2022 Formulary (PDF)
Formulario 2022 (PDF)
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.
Evidence of Coverage (PDF)
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.
Summary of Benefits (PDF)
Resumen de Beneficios 2022 (PDF)
Over-the-Counter Benefit Information
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
• Part B Prescription Drugs
• Durable Medicare Equipment & Prosthetic Devices
• 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.