FEEL BETTER ABOUT YOUR CHOICES

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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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FEEL BETTER ABOUT YOUR PLAN.

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.

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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.

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THE MARKETPLACE OFFERS PLANS TO FIT ALL BUDGETS.

BRONZE

PLAN PAYS 60% FOR COVERED SERVICES

YOU PAY 40%

LOWEST PREMIUMS HIGHEST COST-SHARING

The availability of plans may vary by state and by county. Visit us at

www.WellCarePlans.com to see which options are available in your

area. Benefit grids are provided in the back of this brochure.

SILVER

YOU PAY 30%

MODERATE PREMIUMS MODERATE COST-SHARING

GOLD

YOU PAY 20%

HIGHER PREMIUMS LOWER COST-SHARING

PLATINUM

YOU PAY 10%

HIGHER PREMIUMS LOWEST COST-SHARING

The Affordable Care Act implemented four metal levels of coverage:

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.

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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.

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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 www.WellCarePlans.com 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.

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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 1-855-582-6175 (TTY 1-855-582-6171). 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 www.wellcareplans.com to review the plan details. The summary of benefits contains specific plan information you may need.

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.

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METAL LEVEL

_CATASTROPHIC

STANDARD

BRONZE

Individual Deductible

$6,850 $6,500 Medical /$300 Rx

Family Deductible

$13,700 $13,000 Medical /$600 Rx

Note

Medical and Rx Combined

-Individual Maximum Out of Pocket

$6,850 $6,800

Family Maximum Out of Pocket

$13,700 $13,600

Note

Medical and Rx Combined Medical and Rx Combined

MEDICAL

Inpatient Hospital Care

$0 after Ded $0 after Ded

Emergency Care

Urgent Care

Outpatient Hospital Services

X-rays/Labs

$0 after Ded Basic Lab: $40 (Ded Waived)

X-Ray: $0 after Ded

Advanced Imaging

PCP Office Visits

Visits 1–3: $0 (Ded Waived)

Visits 4+: $0 after Ded $40 (Ded Waived)

Specialist Office Visits

$0 after Ded $80 (Ded Waived)

OTHER SERVICES

Dental – Pediatric

Covered Covered

Vision – Pediatric

Covered Covered

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.

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METAL LEVEL

*** CSR LEVEL C SILVER

Individual Deductible

$2,800

Family Deductible

$5,600

Note

Individual Maximum Out of Pocket

$5,300

Family Maximum Out of Pocket

$10,600

Note

MEDICAL

Inpatient Hospital Care

30% after Ded

Emergency Care

30% after Ded

Urgent Care

$45 after Ded

Outpatient Hospital Services

20% after Ded

X-rays/Labs

20% after Ded

Advanced Imaging

20% after Ded

PCP Office Visits

$15 (Ded Waived)

Specialist Office Visits

$45 (Ded Waived)

OTHER SERVICES

Dental – Pediatric

Covered

Vision – Pediatric

Covered

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.

*** 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.

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METAL LEVEL

*** CSR LEVEL B SILVER

Individual Deductible

$800

Family Deductible

$1,600

Note

Individual Maximum Out of Pocket

$1,650

Family Maximum Out of Pocket

$3,300

Note

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

Covered

Vision – Pediatric

Covered

PHARMACY

Generic

*$5 (Ded Waived)

Preferred Brand

*$30 after Ded

Non-Preferred Brand

*$70 after Ded

Preferred Specialty

**35% after Ded

Non-Preferred Specialty

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METAL LEVEL

*** CSR LEVEL A SILVER

Individual Deductible

$0

Family Deductible

$0

Note

Individual Maximum Out of Pocket

$975

Family Maximum Out of Pocket

$1,950

Note

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

Covered

Vision – Pediatric

Covered

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.

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METAL LEVEL

STANDARD SILVER

Individual Deductible

$2,800

Family Deductible

$5,600

Note

Individual Maximum Out of Pocket

$6,600

Family Maximum Out of Pocket

$13,200

Note

MEDICAL

Inpatient Hospital Care

30% after Ded

Emergency Care

30% after Ded

Urgent Care

$45 after Ded

Outpatient Hospital Services

20% after Ded

X-rays/Labs

20% after Ded

Advanced Imaging

20% after Ded

PCP Office Visits

$15 (Ded Waived)

Specialist Office Visits

$45 (Ded Waived)

OTHER SERVICES

Dental – Pediatric

Covered

Vision – Pediatric

Covered

PHARMACY

Generic

*$5 (Ded Waived)

Preferred Brand

*$40 after Ded

Non-Preferred Brand

*$100 after Ded

Preferred Specialty

**35% after Ded

Non-Preferred Specialty

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METAL LEVEL

GOLD

Individual Deductible

$1,500

Family Deductible

$3,000

Note

Individual Maximum Out of Pocket

$3,000

Family Maximum Out of Pocket

$6,000

Note

MEDICAL

Inpatient Hospital Care

20% after Ded

Emergency Care

20% after Ded

Urgent Care

$35 after Ded

Outpatient Hospital Services

20% after Ded

X-rays/Labs

20% after Ded

Advanced Imaging

20% after Ded

PCP Office Visits

$20 (Ded Waived)

Specialist Office Visits

$35 (Ded Waived)

OTHER SERVICES

Dental – Pediatric

Covered

Vision – Pediatric

Covered

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.

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THERE ARE MANY OPTIONS TO CHOOSE FROM.

CHOOSE THE PLAN THAT CARES.

WELLCARE IS PROUD TO BE YOUR PARTNER IN HEALTH CARE.

Speak with a representative who can explain your options in detail

and help you find the coverage that makes you feel better.

Plan compare: www.WellCarePlans.com

Price your plan today.

CALL 1-855-582-6175 | TTY 1-855-582-6171

MONDAY–FRIDAY, 8 A.M.–8 P.M.

ENROLL NOW.

kynect.ky.gov

CUSTOMER SERVICE LINE

1-855-4kynect

KY033338_HIX_BRO_ENG Internal Approved 04252016

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