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WellCare Health Plans, Inc. ©2015. All rights reserved.

WellCare Health Plans, Inc. ©2015. All rights reserved.

WellCare of Georgia 2016 Product Changes State

Contract Number

GA

H1112032

GA GA

H1112006 H1112027

Plan Name

Counties Impacted

Status

Barrow, Bryan, Butts, Chattahoochee, Clayton, Columbia, De Kalb, Douglas, Fayette, Forsyth, Glynn, Essential (NEW) Gwinnett, Harris, Henry, New Plan Liberty, McDuffie, McIntosh, Merriwether, Muscogee, Newton, Paulding, Rockdale, Spalding, Talbot, Walton Access Meriwether, McDuffie New Expansion Counties Value Meriwether, McDuffie New Expansion Counties 3

This content is for training purposes only. It has not been approved by CMS and cannot be used with Consumers

WellCare Health Plans, Inc. ©2015. All rights reserved.

Georgia

WellCare Access (HMO-SNP)

Year Contract Number State Plan Name Total Premium (Part C part D) In-Network Plan Deductible Maximum Out of Pocket (MOOP) Inpatient Hospital Acute PCP Office Visits Specialist Office Visits Diagnostic Procedures/Tests

Basic Advance

Therapeutic Radiological Services

(MIN) (MAX)

Diagnostic Radiological Services

(MIN) (MAX)

Outpatient Hospital Non-Surgery Outpatient Hospital Surgery Ambulatory Surgery Center Medically Necessary Transportation OTC Amount Frequency Health Club Membership Dental Benefits Vision Benefits Hearing Benefits Rx Deductible Rx Deductible Tiers Tier 1: Preferred Generic

2015 H1112006 GA WellCare Access (HMO SNP) $0.00 $0 $6,700

2016 H1112006 GA WellCare Access (HMO SNP) $0.00 $0 $6,700

$0 co-pay per day for Days 1-90

$0 co-pay per day for Days 1-90

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 24 One-way trips every year $30 every month

$0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 24 One-way trips every year $30 every month

N/A

$0

Dental 750 Vision 100 Hearing 350 $0 Tiers 2 to 5 $0

Dental 500 Vision 100 Hearing 350 $0 Tiers 2 to 5 $0

This content is for training purposes only. It has not been approved by CMS and cannot be used with Consumers.

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WellCare Health Plans, Inc. ©2015. All rights reserved.

Georgia

WellCare Value (HMO)

Year Contract Number State Plan Name Total Premium (Part C part D) In-Network Plan Deductible Maximum Out of Pocket (MOOP) Inpatient Hospital Acute PCP Office Visits Specialist Office Visits Diagnostic Procedures/Tests

Basic Advance

Therapeutic Radiological Services

(MIN) (MAX)

Diagnostic Radiological Services

(MIN) (MAX)

Outpatient Hospital Non-Surgery Outpatient Hospital Surgery Ambulatory Surgery Center Medically Necessary Transportation OTC Amount Frequency Health Club Membership Dental Benefits Vision Benefits Hearing Benefits Rx Deductible Rx Deductible Tiers Tier 1: Preferred Generic

2015 H1112027 GA WellCare Value (HMO) $0.00 N/A $6,700

2016 H1112027 GA WellCare Value (HMO) $0.00 N/A $6,700

$250 co-pay per day for Days 1-7

$400 co-pay per day for Days 1-4

$5 $35 $20 $50 $35 $35 $100 $100 $150 $150 $100 N/A $7 every month

$10 $45 $50 $100 20% 20% $175 $295 $295 $295 $195 N/A $5 every month

N/A

$0

Dental 500 Routine Exam Only Hearing 350 $0 N/A $6

Dental 500 Routine Exam Only Hearing 350 $0 N/A $0

This content is for training purposes only. It has not been approved by CMS and cannot be used with Consumers.

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WellCare Health Plans, Inc. ©2015. All rights reserved.

Georgia

WellCare Essential (HMO-POS)

Year Contract Number State Plan Name Total Premium (Part C part D) In-Network Plan Deductible Maximum Out of Pocket (MOOP)

2016 H1112032 GA WellCare Essential (HMO-POS) $0.00 N/A $4,900

Inpatient Hospital Acute

$450 co-pay per day for Days 1-3

PCP Office Visits Specialist Office Visits Diagnostic Procedures/Tests

Basic Advance

Therapeutic Radiological Services

(MIN) (MAX)

Diagnostic Radiological Services

(MIN) (MAX)

Outpatient Hospital Non-Surgery Outpatient Hospital Surgery Ambulatory Surgery Center Medically Necessary Transportation OTC Amount Frequency Health Club Membership Dental Benefits Vision Benefits Hearing Benefits Rx Deductible Rx Deductible Tiers Tier 1: Preferred Generic

$5 $40 $20 $50 20% 20% $100 $220 $200 $200 $125 N/A $7 every month $0 Preventive plus Routine Exam Only Hearing 350 $0 N/A $0

This content is for training purposes only. It has not been approved by CMS and cannot be used with Consumers.

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WellCare Health Plans, Inc. ©2015. All rights reserved.

WellCare of Georgia GA North: Fulton, DeKalb, Gwinnett, Forsyth, Fayette, Rockdale, Clayton, Henry, Spalding, Butts, Newton, Walton, Barrow, Cherokee, Cobb, Douglas, Paulding Columbus: Muscogee, Harris, Talbot, Chattahoochee, Stewart Meriwether ( NEW)

Southeast: Bryan, Chatham, Columbia Glynn, Liberty, McIntosh, Richmond McDuffie (NEW) Atlanta *

Value Plan not available in Cobb County Columbus Savannah

Augusta

Atl Medical Center Essential Plan not available in Chatham, Cherokee, Cobb, Fulton, Richmond & Stewart

Emory

Doctor’s Hospital

Candler

Augusta Hospital

WellStar

Hughston Hospital

Memorial Health

Medical College of GA

Grady Medical

St. Francis

St. Joseph’s

Select Specialty

Northside Hospital

Columbus Specialty

University Hospital

St. Joseph’s Hospital

*Also Gwinnett Medical & DeKalb Medical This content is for training purposes only. It has not been approved by CMS and cannot be used with consumers.