Broker Resources

Evidence of Coverage

This booklet gives you the details about your Medicare health care and prescription drug coverage from January 1 – December 31, 2022. It explains how to get coverage for the health care services and prescription drugs you need.

Summary of Benefits

You can use this document to compare Wellcare By Fidelis Care programs and the Original Medicare Program. The charts in this booklet list important health benefits. For each benefit, you can see what our program covers and what the Original Medicare Program covers. Our members receive all of the benefits that the Original Medicare Program offers but we also offer additional benefits to help you stay healthy.

Resumen de Beneficios 2022 (PDF)

Out of Network Coverage Rules:

The following services are not covered out-of-network and you will be responsible for all of the costs if you obtain these services:

• Inpatient Acute Care
• Inpatient Mental Health Care
• Skilled Nursing Facility Care
• Primary Care Physicians
• Home Health
• X-rays
• Part B Prescription Drugs
• Durable Medicare Equipment & Prosthetic Devices
• Dialysis
• Outpatient Services including Surgery, X-rays, Outpatient Diagnostic Radiology (e.g. CT scans, PET scans, MRI's, nuclear medicine) and Therapeutic Radiology (e.g. radiation therapy, chemotherapy)
• Diabetic Supplies

If you need medical care that Medicare requires our plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider. You will need to obtain “prior authorization” from us to get this care. In this situation, you will pay the same as you would pay if you got the care from a network provider.

The plan covers emergency care or urgently needed care that you get from an out-of-network provider. For more information about this, and to see what emergency or urgently needed care means, see Section 3 of your Evidence of Coverage.

Wellcare Fidelis Patriot No Premium (HMO-POS) Plan 005

Formulary

Evidence of Coverage

This booklet gives you the details about your Medicare health care and prescription drug coverage from January 1 – December 31, 2022. It explains how to get coverage for the health care services and prescription drugs you need.

Summary of Benefits

You can use this document to compare Wellcare By Fidelis Care programs and the Original Medicare Program. The charts in this booklet list important health benefits. For each benefit, you can see what our program covers and what the Original Medicare Program covers. Our members receive all of the benefits that the Original Medicare Program offers but we also offer additional benefits to help you stay healthy.

Resumen de Beneficios 2022 (PDF)

Out of Network Coverage Rules:

The following services are not covered out-of-network and you will be responsible for all of the costs if you obtain these services:

• Inpatient Acute Care
• Inpatient Mental Health Care
• Skilled Nursing Facility Care
• Primary Care Physicians
• Home Health
• X-rays
• Part B Prescription Drugs
• Durable Medicare Equipment & Prosthetic Devices
• Dialysis
• Outpatient Services including Surgery, X-rays, Outpatient Diagnostic Radiology (e.g. CT scans, PET scans, MRI's, nuclear medicine) and Therapeutic Radiology (e.g. radiation therapy, chemotherapy)
• Diabetic Supplies

If you need medical care that Medicare requires our plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider. You will need to obtain “prior authorization” from us to get this care. In this situation, you will pay the same as you would pay if you got the care from a network provider.

The plan covers emergency care or urgently needed care that you get from an out-of-network provider. For more information about this, and to see what emergency or urgently needed care means, see Section 3 of your Evidence of Coverage.

Wellcare Fidelis No Premium (HMO) Plan 004

Formulary

Evidence of Coverage

This booklet gives you the details about your Medicare health care and prescription drug coverage from January 1 – December 31, 2022. It explains how to get coverage for the health care services and prescription drugs you need.

Summary of Benefits

You can use this document to compare Wellcare By Fidelis Care programs and the Original Medicare Program. The charts in this booklet list important health benefits. For each benefit, you can see what our program covers and what the Original Medicare Program covers. Our members receive all of the benefits that the Original Medicare Program offers but we also offer additional benefits to help you stay healthy.

Resumen de Beneficios 2022 (PDF)

Out-of-Network Coverage Rules

It is important to know which providers are part of our network because, with limited exceptions, while you are a member of our plan you must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which Wellcare By Fidelis Care authorizes use of out-of-network providers. See Chapter 3 (Using the plan’s coverage for your medical services) for more specific information about emergency, out-of-network, and out-of-area coverage.

Wellcare Fidelis Dual Access (HMO D-SNP) Plan 001

Formulary

Evidence of Coverage

This booklet gives you the details about your Medicare health care and prescription drug coverage from January 1 – December 31, 2022. It explains how to get coverage for the health care services and prescription drugs you need.

Evidencia de Cobertura (PDF)

Summary of Benefits

You can use this document to compare Wellcare By Fidelis Care Programs and the Original Medicare Program. The charts in this booklet list important health benefits. For each benefit, you can see what our program covers and what the Original Medicare Program covers. Our members receive all of the benefits that the Original Medicare Program offers but we also offer additional benefits to help you stay healthy.

Resumen de Beneficios (PDF)

Out of Network Coverage Rules

It is important to know which providers are part of our network because, with limited exceptions, while you are a member of our plan you must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which Wellcare By Fidelis Care authorizes use of out-of-network providers. See Chapter 3 (Using the plan’s coverage for your medical services) for more specific information about emergency, out-of-network, and out-of-area coverage.

Fidelis Dual Advantage (HMO SNP) Plan 006

Formulary

2022 처방집 (PDF)

2022年处方集 (PDF)

Annual Notice of Changes

Annual Notice of Changes (PDF)

Aviso anual de cambios (PDF)

연간 변경 공지 (PDF)

年度改變通知

Evidence of Coverage

This booklet gives you the details about your Medicare health care and prescription drug coverage from January 1 – December 31, 2021. It explains how to get coverage for the health care services and prescription drugs you need.

보장의 증거 (PDF)

承保福利說明 (PDF)

Summary of Benefits

You can use this document to compare Fidelis Care Programs and the Original Medicare Program. The charts in this booklet list important health benefits. For each benefit, you can see what our program covers and what the Original Medicare Program covers. Our members receive all of the benefits that the Original Medicare Program offers but we also offer additional benefits to help you stay healthy.

Resumen de Beneficios (PDF)

혜택 요약 (PDF)

福利介紹 (PDF)

Out of Network Coverage Rules

It is important to know which providers are part of our network because, with limited exceptions, while you are a member of our plan you must use network providers to get your medical care and services. The only exceptions are emergencies, urgently needed care when the network is not available (generally, when you are out of the area), out-of-area dialysis services, and cases in which Fidelis Care authorizes use of out-of-network providers. See Chapter 3 (Using the plan’s coverage for your medical services) for more specific information about emergency, out-of-network, and out-of-area coverage.

Wellcare Fidelis Dual Plus (HMO D-SNP) Plan 003

Formulary

Evidence of Coverage

This booklet gives you the details about your Medicare health care and prescription drug coverage from January 1 – December 31, 2022. It explains how to get coverage for the health care services and prescription drugs you need.

Summary of Benefits

You can use this document to compare Wellcare By Fidelis Care programs and the Original Medicare Program. The charts in this booklet list important health benefits. For each benefit, you can see what our program covers and what the Original Medicare Program covers. Our members receive all of the benefits that the Original Medicare Program offers but we also offer additional benefits to help you stay healthy.

Resumen de Beneficios (PDF)