Help Pay for Their Prescription Drug Costs If you get Extra Help from Medicare to help pay for your Medicare prescription drug plan costs, your monthly plan premium will be lower than what it would be if you did not get Extra Help from Medicare. The amount of Extra Help you get will determine your total monthly plan premium as a member of our plan. Click on your state below to see what your monthly plan premium will be if you get Extra Help: Arizona (AZ) Arkansas (AR) California (CA) Connecticut (CT) Florida (FL) Georgia (GA) Hawaii (HI) Illinois (IL) Kentucky (KY) Louisiana (LA) Mississippi (MS) New Jersey (NJ) New York (NY) North Carolina (NC) South Carolina (SC) Tennessee (TN) Texas (TX)

2 The tables below show you what your monthly plan premium will be if you get Extra Help. State: AR Arkansas, Ashley, Baxter, Bradley, Calhoun, Carroll, Chicot, Clark, Clay, Cleburne, Cleveland, Conway, Craighead, Crittenden, Cross, Dallas, Desha, Fulton, Garland, Grant, Greene, Hot Spring, Independence, AR H Monroe, Montgomery, Nevada, Newton, Ouachita, Perry, Phillips, Pike, Poinsett, Prairie, Pulaski, Randolph, Saline, Searcy, Sharp, St. Francis, Stone, Union, Van Buren, White, Woodruff, Yell WellCare Value (HMO- Izard, Jackson, Lawrence, Lee, Lincoln, Lonoke, Marion, Mississippi, $19.00 $21.70 $24.50 $27.20

3 AR AR H H WellCare RX (HMO) Arkansas, Ashley, Baxter, Bradley, Calhoun, Carroll, Chicot, Clark, Clay, Cleburne, Cleveland, Conway, Craighead, Crittenden, Cross, Dallas, Desha, Fulton, Garland, Grant, Greene, Hot Spring, Independence, Izard, Jackson, Lawrence, Lee, Lincoln, Lonoke, Marion, Mississippi, Monroe, Montgomery, Nevada, Newton, Ouachita, Perry, Phillips, Pike, Poinsett, Prairie, Pulaski, Randolph, Saline, Searcy, Sharp, St. Francis, Stone, Union, Van Buren, White, Woodruff, Yell Arkansas, Ashley, Baxter, Bradley, Calhoun, Carroll, Chicot, Clark, Clay, Cleburne, Cleveland, Conway, Craighead, Crittenden, Cross, Dallas, Desha, Fulton, Garland, Grant, Greene, Hot Spring, Independence, Izard, Jackson, Lawrence, Lee, Lincoln, Lonoke, Marion, Mississippi, Monroe, Montgomery, Nevada, Newton, Ouachita, Perry, Phillips, Pike, Poinsett, Prairie, Pulaski, Randolph, Saline, Searcy, Sharp, St. Francis, Stone, Union, Van Buren, White, Woodruff, Yell $0.00 $5.70 $11.30 $17.00 $0.00 $5.30 $10.50 $15.80

4 AR H WellCare Liberty (HMO Arkansas, Ashley, Baxter, Bradley, Calhoun, Carroll, Chicot, Clark, Clay, Cleburne, Cleveland, Conway, Craighead, Crittenden, Cross, Dallas, Desha, Fulton, Garland, Grant, Greene, Hot Spring, Independence, Izard, Jackson, Lawrence, Lee, Lincoln, Lonoke, Marion, Mississippi, Monroe, Montgomery, Nevada, Newton, Ouachita, Perry, Phillips, Pike, Poinsett, Prairie, Pulaski, Randolph, Saline, Searcy, Sharp, St. Francis, Stone, Union, Van Buren, White, Woodruff, Yell $0.00 $5.30 $10.70 $16.00 State: AZ AZ H Care 1st+ (HMO Maricopa, Pima $0.00 $2.80 $5.60 $8.50 State: CA Easy Choice Freedom Plan CA H Los Angeles $0.00 $4.90 $9.80 $14.70 (HMO Easy Choice Plus Plan CA H Orange, Riverside, San Bernardino $0.00 $6.40 $12.80 $19.30 (HMO)

5 CA CA CA H H H Easy Choice Best Plan (HMO) Easy Choice Best Plan (HMO) Easy Choice Plus Plan (HMO) Los Angeles, Orange Riverside, San Bernardino Los Angeles $0.00 $7.10 $14.10 $21.20 State: CT CT H Fairfield, Hartford $0.00 $5.00 $10.00 $15.00 Fairfield, Hartford, Litchfield, CT H WellCare Value (HMO) Middlesex, New Haven, New London, Tolland CT H WellCare Rx (HMO- Fairfield, Hartford, Tolland $0.00 $4.00 $8.00 $12.10 CT H WellCare Preferred (HMO) FairField, Hartford, Litchfield, Middlesex, New London, Tolland $26.60 $29.90 $33.30 $36.60 State: FL Hernando, Hillsborough, Martin, FL H WellCare Dividend (HMO) Okeechobee, Pinellas FL H WellCare Dividend (HMO) Miami-Dade

6 FL H WellCare Select (HMO Broward, Hernando, Hillsborough, Indian River, Manatee, Martin, Miami-Dade, Okeechobee, Orange, Osceola, Pasco, Pinellas, Polk, Seminole, St. Lucie, Sumter, Volusia $0.00 $5.60 $11.20 $16.80 FL H WellCare Value (HMO) Duval FL FL FL H H H WellCare Value (HMO- WellCare Essential (HMO- Alachua, Bay, Calhoun, Escambia, Franklin, Gadsden, Gulf, Holmes, Jefferson, Liberty, Madison, Okaloosa, Wakulla, Washington Martin, Okeechobee, Orange, Osceola, Polk, Seminole, St. Lucie, Sumter, Volusia Alachua, Bay, Bradford, Brevard, Broward, Calhoun, Charlotte, Citrus, Clay, DeSoto, Duval, Escambia, Franklin, Gadsden, Glades, Gulf, Hardee, Hendry, Hernando, Highlands, Hillsborough, Holmes, Indian River, Jefferson, Lake, Lee, Leon, Levy, Liberty, Madison, Manatee, Marion, Martin, Okaloosa, Okeechobee, Orange, Osceola, Palm Beach, Pasco, Pinellas, Polk, Santa Rosa, Sarasota, Seminole, St. Lucie, Sumter, Union, Volusia, Wakulla, Walton, Washington $0.00 $5.40 $10.70 $16.10

7 FL FL FL FL FL H H H H H WellCare Value (HMO- WellCare Essential (HMO- WellCare Liberty (HMO WellCare Liberty (HMO Brevard, Broward, Charlotte, DeSoto, Glades, Hardee, Hendry, Indian River, Lake, Lee, Manatee, Polk, Sarasota, Walton Miami-Dade $0.00 $7.10 $14.20 $21.40 Hernando, Hillsborough, Miami- Dade, Pasco, Pinellas Alachua, Bay, Bradford, Brevard, Broward, Calhoun, Charlotte, Citrus, Clay, DeSoto, Duval, Escambia, Franklin, Gadsden, Glades, Gulf, Hardee, Hendry, Hernando, Highlands, Hillsborough, Holmes, Indian River, Jefferson, Lake, Lee, Leon, Levy, Liberty, Madison, Manatee, Marion, Martin, Okaloosa, Okeechobee, Orange, Osceola, Palm Beach, Pasco, Pinellas, Polk, Santa Rosa, Sarasota, Seminole, St. Lucie, Sumter, Union, Volusia, Wakulla, Walton, Washington $0.00 $6.60 $13.30 $19.90 Miami-Dade $0.00 $7.30 $14.60 $21.80 FL H WellCare Dividend (HMO) Pasco, Polk FL H WellCare Dividend (HMO) Broward, Indian River, Lake, Manatee, Marion, Orange, Osceola, Palm Beach, Seminole, Volusia

8 FL H WellCare Dividend (HMO) Brevard, Charlotte, Duval, Escambia, Gadsden, Highlands, Lee, Sarasota, St. Lucie, Walton FL H WellCare Dividend (HMO) Alachua, Jefferson, Leon FL FL FL H H H WellCare Select (HMO WellCare Guardian (HMO WellCare Guardian (HMO Alachua, Bay, Bradford, Brevard, Calhoun, Charlotte, Citrus, DeSoto, Duval, Escambia, Franklin, Gadsden, Glades, Gulf, Hardee, Hendry, Holmes, Jefferson, Lee, Leon, Levy, Liberty, Madison, Okaloosa, Palm Beach, Santa Rosa, Sarasota, Union, Wakulla, Walton, Washington $0.00 $7.00 $13.90 $20.90 Hillsborough, Pinellas Miami-Dade FL H WellCare Premier (PPO) Citrus, Hernando, Pasco, Sumter FL H WellCare Premier (PPO) Levy FL FL H WellCare Premier (PPO) H WellCare Premier (PPO) Brevard, Indian River,Lake, Martin, Osceola, Palm Beach, Polk,Seminole, St. Lucie Charlotte, Desoto,Glades, Hardee, Hendry, Highlands, Manatee, Okeechobee, Sarasota

9 State: GA Barrow, Bryan, Butts, Chatham, Chattahoochee, Cherokee, Clayton, Cobb, Columbia, DeKalb, Douglas, GA H Fayette, Forsyth, Fulton, Glynn, Gwinnett, Harris, Henry, Liberty, McIntosh, Meriwether, McDuffie, Muscogee, Newton, Paulding, Richmond, Rockdale, Spalding, Stewart, Talbot, Walton $0.00 $6.10 $12.20 $18.40 Barrow, Bryan, Butts, Chatham, Chattahoochee, Cherokee, Clayton, Columbia, DeKalb, Douglas, Fayette, Forsyth, Fulton, Glynn, Gwinnett, GA H WellCare Value (HMO) Harris, Henry, Liberty, McDuffie, McIntosh, Meriwether, Muscogee, Newton, Paulding, Richmond, Rockdale, Spalding, Stewart, Talbot, Walton

10 GA H WellCare Liberty (HMO Barrow, Bryan, Butts, Chatham, Chattahoochee, Cherokee, Clayton, Cobb, Columbia, DeKalb, Douglas, Fayette, Forsyth, Fulton, Glynn, Gwinnett, Harris, Henry, Liberty, McDuffie, McIntosh, Meriwether, Muscogee, Newton, Paulding, Richmond, Rockdale, Spalding, Stewart, Talbot, Walton $0.00 $6.10 $12.20 $18.40 GA H WellCare Choice (HMO) Cobb $0.30 $5.20 $10.10 $15.10 GA GA H WellCare Premier (PPO) H WellCare Prime (PPO) Barrow, Bryan, Butts, Chatham, Chattahoochee, Clayton, Columbia, DeKalb, Douglas, Fayette, Forsyth, Harris, Henry, McDuffie, McIntosh, Meriwether, Muscogee, Newton, Pickens, Richmond, Rockdale, Stewart Barrow, Bryan, Butts, Camden, Chatham, Chattahoochee, Cherokee, Clayton, Cobb, Columbia, DeKalb, Douglas, Fayette, Forsyth, Harris, Henry, McDuffie, McIntosh, Meriwether, Muscogee, Newton, Pickens, Polk, Richmond, Rockdale, Spalding, Stewart, Talbot, Walton $13.90 $19.20 $24.40 $29.70

11 State: HI HI H Ohana Liberty (HMO Hawaii, Honolulu, Kauai, Maui $0.00 $6.40 $12.70 $19.10 State: IL Champaign, Cook, Douglas, Kane, IL H Will WellCare Value (HMO- Kankakee, Knox, Madison, Monroe, Peoria, St. Clair, Tazewell, Vermilion, Champaign, Cook, Douglas, Kane, IL H WellCare Rx (HMO) Kankakee, Knox, Madison, Monroe, Peoria, St. Clair, Tazewell, Vermilion, $0.00 $1.90 $3.80 $5.80 IL IL H WellCare Choice (HMO- H WellCare Plus (HMO) Will Champaign, Cook, Douglas, Kane, Kankakee, Knox, Madison, Monroe, Peoria, St. Clair, Tazewell, Vermilion, Will Champaign, Cook, Douglas, Kane, Kankakee, Knox, Madison, Monroe, Peoria, St. Clair, Tazewell, Vermilion, Will $64.00 $64.00 $64.00 $64.00 $0.00 $3.90 $7.70 $11.60

12 State: KY KY KY KY H WellCare Value (HMO) H H WellCare Liberty (HMO Boone, Bourbon, Bullitt, Campbell, Carroll, Clark, Fayette, Gallatin, Grant, Jefferson, Jessamine, Kenton, Nelson, Owen, Pendleton, Scott Allen, Anderson, Boone, Bourbon, Bullitt, Calloway, Campbell, Carroll, Clark, Daviess, Edmonson, Fayette, Franklin, Gallatin, Grant, Graves, Hardin, Harrison, Hart, Jefferson, Jessamine, Kenton, Madison, Marshall, McCracken, Nelson, Owen, Pendleton, Scott, Simpson, Warren, Woodford Allen, Anderson, Boone, Bourbon, Bullitt, Calloway, Campbell, Carroll, Clark, Daviess, Edmonson, Fayette, Franklin, Gallatin, Grant, Graves, Hardin, Harrison, Hart, Jefferson, Jessamine, Kenton, Madison, Marshall, McCracken, Nelson, Owen, Pendleton, Scott, Simpson, Warren, Woodford $0.00 $1.50 $3.00 $4.50 $0.00 $6.50 $13.00 $19.50 $0.00 $6.70 $13.50 $20.20

13 KY H WellCare Essential (HMO- Allen, Anderson, Bourbon, Bullitt, Calloway, Carroll, Clark, Daviess, Edmonson, Franklin, Gallatin, Grant, Graves, Hardin, Harrison, Hart, Jefferson, Jessamine, Madison, Marshall, McCracken, Nelson, Owen, Pendleton, Scott, Simpson, Warren, Woodford, Boone, Campbell, Fayette, Kenton State: LA Acadia, Ascension, East Baton Rouge, East Feliciana, Grant, Iberville, Jefferson, Jefferson Davis, Lafayette, LA H Livingston, Orleans, Plaquemines, Pointe Coupee, Rapides, St. Bernard, St. Charles, St. Helena, St. James, St. John the Baptist, St. Landry, St. Martin, St. Tammany, Washington, West Baton Rouge, West Feliciana $0.00 $6.10 $12.20 $18.30

14 LA LA H WellCare Value (HMO) H WellCare Liberty (HMO Acadia, Ascension, East Baton Rouge, East Feliciana, Grant, Iberville, Jefferson, Jefferson Davis, Lafayette, Livingston, Orleans, Plaquemines, Pointe Coupee, Rapides, St. Bernard, St. Charles, St. Helena, St. James, St. John the Baptist, St. Landry, St. Martin, St. Tammany, Washington, West Baton Rouge, West Feliciana Acadia, Ascension, East Baton Rouge, East Feliciana, Grant, Iberville, Jefferson, Lafayette, Livingston, Orleans, Plaquemines, Pointe Coupee, Rapides, St. Bernard, St. Charles, St. Helena, St. James, St. John the Baptist, St. Landry, St. Martin, St. Tammany, Washington, West Baton Rouge, West Feliciana $0.00 $6.40 $12.70 $19.10

15 State: MS Adams, Attala, Bolivar, Carroll, Claiborne, Clarke, Coahoma, Copiah, Covington, DeSoto, Forrest, Grenada, Hinds, Holmes, Humphreys, Issaquena, Jasper, Jefferson, MS H Jefferson Davis, Jones, Kemper, WellCare Essential (HMO- Lafayette, Lamar, Lauderdale, Lawrence, Leake, Lincoln, Madison, Marion, Marshall, Neshoba, Newton, Panola, Pike, Quitman, Rankin, Scott, Sharkey, Simpson, Smith, Sunflower, Tallahatchie, Tate, Tunica, Walthall, Warren, Washington, Wayne, Yazoo $24.50 $28.40 $32.20 $36.10

16 MS MS H H WellCare Value (HMO) Adams, Attala, Bolivar, Carroll, Claiborne, Clarke, Coahoma, Copiah, Covington, DeSoto, Forrest, Grenada, Hinds, Holmes, Humphreys, Issaquena, Jasper, Jefferson, Jefferson Davis, Jones, Kemper, Lafayette, Lamar, Lauderdale, Lawrence, Leake, Lincoln, Madison, Marion, Marshall, Neshoba, Newton, Panola, Pike, Quitman, Rankin, Scott, Sharkey, Simpson, Smith, Sunflower, Tallahatchie, Tate, Tunica, Walthall, Warren, Washington, Wayne, Yazoo Adams, Attala, Bolivar, Carroll, Claiborne, Clarke, Coahoma, Copiah, Covington, Desoto, Forrest, Grenada, Hinds, Holmes, Humphreys, Issaquena, Jasper, Jefferson, Jefferson Davis, Jones, Kemper, Lafayette, Lamar, Lauderdale, Lawrence, Leake, Lincoln, Madison, Marion, Marshall, Neshoba, Newton, Panola, Pike, Quitman, Rankin, Scott, Sharkey, Simpson, Smith, Sunflower, Tallahatchie, Tate, Tunica, Walthall, Warren, Washington, Wayne, Yazoo $0.00 $6.40 $12.90 $19.30

17 MS H WellCare Liberty (HMO Adams, Attala, Bolivar, Carroll, Claiborne, Clarke, Coahoma, Copiah, Covington, DeSoto, Forrest, Grenada, Hinds, Holmes, Humphreys, Issaquena, Jasper, Jefferson, Jefferson Davis, Jones, Kemper, Lafayette, Lamar, Lauderdale, Lawrence, Leake, Lincoln, Madison, Marion, Marshall, Neshoba, Newton, Panola, Pike, Quitman, Rankin, Scott, Sharkey, Simpson, Smith, Sunflower, Tallahatchie, Tate, Tunica, Walthall, Warren, Washington, Wayne, Yazoo $0.00 $5.90 $11.80 $17.80 State: NC NC H WellCare Value (HMO) Durham, Orange NC H WellCare Value (HMO) Henderson, Madison, McDowell, Polk, Transylvania NC H WellCare Value (HMO) Buncombe $5.90 $9.20 $12.40 $15.70 NC H Durham, Orange, Henderson, Madison, McDowell, Polk, Transylvania, Buncombe $0.00 $4.80 $9.60 $14.50

18 State: NJ NJ H WellCare Value (HMO) Bergen, Essex, Hudson, Morris NJ H WellCare Value (HMO) Middlesex, Passaic, Somerset, Union $1.10 $5.80 $10.50 $15.30 State: NY Albany, Broome, Erie, Monroe, NY H Ulster WellCare Liberty (HMO Niagara, Oneida, Orange, Rensselaer, Rockland, Saratoga, Schenectady, $0.00 $5.10 $10.20 $15.30 NY H Broome, Dutchess, Erie, Niagara, Oneida, Orange, Rockland, Saratoga, Schenectady, Suffolk, Wayne, Westchester $0.00 $6.40 $12.90 $19.30 NY H WellCare Value (HMO) Monroe $25.90 $27.40 $28.90 $30.50 NY H WellCare Value (HMO) Albany, Broome, Erie, Niagara, Oneida, Rensselaer, Rockland, Saratoga, Schenectady

19 NY NY NY NY H H H WellCare Choice (HMO- WellCare Choice (HMO- H WellCare Rx (HMO) Bronx Kings, New York, Queens, Richmond Bronx, Kings, Nassau, New York, Queens, Richmond Bronx, Kings, New York, Queens, Richmond $0.00 $9.20 $18.40 $27.70 $0.00 $3.60 $7.20 $10.90 NY H WellCare Choice (HMO) Nassau $27.20 $29.10 $31.10 $33.00 NY H WellCare Choice (HMO) Ulster $20.00 $23.20 $26.50 $29.70 NY H WellCare Essential (HMO) Erie, Niagara, Oneida, Schenectady NY H WellCare Preferred (HMO- Bronx, Kings, New York, Queens, Richmond, Westchester $45.70 $47.50 $49.30 $51.20 NY H WellCare Value (HMO) Dutchess, Onondaga, Orange, Wayne $51.20 $53.10 $55.10 $57.00 NY H WellCare Premier (PPO) New York State: SC SC H Abbeville, Cherokee, Greenville, Greenwood, McCormick, Newberry, Pickens, Saluda, Spartanburg, Union $0.00 $5.70 $11.50 $17.20

20 SC SC SC SC SC H WellCare Value (HMO) H WellCare Value (HMO) H WellCare Essential (HMO- H WellCare Premier (PPO) H WellCare Prime (PPO) Cherokee, Greenville, Pickens, Saluda, Spartanburg, Union Abbeville, Greenwood, McCormick, Newberry Greenwood, Pickens $19.20 $21.90 $24.60 $27.30 Greenville, Laurens, Richland, Spartanburg, Union Abbeville, Cherokee, Greenville, Laurens, McCormick, Newberry, Richland, Saluda, Spartanburg, Union $14.80 $18.60 $22.40 $26.20 State: TN Anderson, Bledsoe, Blount, Bradley, Campbell, Carter, Claiborne, Cocke, Crockett, Dyer, Fayette, Grainger, Greene, Grundy, Hamblen, Hamilton, TN H Hancock, Hardeman, Hawkins, WellCare Value (HMO- Haywood, Jefferson, Johnson, Knox, Lake, Loudon, Marion, McMinn, McNairy, Meigs, Monroe, Morgan, Obion, Polk, Rhea, Roane, Scott, Sequatchie, Sevier, Sullivan, Unicoi, Union, Washington, Weakley

21 TN H Anderson, Bedford, Benton, Bledsoe, Blount, Bradley, Campbell, Cannon, Carroll, Carter, Cheatham, Chester, Claiborne, Clay, Cocke, Coffee, Crockett, Cumberland, Davidson, Decatur, DeKalb, Dyer, Fayette, Fentress, Franklin, Giles, Grainger, Greene, Grundy, Hamblen, Hamilton, Hancock, Hardeman, Hardin, Hawkins, Haywood, Henderson, Henry, Hickman, Houston, Humphreys, Jackson, Jefferson, Johnson, Knox, Lake, Lauderdale, Lawrence, Lewis, Loudon, Macon, Madison, Marion, Marshall, Maury, McMinn, McNairy, Meigs, Monroe, Montgomery, Moore, Morgan, Obion, Overton, Perry, Pickett, Polk, Rhea, Roane, Robertson, Rutherford, Scott, Sequatchie, Sevier, Shelby, Smith, Stewart, Sullivan, Sumner, Tipton, Trousdale, Unicoi, Union, Van Buren, Warren, Washington, Wayne, Weakley, White, Williamson, Wilson $0.00 $7.00 $14.00 $21.10

22 TN TN TN H WellCare Dividend (HMO) H WellCare RX (HMO) H WellCare Choice (HMO- Anderson, Bedford, Blount, Cannon, Carroll, Cheatham, Chester, Claiborne, Cocke, Coffee, Crockett, Davidson, Dyer, Fayette, Grainger, Hamblen, Hamilton, Hardeman, Hardin, Haywood, Henderson, Henry, Knox, Lauderdale, Lewis, Macon, Madison, Marshall, Maury, Montgomery, Morgan, Robertson, Rutherford, Sevier, Shelby, Stewart, Sumner, Tipton, Trousdale, Wayne, Williamson, Wilson Anderson, Bedford, Benton, Blount, Cannon, Carroll, Cheatham, Chester, Claiborne, Cocke, Coffee, Crockett, Davidson, Decatur, Dyer, Fayette, Franklin, Giles, Grainger, Hamblen, Hamilton, Hardeman, Hardin, Haywood, Henderson, Henry, Hickman, Houston, Humphreys, Knox, Lauderdale, Lawrence, Lewis, Macon, Madison, Marshall, Maury, Montgomery, Moore, Morgan, Perry, Robertson, Rutherford, Sevier, Shelby, Stewart, Sumner, Tipton, Trousdale, Wayne, Williamson, Wilson $0.00 $4.90 $9.80 $14.80 Davidson, Hamilton, Knox, Shelby $60.30 $64.00 $67.60 $71.30

23 State: TX TX TX TX TX TX TX TX H H H WellCare Value (HMO- WellCare Value (HMO- H WellCare Dividend (HMO) H H H WellCare Liberty (HMO WellCare Liberty (HMO WellCare Dividend Prime (HMO) Bexar, Dallas, Denton, El Paso, Harris, Jefferson Fort Bend, Galveston, Johnson, Montgomery, Tarrant Bexar, Dallas, Denton, El Paso, Fort Bend, Galveston, Harris, Jefferson, Johnson, Montgomery, Tarrant Bexar, Dallas, Denton, El Paso, Fort Bend, Galveston, Harris, Jefferson, Johnson, Montgomery, Tarrant Bexar, Dallas, Denton, El Paso, Fort Bend, Galveston, Harris, Jefferson, Johnson, Montgomery Dallas, Denton, Fort Bend, Galveston, Johnson, Montgomery, Tarrant Bexar, Dallas, Denton, El Paso, Fort Bend, Harris $0.00 $5.20 $10.40 $15.60 $0.00 $4.90 $9.70 $14.60 $0.00 $5.30 $10.60 $16.00

24 *This does not include any Medicare Part B premium you may have to pay. WellCare/ʽOhana/Easy Choice s premium includes coverage for both medical services and prescription drug coverage. If you aren t getting Extra Help, you can see if you qualify by calling: Medicare or TTY users call (24 hours a day/7 days a week), Your State Medicaid Office, or The Social Security Administration at TTY users should call between 7 a.m. and 7 p.m., Monday through Friday. If you have any questions, please call call Customer Service toll-free at the number listed on the following pages for your state and plan from 8 a.m. to 8 p.m., all time zones, Monday Friday. Between October 1 and February 14, representatives are available Monday Sunday, 8 a.m. to 8 p.m., all time zones.

25 We re always just a phone call away! If you re ready to enroll or have enrollment questions, call (CA), (HI), or (All others). Representatives are available from 8 a.m. to 8 p.m., 7 days a week. If you re already a member, call the number for your state/plan listed below. Arkansas: California:, WellCare Liberty (HMO WellCare Advance (HMO-, WellCare Rx (HMO), WellCare Value (HMO Easy Choice Freedom Plan (HMO, Easy Choice Best Plan (HMO), Easy Choice Plus Plan (HMO) Connecticut: WellCare Rx (HMO-, WellCare Value (HMO), WellCare Preferred (HMO) Florida: Georgia:, WellCare Liberty (HMO, WellCare Select (HMO, WellCare Guardian (HMO WellCare Dividend (HMO), WellCare Essential (HMO-, WellCare Premier (PPO), WellCare Value (HMO/HMO , WellCare Liberty (HMO WellCare Advance (HMO-, WellCare Choice (HMO) WellCare Value (HMO), WellCare Premier (PPO), WellCare Prime (PPO) Hawaii: Ohana Liberty (HMO Illinois: Kentucky: WellCare Choice (HMO-, WellCare Plus (HMO) WellCare Rx (HMO), WellCare Value (HMO , WellCare Liberty (HMO WellCare Value (HMO), WellCare Essential (HMO TTY for all of the above Nurse Advice Line (24 hours, 7 days a week) Remaining states (LA, MS, NJ, NY, NC, SC, TN, and TX) on following page Hours of operation are Monday Friday, 8 a.m. to 8 p.m. Between October 1 and February 14, representatives are available Monday Sunday, 8 a.m. to 8 p.m., or visit us anytime at or Keep in touch! If you move or change phone numbers, let us know so we can continue providing you with quality health care services. Simply call Customer Service at the telephone number listed for your state/plan, shown above. Also be sure to update your contact information with Medicare, which you can do by calling the Social Security Administration at , Monday through Friday, 7 a.m. to 7 p.m. TTY users may call WellCare 2017 NA8WCMINS01028E_0000

26 We re always just a phone call away! If you re ready to enroll or have enrollment questions, call (CA), (HI), or (All others). Representatives are available from 8 a.m. to 8 p.m., 7 days a week. If you re already a member, call the number for your state/plan listed below. Louisiana: Mississippi: New Jersey: New York: North Carolina: South Carolina: Tennessee: Texas:, WellCare Liberty (HMO WellCare Value (HMO) , WellCare Liberty (HMO WellCare Advance (HMO-, WellCare Essential (HMO-, WellCare Value (HMO) WellCare Liberty (HMO WellCare Value (HMO) WellCare Liberty (HMO WellCare Advance (HMO), WellCare Choice (HMO/HMO-, WellCare Essential (HMO), WellCare Preferred (HMO-, WellCare Rx (HMO), WellCare Value (HMO), WellCare Premier (PPO) WellCare Value (HMO) WellCare Advance (HMO-, WellCare Value (HMO), WellCare Essential (HMO-, WellCare Premier (PPO), WellCare Prime (PPO) WellCare Advance (HMO-, WellCare Dividend (HMO), WellCare Rx (HMO), WellCare Value (HMO-, WellCare Choice (HMO , WellCare Liberty (HMO WellCare Dividend (HMO), WellCare Dividend Prime (HMO), WellCare Value (HMO TTY for all of the above Nurse Advice Line (24 hours, 7 days a week) Remaining states (AR, CA, CT, FL, GA, HI, IL and KY) on previous page Hours of operation are Monday Friday, 8 a.m. to 8 p.m. Between October 1 and February 14, representatives are available Monday Sunday, 8 a.m. to 8 p.m., or visit us anytime at or Keep in touch! If you move or change phone numbers, let us know so we can continue providing you with quality health care services. Simply call Customer Service at the telephone number listed for your state/plan, shown above. Also be sure to update your contact information with Medicare, which you can do by calling the Social Security Administration at , Monday through Friday, 7 a.m. to 7 p.m. TTY users may call WellCare 2017 NA8WCMINS01028E 0000

27 ʽOhana Health Plan, a plan offered by WellCare Health Insurance of Arizona, Inc. WellCare (including Easy Choice Health Plan Inc., a WellCare company,) is a Medicare Advantage organization with a Medicare contract for HMO, HMO-POS, HMO SNP and PPO plans. Enrollment in WellCare, ʽOhana or Easy Choice depends on contract renewal. Special Needs Plans: Dual Eligible Special Needs Plans have a contract with the state Medicaid program. Our Chronic Special Needs Plans are available to anyone with Medicare who has been diagnosed with chronic heart failure, diabetes or cardiovascular disorders. Some plans are available to those who have medical assistance from both the state and Medicare. For TennCare Members, 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. 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. You must continue to pay your Medicare Part B premium. If you meet certain eligibility requirements for both Medicare and Medicaid, your Part B premiums may be covered in full. Please contact WellCare/ʽOhana/Easy Choice for details