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 |
Optional Supplemental Benefits Flyers
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