Declaration of Prior Prescription Drug Coverage

Are you a Wellcare or Wellcare by ‘Ohana member who would like to submit a Late Enrollment Penalty (LEP) attestation?

Use this form to submit the information.

We will be notified once the plan has receipt of this form.

Date:

Enrollee Name:

Mailing Address:

Phone Number:

Medicare Health Insurance Claim #:
(from red, white and blue Medicare card)

Name of Plan:

Date From:

Date To:

Please check all boxes that apply to you.

I had creditable* prescription drug coverage from an Employer/Union, including the Federal Employees Health Benefits Program (FEHBP)

Name:

Date From:

Date To:

I had creditable* prescription drug coverage from Medicaid, State Pharmaceutical Assistance Program (SPAP), or another plan sponsored by my state

Name of SPAP:

If you are in an SPAP, what state do you live in:

Date From:

Date To:

I had prescription drug coverage through my VA benefits (veterans, survivor, or dependent benefits)

Date From:

Date To:

I had prescription drug coverage through my TRICARE or other military coverage

Date From:

Date To:

I had a Medigap (Medicare Supplemental) policy with creditable* prescription drug coverage

Date From:

Date To:

I had prescription drug coverage through the Indian Health Service, a Tribe or Tribal organization, or an Urban Indian organization (I/T/U)

Date From:

Date To:

I had prescription drug coverage through PACE (Program of All-Inclusive Care for the Elderly)

Date From:

Date To:

I had creditable* prescription drug coverage from a different source not listed above.

Name of other source:

Date From:

Date To:

I have/had extra help from Medicare to pay for my prescription drug coverage.

Date From:

Date To:

I lived in an area affected by Hurricane Katrina at the time of the hurricane (August 2005) and I joined a Medicare prescription drug plan before December 31, 2006.

Name of Parish:

Date From:

Date To:

I never had creditable* drug coverage

* “Creditable” means that your prior coverage met Medicare’s minimum standards

Please complete this section: "To the best of my knowledge, the information on this form is true and correct. I understand that if I didn’t have creditable coverage and/or don’t give proof of creditable prescription drug coverage if asked, my premium may be higher.

I understand that by completing this form (or completion by a person authorized to act on behalf of the individual under the laws of the State where the individual resides) means that I have read and understand the contents of this declaration."

I attest that this information is accurate.

Date:

If you are the representative, you must provide the following information:

Name:

Address:

City

State:

Zip:

Relationship to Enrollee:

Phone Number:

Multi-language Interpreter Services

‘Ohana Health Plan, a plan offered by WellCare Health Insurance of Arizona, Inc.

Washington residents: Health Net Life Insurance Company is contracted with Medicare for PPO plans. “Wellcare by Health Net” is issued by Health Net Life Insurance Company.

Washington residents: “Wellcare” is issued by WellCare Health Insurance Company of Washington, Inc.

Washington residents: “Wellcare” is issued by Coordinated Care of Washington, Inc.

“Wellcare” is issued by WellCare Prescription Insurance, Inc.

Louisiana D-SNP members: As a Wellcare HMO D-SNP member, you have coverage from both Medicare and Medicaid. You receive your Medicare health care and prescription drug coverage through Wellcare and are also eligible to receive additional health care services and coverage through Louisiana Medicaid. Learn more about providers who participate in Louisiana Medicaid by visiting www.myplan.healthy.la.gov/en/findprovider or www.louisianahealthconnect.com. For detailed information about Louisiana Medicaid benefits, please visit the Medicaid website at https://Idh.la.gove/medicaid and select the “Learn about Medicaid Services” link. To request a written copy of our Medicaid Provider Directory, please contact us.

Texas D-SNP members: As a Wellcare HMO D-SNP member, you have coverage from both Medicare and Medicaid. You receive your Medicare health care and prescription drug coverage through Wellcare and are also eligible to receive additional health care services and coverage through Texas Medicaid. Learn more about providers who participate in Texas Medicaid by visiting wellcarefindaprovider.com. For detailed information about Texas Medicaid benefits, please visit the Texas Medicaid website at www.hhs.texas.gov/services/health/medicaid-chip/medicaid-chip-members/starplus. To request a written copy of our Medicaid Provider Directory, please contact us.

Notice: TennCare is not responsible for payment for these benefits, except for appropriate cost sharing amounts. TennCare is not responsible for guaranteeing the availability or quality of these benefits. Any benefits above and beyond traditional Medicare benefits are applicable to Wellcare Medicare Advantage only and do not indicate increased Medicaid benefits.

Declaration of Prior Prescription Drug Coverage

Disclaimers