Plan Benefit Materials |

Plan Materials and Forms

 

Listed below are some documents that may be helpful at different times during your membership. 

This booklet gives you a summary of costs and coverage in your plan. 

Please select the document for your plan and county:

For HMO Members:

Plan Name CMS# County Summary of Benefits
Allwell Medicare (HMO) H3499 - 001

Boone, Delaware, Hamilton, Hancock, Hendricks, Howard, Johnson, Madison, Marion, Posey, Shelby, Tippecanoe, Tipton, Vanderburgh, and Warrick

Allwell Medicare (HMO) H3499 - 002

Allen, Elkhart, LaPorte, Lake, Porter, St. Joseph, Wells and Whitley

For HMO D-SNP Members:

Plan Name CMS# County Summary of Benefits
Allwell Dual Medicare (HMO D-SNP) H3499 - 005

Allen, Boone, Delaware, Elkhart, Hamilton, Hancock, Hendricks, Howard, Johnson, La Porte, Lake, Madison, Marion, Porter, Posey, Shelby, St. Joseph, Tippecanoe, Tipton, Vanderburgh, Warrick, Wells and Whitley

For PPO Members:

Plan Name CMS# County Summary of Benefits
Allwell Medicare (PPO) H6348 - 001

Boone, Delaware, Hamilton, Hancock, Hendricks, Howard, Johnson, Madison, Marion, Shelby, Tippecanoe and Tipton

Allwell Medicare (PPO) H6348 - 002

Allen, Elkhart, St. Joseph, Wells and Whitley

Allwell Medicare (PPO) H6348 - 003

Posey, Vanderburgh and Warrick

Allwell Medicare (PPO) H6348 - 004 LaPorte, Lake and Porter

This booklet gives you a complete list of services, limitations and exclusions for your plan coverage.

Please select the document for your plan and county:

For HMO Members:

Plan Name CMS# County Evidence of Coverage
Allwell Medicare (HMO) H3499 - 001

Boone, Deleware, Hamilton, Hancock, Hendricks, Howard, Johnson, Madison, Marion, Posey, Shelby, Tippercanoe, Tipton, Vanderburgh and Warrick

Allwell Medicare (HMO) H3499 - 002

Allen, Elkhart, LaPorte, Lake, Porter, St. Joseph, Wells and Whitley

For HMO D-SNP Members:

Plan Name CMS# County Evidence of Coverage
Allwell Dual Medicare (HMO D-SNP) H3499 - 005

Allen, Boone, Delaware, Elkhart, Hamilton, Hancock, Hendricks, Howard, Johnson, La Porte, Lake, Madison, Marion, Porter, Posey, Shelby, St. Joseph, Tippecanoe, Tipton, Vanderburgh, Warrick, Wells and Whitley

For PPO Members:

Plan Name CMS# County Evidence of Coverage
Allwell Medicare (PPO) H6348 - 001

Boone, Delaware, Hamilton, Hancock, Hendricks, Howard, Johnson, Madison, Marion, Shelby, Tippecanoe and Tipton

Allwell Medicare (PPO) H6348 - 002

Allen, Elkhart, St. Joseph, Wells and Whitley

Allwell Medicare (PPO) H6348 - 003

Posey, Vanderburgh and Warrick

Allwell Medicare (PPO) H6348 - 004 LaPorte, Lake and Porter

If you were enrolled in Allwell from Managed Health Services (MHS) last year, this booklet will tell you about changes to your plan’s costs and benefits for the coming year.

Please select the document for your plan and county:

For HMO Members:

Plan Name CMS# County Annual Notice of Changes
Allwell Medicare (HMO) H3499 - 001

Boone, Delaware, Hamilton, Hancock, Hendricks, Howard, Johnson, Madison, Marion, Posey, Shelby, Tippecanoe, Tipton, Vanderburgh, and Warrick

Allwell Medicare (HMO) H3499 - 002

Allen, Elkhart, LaPorte, Lake, Porter, St. Joseph, Wells and Whitley

For HMO D-SNP Members:

Plan Name CMS# County Annual Notice of Changes
Allwell Dual Medicare (HMO D-SNP) H3499 - 005

Allen, Boone, Delaware, Elkhart, Hamilton, Hancock, Hendricks, Howard, Johnson, La Porte, Lake, Madison, Marion, Porter, Posey, Shelby, St. Joseph, Tippecanoe, Tipton, Vanderburgh, Warrick, Wells and Whitley

For PPO Members:

Plan Name CMS# County Annual Notice of Changes
Allwell Medicare (PPO) H6348 - 001

Boone, Delaware, Hamilton, Hancock, Hendricks, Howard, Johnson, Madison, Marion, Shelby, Tippecanoe and Tipton

Allwell Medicare (PPO) H6348 - 002

Allen, Elkhart, St. Joseph, Wells and Whitley

Allwell Medicare (PPO) H6348 - 003

Posey, Vanderburgh and Warrick

Allwell Medicare (PPO) H6348 - 004 LaPorte, Lake and Porter

Your current plan may have an over-the-counter (OTC) benefit that lets you buy OTC health and wellness products. This catalog includes a list of OTC items that you can order to be mailed to your home. Check the catalog for item limits.

Ordering is easy. Just follow the steps in your plan's catalog.

Don’t want to wait? You may be able to pick up your OTC products from a CVS store near you. Please note: this does not include CVS locations inside of Target stores.

Connect to the CVS OTC website to view available products and store information.

 

 

Material ID: Y0020_20_17590WEB_C_03192020