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	Summary of Benefits, H3499 - 001 - English (PDF)
Allwell Medicare (HMO)	H3499 - 002	Allen, Elkhart, LaPorte, Lake, Porter, St. Joseph, Wells and Whitley	Summary of Benefits, H3499 - 002 - English (PDF)

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	Summary of Benefits, H3499 - 005 - English (PDF)

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	Summary of Benefits, H6348 - 001 - English (PDF)
Allwell Medicare (PPO)	H6348 - 002	Allen, Elkhart, St. Joseph, Wells and Whitley	Summary of Benefits, H6348 - 002 - English (PDF)
Allwell Medicare (PPO)	H6348 - 003	Posey, Vanderburgh and Warrick	Summary of Benefits, H6348 - 003 - English (PDF)
Allwell Medicare (PPO)	H6348 - 004	LaPorte, Lake and Porter	Summary of Benefits, H6348 - 004 - 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
Allwell Medicare (HMO)	H3499 - 001	Boone, Deleware, Hamilton, Hancock, Hendricks, Howard, Johnson, Madison, Marion, Posey, Shelby, Tippercanoe, Tipton, Vanderburgh and Warrick	Evidence of Coverage, H3499 - 001 - English (PDF)
Allwell Medicare (HMO)	H3499 - 002	Allen, Elkhart, LaPorte, Lake, Porter, St. Joseph, Wells and Whitley	Evidence of Coverage, H3499 - 002 - English (PDF)

For HMO D-SNP Members:

2020 Medicare Defined Cost Sharing Amounts Notice (PDF)

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	Evidence of Coverage, H3499 - 005 - English (PDF)

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	Evidence of Coverage, H6348 - 001 - English (PDF)
Allwell Medicare (PPO)	H6348 - 002	Allen, Elkhart, St. Joseph, Wells and Whitley	Evidence of Coverage, H6348 - 002 - English (PDF)
Allwell Medicare (PPO)	H6348 - 003	Posey, Vanderburgh and Warrick	Evidence of Coverage, H6348 - 003 - English (PDF)
Allwell Medicare (PPO)	H6348 - 004	LaPorte, Lake and Porter	Evidence of Coverage, H6348 - 004 - 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
Allwell Medicare (HMO)	H3499 - 001	Boone, Delaware, Hamilton, Hancock, Hendricks, Howard, Johnson, Madison, Marion, Posey, Shelby, Tippecanoe, Tipton, Vanderburgh, and Warrick	Annual Notice of Changes, H3499-001 - English (PDF) Annual Notice of Changes, H349-003-001 - English (PDF)
Allwell Medicare (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)

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	Annual Notice of Changes, H3499-005 - English (PDF)

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	Annual Notice of Changes, H6348-001 - English (PDF)
Allwell Medicare (PPO)	H6348 - 002	Allen, Elkhart, St. Joseph, Wells and Whitley	Annual Notice of Changes, H6348-002 - English (PDF)
Allwell Medicare (PPO)	H6348 - 003	Posey, Vanderburgh and Warrick	Annual Notice of Changes, H6348-003 - English (PDF)
Allwell Medicare (PPO)	H6348 - 004	LaPorte, Lake and Porter	Annual Notice of Changes, H6348-004 - 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

Plan Name	CMS#	County	Summary of Benefits
Allwell Medicare (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	Summary of Benefits, H3499 - 002 - English (PDF)
Allwell Medicare Boost (HMO)	H3499 - 007	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	Summary of Benefits, H3499 - 007 - English (PDF)
Allwell Medicare Complement (HMO)	H3499 - 008	Adams, Allen, Bartholomew, Benton, Blackford, Boone, Brown, Carroll, Cass, Clark, Clay, Clinton, Crawford, Daviess, De Kalb, Dearborn, Decatur, Delaware, Dubois, Elkhart, Fayette, Floyd, Fountain, Franklin, Fulton, Gibson, Grant, Greene, Hamilton, Hancock, Harrison, Hendricks, Henry, Howard, Huntington, Jackson, Jasper, Jay, Jefferson, Jennings, Johnson, Knox, Kosciusko, La Porte, Lagrange, Lake, Lawrence, Madison, Marion, Marshall, Martin, Miami, Monroe, Montgomery, Morgan, Newton, Noble, Ohio, Orange, Owen, Parke, Perry, Pike, Porter, Posey, Pulaski, Putnam, Randolph, Ripley, Rush, Scott, Shelby, Spencer, St. Joseph, Starke, Steuben, Sullivan, Switzerland, Tippecanoe, Tipton, Union, Vanderburgh, Wabash, Warren, Warrick, Washington, Wayne, Wells, White and Whitley counties	Summary of Benefits, H3499 - 008 - English (PDF)

Plan Name	CMS#	County	Evidence of Coverage
Allwell Medicare (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	Evidence of Coverage, H3499 - 002 - English (PDF)
Allwell Medicare Boost (HMO)	H3499 - 007	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	Evidence of Coverage, H3499 - 007 - English (PDF)
Allwell Medicare Complement (HMO)	H3499 - 008	Adams, Allen, Bartholomew, Benton, Blackford, Boone, Brown, Carroll, Cass, Clark, Clay, Clinton, Crawford, Daviess, De Kalb, Dearborn, Decatur, Delaware, Dubois, Elkhart, Fayette, Floyd, Fountain, Franklin, Fulton, Gibson, Grant, Greene, Hamilton, Hancock, Harrison, Hendricks, Henry, Howard, Huntington, Jackson, Jasper, Jay, Jefferson, Jennings, Johnson, Knox, Kosciusko, La Porte, Lagrange, Lake, Lawrence, Madison, Marion, Marshall, Martin, Miami, Monroe, Montgomery, Morgan, Newton, Noble, Ohio, Orange, Owen, Parke, Perry, Pike, Porter, Posey, Pulaski, Putnam, Randolph, Ripley, Rush, Scott, Shelby, Spencer, St. Joseph, Starke, Steuben, Sullivan, Switzerland, Tippecanoe, Tipton, Union, Vanderburgh, Wabash, Warren, Warrick, Washington, Wayne, Wells, White and Whitley counties	Evidence of Coverage, H3499 - 008 - English (PDF)

Plan Benefit Materials |

Plan Materials and Forms

For HMO Members:

For HMO D-SNP Members:

For PPO Members:

For HMO Members:

For HMO D-SNP Members:

For PPO Members:

For HMO Members:

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:

For HMO Members:

For HMO D-SNP Members:

For PPO Members:

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 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

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