Statements of Understanding

When completing your enrollment in a WellCare Prescription Drug Plan, you understand and acknowledge the following:

1. If your plan has a monthly plan premium, you can pay your monthly plan premium by mail or electronic funds transfer (EFT) each month. You can also choose to pay your premium by automatic deduction from your Social Security or Railroad Retirement Board benefit check each month. If you don't select a payment option, you will receive a coupon book/payment book.

2. If you qualify for Extra Help with your Medicare prescription drug coverage costs, Medicare will pay all or part of your plan premiums. If Medicare pays only a portion of this premium, we will bill you for the amount that Medicare does not cover.

3. People with limited incomes may qualify for Extra Help to pay for their prescription drug costs. If you qualify, Medicare could pay for up to seventy-five (75) percent or more of your drug costs, including monthly prescription drug premiums, annual deductibles and coinsurance. Additionally, those who qualify will not be subject to the coverage gap or a late enrollment penalty. Many people are eligible for these savings and don’t even know it. For more information about this Extra Help, contact your local Social Security office, or call 1-800-MEDICARE (1-800-633-4227), 24 hours per day, 7 days per week. TTY users should call 1-877-486-2048. You can also apply for Extra Help online at www.socialsecurity.gov/prescriptionhelp.

4. If you are a member of a Medicare Advantage Plan (like an HMO or PPO), you may already have prescription drug coverage from your Medicare Advantage Plan that will meet your needs. By joining WellCare, your membership in your Medicare Advantage Plan may end. This will affect both your doctor and hospital coverage as well as your prescription drug coverage. Read the information that your Medicare Advantage Plan sends you and if you have any questions, contact your Medicare Advantage Plan.

5. If you currently have health coverage from an employer or union, joining WellCare could affect your employer or union health benefits. You could lose your employer or union health coverage if you join WellCare. Read the communications your employer or union sends you. If you have questions, visit their Web site or contact the office listed in their communications. If there isn’t any information on whom to contact, your benefits administrator or the office that answers questions about your coverage can help.

6. WellCare is a Medicare drug plan and has a contract with the federal government. You understand that this prescription drug coverage is in addition to your coverage under Medicare; therefore, you will need to keep your Medicare Part A or Part B coverage. It is your responsibility to inform WellCare of any prescription drug coverage that you have or may get in the future.

7. You can only be in one Medicare Prescription Drug Plan at a time. Once your enrollment in WellCare is approved by Medicare, you will be automatically disenrolled from your current plan. You don’t need to take any action to be disenrolled from your current plan.

8. Enrollment in this plan is generally for the entire year. Once you enroll, you may leave this plan or make changes only at certain times of the year when an enrollment period is available (example: you may make changes generally during the Annual Enrollment Period October 15–December 7 of every year), or under certain special circumstances.

9. WellCare serves a specific service area. If you move out of the area that WellCare serves, you need to notify the plan so you can disenroll and find a new plan in your new area. You understand you must use network pharmacies except in an emergency when you cannot reasonably use WellCare network pharmacies.

10. Once you are a member of WellCare, you have the right to appeal plan decisions about payment or services if you disagree. You will read the Evidence of Coverage document from WellCare when you get it to know which rules you must follow in order to receive coverage.

11. You understand that if you leave this plan and don’t have or get other Medicare prescription drug coverage or creditable prescription drug coverage (as good as Medicare’s) for a continuous period of 63 days or more, you may have to pay a late enrollment penalty in addition to your premium for Medicare prescription drug coverage in the future. If you qualify for certain exceptions such as receiving Extra Help, you may not be required to pay this penalty.

12. The person who is discussing plan options with you is either employed by or contracted with WellCare. This person may be paid based on your enrollment in a WellCare plan.

13. Counseling services may be available in your state to provide advice concerning Medicare Supplement Insurance or other Medicare Advantage or Prescription Drug Plans options, medical assistance through the state Medicaid program and the Medicare Savings Program.

14. By joining this Medicare Prescription Drug Plan, you acknowledge that WellCare will release your information to Medicare and other plans as is necessary for treatment, payment and health care operations. You also acknowledge that WellCare will release your information, including your prescription drug event data, to Medicare, who may release it for research and other purposes that follow all applicable federal statutes and regulations. The information that you have provided for this enrollment request is correct to the best of your knowledge. You understand that if you intentionally provide false information on this form, you will be disenrolled from the plan.

15. On this date, you understand that by completing this enrollment request, you understand the enrollment application process. If you are not the enrollee, only authorized individuals can enroll on behalf of an enrollee. Your agreement means you certify that: 1) you are authorized under state law to complete this enrollment, and 2) documentation of this authority is available upon request by WellCare or by Medicare.

S5967_NA016406_PDP_WEB_ENG CMS Approved 10272011