Plan Benefit Materials |

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

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

For PPO Members:

Plan Name CMS# County Summary of Benefits
Wellcare No Premium Open (PPO) H6348 - 002

Allen, Elkhart, St. Joseph, Wells and Whitley

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

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

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

Wellcare No Premium Open (PPO) H6348 - 002

Allen, Elkhart, St. Joseph, Wells and Whitley

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

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

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

Wellcare No Premium Open (PPO) H6348 - 002

Allen, Elkhart, St. Joseph, Wells and Whitley

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