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여러분과함께합니다. 고품질의료서비스 2018 (EOC) Medicare Advantage California Orange, Riverside, San Bernardino Easy Choice Health Plan, Inc. H5087002000 2018-01-01~2018-12-31 Easy Choice Plus Plan (HMO) 406-002-000 H5087_WCM_01308K CMS Accepted Form CMS 10260-ANOC/EOC (Approved 05/2017) WellCare 2017 OMB Approval 0938-1051 (Expires: May 31, 2020) CA8RMREOC02145K_0002

2018 1 1 ~ 2018 12 31 : Easy Choice Plus Plan (HMO) Medicare 2018 1 1 12 31 Medicare.... Easy Choice Plus Plan (HMO) Easy Choice Health Plan, Inc. ( Easy Choice Health Plan, Inc.. Easy Choice Plus Plan (HMO) ). WellCare Easy Choice Health Plan (HMO) Medicare Medicare Advantage. Easy Choice.,,,. 1-866-999-3945. (TTY 711.) -, 8-8. 10 1 2 14, 8-8., (CD). ( )., / / 2019 1 1., /.. H5087_WCM_01308K CMS Accepted Form CMS 10260-ANOC/EOC OMB Approval 0938-1051 (Expires: May 31, 2020) (Approved 05/2017) WellCare 2017 CA8RMREOC02145K_0002

2018 Easy Choice Plus Plan (HMO) H5087_WCM_00962Z CMS ACCEPTED 06262017 WellCare 2017 CA7WCMINS00962Z_0000

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2018 Easy Choice Plus Plan (HMO) 8 1 : 5.4 Part D,?...18 6 Part D?...19 6.1 Part D?...19 6.2 Part D?...19 6.3 Part D,?...20 6.4 Part D,? 20 7...20 7.1...21 7.2?...23 8...24 8.1...24 9...25 9.1...25 10...25 10.1,?...25

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2018 Easy Choice Plus Plan (HMO) 20 1 :, 2016 :, 2016 :, 2016 : Part D ( ) $33.60 $107,000, $133,500 $214,000, $267,000 $133,500, $160,000 $267,000, $320,000 $54.20 $160,000 $85,000 $320,000 $74.80 6.3 Part D,?,., 1-800-772-1213 (TTY 1-800-325-0778). 6.4 Part D,? Medicare Part D (Medicare ).,. 7 Medicare. Medicare. 2, Medicare Part A Medicare Part B. ( Part A ) Medicare Part A.

2018 Easy Choice Plus Plan (HMO) 21 1 : Medicare Part B. Medicare. Part D., IRMAA. $85,000.01 ( ) $170,000.01 Medicare Part D (Medicare ). z,. z Medicare. z Part D 1, 6. https://www.medicare.gov 1-800-MEDICARE (1-800-633-4227) 7, 24. TTY 1-877-486-2048. 1-800-772-1213. TTY 1-800-325-0778. 2018 Medicare ' 2018 Medicare Medicare. Medicare Part B Part D. Medicare Medicare. Medicare 1. '2018 Medicare Medicare (https://www.medicare.gov). 1-800-MEDICARE (1-800-633-4227) 7, 24. TTY 1-877-486-2048. 7.1.,.. 3..

2018 Easy Choice Plus Plan (HMO) 22 1 : 1:... 28. WellCare... WellCare, P.O. Box 78230, Phoenix, AZ 85062-8230. ( : (HHS) Medicare Medicaid (CMS)). (NSF) $30.. WellCare.. 2:, www.wellcare.com/medicare,... 1.,., 12... 1. www.wellcare.com/medicare. 2.. 3. /... 4.. 5.., ID.

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2018 Easy Choice Plus Plan (HMO) 29 2 : 1 Easy Choice Plus Plan (HMO) (, ), Easy Choice Plus Plan (HMO).. - 1-866-999-3945. -, 8-8. 10 1 2 14, 8-8.. TTY 711.. -, 8-8. 10 1 2 14, 8-8. 1-877-999-3945 Easy Choice Health Plan Attn: Customer Service Department 10803 Hope St., Suite B Cypress, CA 90630 www.wellcare.com/medicare

2018 Easy Choice Plus Plan (HMO) 30 2 :. 9 ( (,, )).. - 1-866-999-3945. -, 8-8. 10 1 2 14, 8-8. TTY 711.. -, 8-8. 10 1 2 14, 8-8. 1-877-277-1809 WellCare Health Plans Coverage Determinations Department - Medical P.O. Box 31397 Tampa, FL 33631

2018 Easy Choice Plus Plan (HMO) 31 2 :. 9 ( (,, )). - 1-866-999-3945. -, 8-8. 10 1 2 14, 8-8. TTY 711.. -, 8-8. 10 1 2 14, 8-8. 1-855-571-2053 WellCare Health Plans Appeals Department - Medical P.O. Box 31368 Tampa, FL 33631-3368

2018 Easy Choice Plus Plan (HMO) 32 2 :.. (.) 9 ( (,, )). - 1-866-999-3945. -, 8-8. 10 1 2 14, 8-8. TTY 711.. -, 8-8. 10 1 2 14, 8-8. 1-855-571-2053 MEDICARE WellCare Health Plans Grievance Department P.O. Box 31384 Tampa, FL 33631-3384 Medicare. Medicare https://www.medicare.gov/medicarecomplaintform/home.aspx.

2018 Easy Choice Plus Plan (HMO) 33 2 : Part D Part D. Part D 9 ( (,, )). Part D - 1-866-999-3945. -, 8-8. 10 1 2 14, 8-8. TTY 711.. -, 8-8. 10 1 2 14, 8-8. 1-877-277-1809 www.wellcare.com/medicare

2018 Easy Choice Plus Plan (HMO) 34 2 : Part D. Part D 9 ( (,, )). Part D - 1-866-999-3945. -, 8-8. 10 1 2 14, 8-8. TTY 711.. -, 8-8. 10 1 2 14, 8-8. 1-866-388-1766 WellCare Prescription Insurance, Inc. Attn: Part D Appeals, P.O. Box 31383 Tampa, FL 33631-3383 : WellCare Prescription Insurance, Inc. Attn: Part D Appeals, 8735 Henderson Road, Ren 4 Tampa, FL 33633 www.wellcare.com/medicare

2018 Easy Choice Plus Plan (HMO) 35 2 : Part D.. (.) Part D 9 ( (,, )). Part D - 1-866-999-3945. -, 8-8. 10 1 2 14, 8-8. TTY 711.. -, 8-8. 10 1 2 14, 8-8. 1-855-571-2053 WellCare Health Plans Grievance Department P.O. Box 31384 Tampa, FL 33631-3384 MEDICARE Medicare. Medicare https://www.medicare.gov/medicarecomplaintform/home.aspx.

2018 Easy Choice Plus Plan (HMO) 36 2 : 7 ( ). :,. 9 ( (,, )). - 1-866-999-3945 -, 8-8. 10 1 2 14, 8-8.. TTY 711.. -, 8-8. 10 1 2 14, 8-8. 1-877-999-3945 WellCare Health Plans Pharmacy - Prescription Reimbursement Department P.O. Box 31577 Tampa, FL 33631-3577 WellCare Health Plans Medical Reimbursement Department P.O. Box 31370 Tampa, FL 33631 www.wellcare.com/medicare

2018 Easy Choice Plus Plan (HMO) 37 2 : 2 Medicare ( Medicare ) Medicare 65, 65 (ESRD) ( ). Medicare Medicare Medicaid ( CMS ). Medicare Advantage. Medicare - 1-800-MEDICARE 1-800-633-4227. 7, 24. TTY 1-877-486-2048..

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2018 Easy Choice Plus Plan (HMO) 39 2 : 3 (Medicare, ) (SHIP). California SHIP (HICAP). (HICAP) ( ). Medicare. (HICAP) Medicare. Medicare,, Medicare. (HICAP) Medicare. (HICAP) (California SHIP) 1-800-434-0222 TTY 711. 1300 National Drive, Suite 200 Sacramento, CA 95834 http://www.aging.ca.gov/hicap

2018 Easy Choice Plus Plan (HMO) 40 2 : 4 (Medicare Medicare ) Medicare. California, Livanta. Livanta. Medicare Medicare. Livanta.. Livanta : z. z. z, (CORF). Livanta (California ) 1-877-588-1123 -, 8 30-5 30 TTY 1-855-887-6668. Livanta, LLC, BFCC - QIO Area 5 9090 Junction Drive, Suite 10 Annapolis Junction, MD 20701 www.bfccqioarea5.com

2018 Easy Choice Plus Plan (HMO) 41 2 : 5 Medicare. 65 (ESRD) Medicare. Medicare. Medicare. Medicare. Medicare. Part D.,.,. - 1-800-772-1213., 7-7. 24. TTY 1-800-325-0778.., 7-7. https://www.ssa.gov

2018 Easy Choice Plus Plan (HMO) 42 2 : 6 Medi-Cal ( ) Medi-Cal. Medicare Medi-Cal., Medi-Cal Medicare Medicare Medicare. Medicare. z Medicare (QMB) : Medicare Part A Part B, (, ). ( QMB Medicaid (QMB+).) z Medicare (SLMB) : Part B. ( SLMB Medicaid (SLMB+).) z (QI) : Part B. z (QDWI) : Part A. Medicaid Medi-Cal. Medi-Cal (California Medicaid ) - 1-800-541-5555, -, 8 5 TTY 1-800-896-2512. Conduent, 820 Stillwater Road West Sacramento, CA 95605-1630 http://www.medi-cal.ca.gov/default.asp

2018 Easy Choice Plus Plan (HMO) 43 2 : 7 Medicare Extra Help Medicare Extra Help.. Medicare,. Extra Help. Extra Help. Extra Help. Medicare Extra Help. Extra Help. Extra Help. z 1-800-MEDICARE (1-800-633-4227). TTY 1-877-486-2048 7, 24. z ( : 1-800-772-1213). - 7-7. TTY 1-800-325-0778 ( ). z Medicaid ( ). ( 6 ). Extra Help,. z (BAE) Extra Help.. WellCare. 6 Medicaid 6 Medicaid { (SSA)

2018 Easy Choice Plus Plan (HMO) 44 2 : 6 Medicaid 6 Medicaid Medicaid 6 Medicaid 6 1 Medicaid Medicaid 6 1 ( ) Medicaid 6 Medicaid SSI... Extra Help... 6 HCBS ( ), 6 HCBS 6 HCBS, 6 HCBS, HCBS HCBS. BAE : 1-877-844-8531 ( : BAE) OR : WellCare Health Plans Attn: LISOVR P.O. Box 31392 Tampa, FL 33631-3392

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2018 Easy Choice Plus Plan (HMO) 113 4 : ( ) LIBERTY Dental Plan of California, Inc. CA 2000,, $2000 99 1. Liberty Dental. Liberty Dental. 99. 99.. 99. 99. CDT D0120 $0.00 D0140 $0.00 D0150 $0.00 D0160, $0.00 D0170,, $0.00 D0171, $0.00 D0180 $0.00 D0210, $0.00 D0220,, $0.00 D0230,, $0.00 D0240, $0.00 D0250 2D, $0.00 D0251 $0.00 D0270, $0.00 D0272, 2 $0.00 D0274, 4 $0.00 D0460 $0.00 D0470 $0.00 D1110, $0.00 D1120, $0.00 D1208, $0.00 D1310 $0.00 D1320 / $0.00 D1330 $0.00 CDT-2017: Current Dental Terminology, 2016 American Dental Association.. CAD2000-20161115 Making members shine, one smile at a time

2018 Easy Choice Plus Plan (HMO) 114 4 : ( ) CDT D2140, 1, $0.00 D2150, 2, $0.00 D2160, 3, $0.00 D2161, 4, $0.00 D2330, 1, $0.00 D2331, 2, $0.00 D2332, 3, $0.00 D2335, 4 / $0.00 D2390, $0.00 D2391, 1, $0.00 D2392, 2, $0.00 D2393, 3, $0.00 D2394, 4, $0.00 *,, : ( ) $250.00.. 1. : ( : Sunrise, Captek, Vitadure-N, Hi-Ceram, Optec, HSP, In-Ceram, Empress, Cerec, AllCeram, Procera, Lava ) CDT. 2. :,.. 3. :... 4. : a), b), c). D2720, $0.00* D2721, $0.00* D2722, $0.00* D2740, / $0.00* D2750, $0.00* D2751, $0.00* D2752, $0.00* D2780, 3/4 $0.00* D2781, 3/4 $0.00 D2782, 3/4 $0.00* D2783, 3/4 / $0.00* D2790, $0.00* D2791, $0.00 D2792, $0.00* D2910,, $0.00 D2920 $0.00 CDT-2017: Current Dental Terminology, 2016 American Dental Association.. CAD2000-20161115 Making members shine, one smile at a time

2018 Easy Choice Plus Plan (HMO) 115 4 : ( ) CDT ( ) D2931, $0.00 D2932 $0.00 D2933, $0.00 D2940 $0.00 D2950, ( ) $0.00 D2951,, $0.00 D2952, $0.00 D2953, $0.00 D2954 $0.00 D2955 $0.00 D2957, $0.00 D3110 ( ) $0.00 D3120 ( ) $0.00 D3220 ( ) $0.00 D3221,, $0.00 D3230,, ( ) $0.00 D3240,, ( ) $0.00 D3310, ( ) $0.00 D3320, ( ) $0.00 D3330, ( ) $0.00 D3331 ; $0.00 D3333 $0.00 D3346 - $0.00 D3347 - $0.00 D3348 - $0.00 D3351 /, $0.00 D3352 /, $0.00 D3353 / $0.00 D3410, $0.00 D3421, ( ) $0.00 D3425, ( ) $0.00 D3426, ( ) $0.00 D3430, $0.00 D3910 $0.00 D4210 /, 4 $0.00 D4211 /, 1-3 $0.00 D4260, 4 $0.00 D4261, 1-3 $0.00 : / (2). D4341, 4 $0.00 D4342, 1-3 $0.00 D4346, $0.00 CDT-2017: Current Dental Terminology, 2016 American Dental Association.. CAD2000-20161115 Making members shine, one smile at a time

2018 Easy Choice Plus Plan (HMO) 116 4 : ( ) CDT ( ) D4355 ( ) $0.00 D4381 / $0.00 D4920 ( ) $0.00 D5110, $0.00 D5120, $0.00 D5130, $0.00 D5140, $0.00 D5211, $0.00 D5212, $0.00 D5213, / $0.00 D5214, / $0.00 D5221, $0.00 D5222, $0.00 D5223,, $0.00 D5224,, $0.00 D5410, $0.00 D5411, $0.00 D5421, $0.00 D5422, $0.00 D5510 $0.00 D5520, $0.00 D5610 $0.00 D5620 $0.00 D5630, $0.00 D5640, $0.00 D5650 $0.00 D5660, $0.00 D5730, $0.00 D5731, $0.00 D5740, $0.00 D5741, $0.00 D5750, $0.00 D5751, $0.00 D5760, $0.00 D5761, $0.00 D5850, $0.00 D5851, $0.00 CDT-2017: Current Dental Terminology, 2016 American Dental Association.. CAD2000-20161115 Making members shine, one smile at a time

2018 Easy Choice Plus Plan (HMO) 117 4 : ( ) CDT *, ( ) : ( ) $250.00.. 1. : ( : Sunrise, Captek, Vitadure-N, Hi-Ceram, Optec, HSP, In-Ceram, Empress, Cerec, AllCeram, Procera, Lava ) CDT. 2. :,.. 3. :... 4. : a), b), c). D6210, $0.00* D6211, $0.00 D6212, $0.00* D6240, $0.00* D6241, $0.00* D6242, $0.00* D6245, / $0.00* D6250, $0.00* D6251, $0.00* D6252, $0.00* D6720, $0.00* D6721, $0.00* D6722, $0.00* D6740, / $0.00* D6750, $0.00* D6751, $0.00* D6752, $0.00* D6780, ¾ $0.00* D6781, ¾ $0.00 D6782, ¾ $0.00* D6783, ¾ / $0.00* D6790, $0.00* D6791, $0.00 D6792, $0.00* D6930 $0.00 D6980, $0.00 CDT-2017: Current Dental Terminology, 2016 American Dental Association.. CAD2000-20161115 Making members shine, one smile at a time

2018 Easy Choice Plus Plan (HMO) 118 4 : ( ) CDT D7111,, $0.00 D7140, $0.00 D7210 /, $0.00 D7220, $0.00 D7230, $0.00 D7240, $0.00 D7241,, $0.00 D7250 ( ) $0.00 D9110 ( ), $0.00 D9211 $0.00 D9212 $0.00 D9215 $0.00 D9310 $0.00 D9311 $0.00 D9410 / $0.00 D9420 $0.00 D9430,,, $0.00 D9440, $0.00 D9930,,, $0.00 D9986 $0.00 D9987 $0.00 D9991, $0.00 D9992, $0.00 D9993, $0.00 D9994, $0.00 LIBERTY Dental. LIBERTY Dental.,. CDT-2017: Current Dental Terminology, 2016 American Dental Association.. CAD2000-20161115 Making members shine, one smile at a time

2018 Easy Choice Plus Plan (HMO) 119 4 : ( ) : 1. (D0120) 6 1, (D0150) 6 1. 2. - (D0140) 1. 3. - 1. 4. ( ) 36 1. 5. 12 2 4. 6. - 21 6 1. 7. - 21 6 1. 8.,, ( ) 24 1. 9. 36 1. 10. 5 1, ( ). 11.,. 12. 3 3. 13. 3 1 2 3. 14. 36 1. 15. 36 1. 16. 24 1. 17., 5 1. 18.. 5. 19. 5 1. 20. 12 2. 21. 12 2. 22. - ( ) 12 2. 23. 12 2. 24. 12 2. 25. 12 2. CDT-2017: Current Dental Terminology, 2016 American Dental Association.. CAD2000-20161115 Making members shine, one smile at a time

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7

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8

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2018 Easy Choice Plus Plan (HMO) 184 8 : 1 1.1 (, ) To get information from us in a way that works for you, please call Customer Service (phone numbers are printed on the back cover of this booklet). Our plan has people and free interpreter services available to answer questions from disabled and non-english speaking members. We also have materials available in languages other than English that are spoken in the plan s service area. We can also give you information in Braille, in large print, or other alternate formats at no cost if you need it. We are required to give you information about the plan s benefits in a format that is accessible and appropriate for you. To get information from us in a way that works for you, please call Customer Service (phone numbers are printed on the back cover of this booklet) or contact a WellCare Civil Rights Coordinator. If you have any trouble getting information from our plan in a format that is accessible and appropriate for you, please call to file a grievance with Customer Service (phone numbers are printed on the back cover of this booklet). You may also file a complaint with Medicare by calling 1-800-MEDICARE (1-800-633-4227) or directly with the Office for Civil Rights. Contact information is included in this Evidence of Coverage or with this mailing, or you may contact Customer Service for additional information. Para obtener información de una manera que le sea conveniente, llame al Servicio de Atención al Cliente (los números de teléfono se encuentran impresos en la parte posterior de este folleto). Nuestro plan dispone de profesionales y servicios de interpretación gratuitos para atender preguntas de miembros con algún impedimento o que no hablen inglés. A parte del inglés, también disponemos de contenido para usted en otros idiomas habituales en el área de servicio del plan. Si lo precisara, podemos darle la información en braille, letra grande u otros formatos de forma gratuita. Tenemos la obligación de ofrecerle la información sobre los beneficios del plan en un formato que le resulte accesible y conveniente. Para obtener información de una manera que le sea conveniente, llame al Servicio de Atención al Cliente (los números de teléfono se encuentran impresos en la parte posterior de este folleto) o contacte con un Coordinador de Derechos Civiles de WellCare. Si se encuentra con algún problema para poder recibir la información de nuestro plan en un formato que le resulte accesible y conveniente, llame para presentar una protesta ante el Servicio de Atención al Cliente (los números de teléfono se encuentran impresos en la parte posterior de este folleto). También puede

2018 Easy Choice Plus Plan (HMO) 185 8 : presentar una queja ante Medicare si llama al 1-800-MEDICARE (1-800-633-4227) o directamente a través de la Oficina de Derechos Civiles. En la presente Evidencia de Cobertura o correo se incluye la información de contacto. Para más información, también puede contactar con el Servicio de Atención al Cliente.

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