Plan Materials and Forms

Information about plan benefits, services, and drug costs can be found in your plan materials.

Look at your Allwell from Managed Health Services (MHS) member ID card for your plan number and type to view materials for your plan.

View a sample of an Allwell Member ID Card to see where this information is located.

You can also look for plan materials based on the plan name and the county you live in.

If you don’t have a Allwell from Managed Health Services (MHS) ID card or have questions about plan materials, give us a call. We’re here to help.

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
Wellcare Giveback (HMO)	H3499 - 007	Boone, Delaware, Hamilton, Hancock, Hendricks, Howard, Johnson, Madison, Marion, Posey, Shelby, Tippecanoe, Tipton, Vanderburgh, and Warrick	Summary of Benefits, H3499 - 001 - English (PDF)
Wellcare No Premium (HMO)	H3499 - 002	Allen, Elkhart, LaPorte, Lake, Porter, St. Joseph, Wells and Whitley	Summary of Benefits, H3499 - 002 - English (PDF)
Wellcare Assist (HMO)	H3499-008		Summary of Benefits, H3499 - 008 - English (PDF)

For HMO D-SNP Members:

Plan Name	CMS#	County	Summary of Benefits
Wellcare Dual Access (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	Summary of Benefits, H3499 - 005 - English (PDF)

For PPO Members:

Plan Name	CMS#	County	Summary of Benefits
Wellcare No Premium Open (PPO)	H6348 - 002	Allen, Elkhart, St. Joseph, Wells and Whitley	Summary of Benefits, H6348 - 002 - English (PDF)
Wellcare Patriot Giveback Open (PPO)	H6348 - 005	LaPorte, Lake and Porter	Summary of Benefits, H6348 - 005 - English (PDF)

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
Wellcare Giveback (HMO)	H3499 - 007	Boone, Deleware, Hamilton, Hancock, Hendricks, Howard, Johnson, Madison, Marion, Posey, Shelby, Tippercanoe, Tipton, Vanderburgh and Warrick	Evidence of Coverage, H3499 - 007 - English (PDF)
Wellcare No Premium (HMO)	H3499 - 002	Allen, Elkhart, LaPorte, Lake, Porter, St. Joseph, Wells and Whitley	Evidence of Coverage, H3499 - 002 - English (PDF)
Wellcare Assist (HMO)	H3499 - 008		Evidence of Coverage, H3499 - 008 - English (PDF)

For HMO D-SNP Members:

Plan Name	CMS#	County	Evidence of Coverage
Wellcare Dual Access (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	Evidence of Coverage, H3499 - 005 - English (PDF)

For PPO Members:

Plan Name	CMS#	County	Evidence of Coverage
Wellcare No Premium Open (PPO)	H6348 - 001	Boone, Delaware, Hamilton, Hancock, Hendricks, Howard, Johnson, Madison, Marion, Shelby, Tippecanoe and Tipton	Evidence of Coverage, H6348 - 001 - English (PDF)
Wellcare No Premium Open (PPO)	H6348 - 002	Allen, Elkhart, St. Joseph, Wells and Whitley	Evidence of Coverage, H6348 - 002 - English (PDF)
Wellcare Patriot Giveback Open (PPO)	H6348 - 005	LaPorte, Lake and Porter	Evidence of Coverage, H6348 - 005 - English (PDF)

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
Wellcare Giveback (HMO)	H3499 - 007	Boone, Delaware, Hamilton, Hancock, Hendricks, Howard, Johnson, Madison, Marion, Posey, Shelby, Tippecanoe, Tipton, Vanderburgh, and Warrick	Annual Notice of Changes, H3499-007 - English (PDF) Annual Notice of Changes, H349-003-001 - English (PDF)
Wellcare No Premium (HMO)	H3499 - 002	Allen, Elkhart, LaPorte, Lake, Porter, St. Joseph, Wells and Whitley	Annual Notice of Changes, H3499-002 - English (PDF) Annual Notice of Changes, H3499-004-002 - English (PDF)
Wellcare Assist (HMO)	H3499 - 008		Annual Notice of Changes, H3499-008 - English (PDF)

For HMO D-SNP Members:

Plan Name	CMS#	County	Annual Notice of Changes
Wellcare Dual Access (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	Annual Notice of Changes, H3499-005 - English (PDF)

For PPO Members:

Plan Name	CMS#	County	Annual Notice of Changes
Wellcare No Premium Open (PPO)	H6348 - 001	Boone, Delaware, Hamilton, Hancock, Hendricks, Howard, Johnson, Madison, Marion, Shelby, Tippecanoe and Tipton	Annual Notice of Changes, H6348-001 - English (PDF)
Wellcare No Premium Open (PPO)	H6348 - 002	Allen, Elkhart, St. Joseph, Wells and Whitley	Annual Notice of Changes, H6348-002 - English (PDF)

Optional Benefit Individual Enrollment Form (PDF)

Optional Supplemental Benefits Flyers

Acupuncture National Coverage (PDF)

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.

Over-the-Counter Catalog - English / Spanish (PDF)

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

Over-The-Counter Benefits

Plan Name	CMS#	County	Annual Notice of Changes
Allwell Medicare (HMO)	H3499 -001- 002	Boone, Delaware, Hamilton, Hancock, Hendricks, Howard, Johnson, Madison, Marion, Shelby, Tippecanoe and Tipton counties	Annual Notice of Change, H3499 -001- 002 - English (PDF)
Allwell Medicare Boost (HMO)	H3499 - 002	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 counties	Annual Notice of Change, H3499 - 002 - English (PDF)

Plan Name	CMS#	County	Annual Notice of Change
Allwell Medicare (PPO)	H6348 - 001	Boone, Delaware, Hamilton, Hancock, Hendricks, Howard, Johnson, La Porte, Lake, Madison, Marion, Porter, Posey, Shelby, Tippecanoe, Tipton, Vanderburgh and Warrick counties	Annual Notice of Change, H6348 - 001 - English (PDF)
Allwell Medicare (PPO)	H6348 - 002	Allen, Elkhart, St. Joseph, Wells and Whitley counties	Annual Notice of Change, H6348 - 002 - English (PDF)
Allwell Medicare (PPO)	H6348 - 003-001	Allen, Elkhart, St. Joseph, Wells and Whitley counties	Annual Notice of Change, H6348 - 003-001 - English (PDF)
Allwell Medicare (PPO)	H6348 - 004-001	Allen, Elkhart, St. Joseph, Wells and Whitley counties	Annual Notice of Change, H6348 - 004-001 - English (PDF)

Plan Benefit Materials |

Plan Materials and Forms

For HMO Members:

For HMO D-SNP Members:

For PPO Members:

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For HMO D-SNP Members:

For PPO Members:

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For HMO D-SNP Members:

For PPO Members:

Plan Benefit Materials

For HMO Members:

For HMO D-SNP Members:

For PPO Members:

For HMO Members:

For HMO D-SNP Members:

For PPO Members:

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For HMO D-SNP Members:

For PPO Members:

Plan Benefit Materials |

Plan Materials and Forms

Summary of Benefits (SB)

For HMO Members:

For HMO D-SNP Members:

For PPO Members:

Evidence Of Coverage (EOC)

For HMO Members:

For HMO D-SNP Members:

For PPO Members:

Annual Notice of Changes (ANOC)

For HMO Members:

For HMO D-SNP Members:

For PPO Members:

Optional Benefit Form and Flyer

Acupuncture Coverage Form

Over-the-Counter Benefits

Over-The-Counter Benefits

Plan Benefit Materials

Summary of Benefits (SB)

For HMO Members:

For HMO D-SNP Members:

For PPO Members:

Evidence Of Coverage (EOC)

For HMO Members:

For HMO D-SNP Members:

For PPO Members:

Annual Notice of Changes (ANOC)

For HMO Members:

For HMO D-SNP Members:

For PPO Members:

Optional Supplemental Benefits Flyers

Acupuncture Coverage Form

Optional Benefit Individual Form

Over-The-Counter Benefits