Plan Benefit Materials

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

Plans	CMS#	County	Summary of Benefits
Wellcare No Premium (HMO)	H0351 - 053	Cochise, Coconino, Gila, Graham, Greenlee, La Paz, Mohave, Santa Cruz, Yavapai, Yuma	Summary of Benefits, H0351 - 053 - English (PDF) Summary of Benefits, H0351 - 053 - Spanish (PDF)
Wellcare Giveback (HMO)	H0351 - 054	Cochise, Coconino, Gila, Graham, Greenlee, La Paz, Mohave, Santa Cruz, Yavapai, Yuma	Summary of Benefits, H0351 - 054 - English (PDF) Summary of Benefits, H0351 - 054 - Spanish (PDF)
Wellcare No Premium (HMO)	H0351 - 063	Maricopa, Pima, Pinal	Summary of Benefits, H0351 - 063 - English (PDF) Summary of Benefits, H0351 - 063 - Spanish (PDF)
Wellcare Assist (HMO)	H0351 - 061	Cochise, Coconino, Gila, Graham, Greenlee, La Paz, Mohave, Santa Cruz, Yavapai, Yuma	Summary of Benefits, H0351 - 061- English (PDF) Summary of Benefits, H0351 - 061 - Spanish (PDF)
Wellcare Assist (HMO)	H0351 - 062	Maricopa, Pima, Pinal	Summary of Benefits, H0351 - 062 English (PDF) Summary of Benefits, H5590 - 062 Spanish (PDF)
Wellcare Giveback (HMO)	H0351 - 064	Maricopa, Pima, Pinal	Summary of Benefits, H0351 - 064 English (PDF) Summary of Benefits, H0351 - 064 Spanish (PDF)

For HMO D-SNP and C-SNP Members

Plans	CMS#	County	Summary of Benefits
Wellcare Dual Liberty (HMO D-SNP)	H5590 - 008	Cochise, Gila, Graham, Greenlee, La Paz, Maricopa, Pima, Pinal, Santa Cruz, Yuma	Summary of Benefits, H5590 - 008 - English (PDF) Summary of Benefits, H5590 - 008 - Spanish (PDF)
Wellcare Dual Liberty (HMO D-SNP)	H5590 - 009	Apache, Coconino, Mohave, Navajo, Yavapai	Summary of Benefits, H5590 - 009 - English (PDF) Summary of Benefits, H5590 - 009 - Spanish (PDF)
Wellcare Specialty No Premium (HMO C-SNP)	H0351 - 038	Maricopa, Pima and Pinal	Summary of Benefits, H0351 - 038 - English (PDF) Summary of Benefits, H0351 - 038 - Spanish (PDF)
Wellcare Specialty No Premium (HMO C-SNP)	H0351 - 057	Cochise, Mohave, Santa Cruz, Yavapai, Yuma	Summary of Benefits, H0351 - 057 - English (PDF) Summary of Benefits, H0351 - 057 - Spanish (PDF)

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

Plans	CMS#	County	Evidence of Coverage
Wellcare No Premium (HMO)	H0351 - 053	Cochise, Coconino, Gila, Graham, Greenlee, La Paz, Mohave, Santa Cruz, Yavapai, Yuma	Evidence of Coverage, H0351 - 053 - English (PDF) Evidence of Coverage, H0351 - 053 - Spanish (PDF) Dental Benefit Details English (PDF) Dental Benefit Details Spanish (PDF)
Wellcare Giveback (HMO)	H0351 - 054	Cochise, Coconino, Gila, Graham, Greenlee, La Paz, Mohave, Santa Cruz, Yavapai, Yuma	Evidence of Coverage, H0351 - 054 - English (PDF) Evidence of Coverage, H0351 - 054 - Spanish (PDF) Dental Benefit Details English (PDF) Dental Benefit Details Spanish (PDF)
Wellcare No Premium (HMO)	H0351 - 063	Maricopa, Pima, Pinal	Evidence of Coverage, H0351 - 063 - English (PDF) Evidence of Coverage, H0351 - 063 - Spanish (PDF) Dental Benefit Details English (PDF) Dental Benefit Details Spanish (PDF)
Wellcare Assist (HMO)	H0351 - 061	Cochise, Coconino, Gila, Graham, Greenlee, La Paz, Mohave, Santa Cruz, Yavapai, Yuma	Evidence of Coverage, H0351 - 061 - English (PDF) Evidence of Coverage, H0351 - 061 - Spanish (PDF) Dental Benefit Details English (PDF) Dental Benefit Details Spanish (PDF)
Wellcare Assist (HMO)	H0351 - 062	Maricopa, Pima, Pinal	Evidence of Coverage, H0351 - 062 - English (PDF) Evidence of Coverage, H0351 - 062 - Spanish (PDF) Dental Benefit Details - English (PDF) Dental Benefit Details - Spanish (PDF)
Wellcare Giveback (HMO)	H0351 - 064	Maricopa, Pima, Pinal	Evidence of Coverage, H0351 - 064 - English (PDF) Evidence of Coverage, H0351 - 064 - Spanish (PDF) Dental Benefit Details English (PDF) Dental Benefit Details Spanish (PDF)

For HMO D-SNP and C-SNP Members

Plans	CMS#	County	Evidence of Coverage
Wellcare Dual Liberty (HMO D-SNP)	H5590 - 008	Cochise, Gila, Graham, Cochise, Gila, Graham, Greenlee, La Paz, Maricopa, Pima, Pinal, Santa Cruz, Yuma	Evidence of Coverage, H5590 - 008 - English (PDF) Evidence of Coverage, H5590 - 008 - Spanish (PDF) Dental Benefits Details English (PDF) Dental Benefits Details Spanish (PDF)
Wellcare Dual Liberty (HMO D-SNP)	H5590 - 009	Apache, Coconino, Mohave, Navajo, Yavapai	Evidence of Coverage, H5590 - 009 - English (PDF) Dental Benefits Details English (PDF)
Wellcare Specialty No Premium (HMO C-SNP)	H0351 - 038	Maricopa, Pima, Pinal	Evidence of Coverage, H0351 - 038 - English (PDF) Evidence of Coverage, H0351 - 038 - Spanish (PDF) Dental Benefit Details English (PDF) Dental Benefit Details Spanish (PDF)
Wellcare Specialty No Premium (HMO C-SNP)	H0351 - 057	Cochise, Mohave, Santa Cruz, Yavapai, Yuma	Evidence of Coverage, H0351 - 057 - English (PDF) Evidence of Coverage, H0351 - 057 - Spanish (PDF) Dental Benefit Details English (PDF) Dental Benefit Details Spanish (PDF)

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

Plans	CMS#	County	Annual Notice of Changes
Wellcare No Premium (HMO)	H0351 - 053	Cochise, Coconino, Gila, Graham, Greenlee, La Paz, Mohave, Santa Cruz, Yuma	Annual Notice of Changes, H0351-053- English (PDF) Annual Notice of Changes, H0351-053 - Spanish (PDF)
Wellcare Giveback (HMO)	H0351 - 054	Cochise, Coconino, Gila, Graham, Greenlee, La Paz, Mohave, Santa Cruz, Yuma	Annual Notice of Changes, H0351-054 - English (PDF) Annual Notice of Changes, H0351-054 - Spanish (PDF)
Wellcare Giveback (HMO)	H0351-060-002 to H0351-054	Cochise, Coconino, Gila, Graham, Greenlee, La Paz, Mohave, Santa Cruz, Yuma	Annual Notice of Changes, H0351-060-002 to H0351-054 - English (PDF) Annual Notice of Changes, H0351-060-002 to H0351-054 Spanish (PDF)
Wellcare No Premium (HMO)	H0351-058-002 to H0351-053	Cochise, Coconino, Gila, Graham, Greenlee, La Paz, Mohave, Santa Cruz, Yavapai, Yuma	Annual Notice of Changes, H0351-058-002 to H0351-053 - English (PDF) Annual Notice of Changes, H0351-058-002 to H0351-053 - Spanish (PDF)
Wellcare No Premium (HMO)	H0351-058-001 to H0351-063	Maricopa, Pima, Pinal	Annual Notice of Changes, H0351-058-001 to H0351-063 - English (PDF) Annual Notice of Changes, H0351-058-001 to H0351-063 - Spanish (PDF)
Wellcare No Premium (HMO)	H0351-059-001 to H0351-063	Maricopa, Pima, Pinal	Annual Notice of Changes, H0351-059-001 to H0351-063 - English (PDF) Annual Notice of Changes, H0351-059-001 to H0351-063 - Spanish (PDF)
Wellcare Assist (HMO)	H0351-061	Cochise, Coconino, Gila, Graham, Greenlee, La Paz, Mohave, Santa Cruz, Yavapai, Yuma	Annual Notice of Changes, H0351-061 - English (PDF) Annual Notice of Changes, H0351-061- Spanish (PDF)
Wellcare Assist (HMO)	H0351-059-002 to H0351-061	Cochise, Coconino, Gila, Graham, Greenlee, La Paz, Mohave, Santa Cruz, Yavapai, Yuma	Annual Notice of Changes, H0351-059-002 to H0351-061 - English (PDF) Annual Notice of Changes, H0351-059-002 to H0351-061- Spanish (PDF)
Wellcare Giveback (HMO)	H0351-060-001 to H0351-064	Maricopa, Pima, Pinal	Annual Notice of Changes, H0351-060-001 to H0351-064 - English (PDF) Annual Notice of Changes, H0351-060-001 to H0351-064 - English (PDF)

For HMO D-SNP and C-SNP Members

Plans	CMS#	County	Annual Notice of Change
Wellcare Dual Liberty (HMO D-SNP)	H5590 - 008	Cochise, Gila, Graham, Greenlee, La Paz, Maricopa, Pima, Pinal, Santa Cruz, Yuma	Annual Notice of Changes, H5590 - 008 - English (PDF) Annual Notice of Changes, H5590 - 008 - Spanish (PDF)
Wellcare Dual Liberty (HMO D-SNP)	H0351-059-001 to H5590-008	Cochise, Gila, Graham, Greenlee, La Paz, Maricopa, Pima, Pinal, Santa Cruz, Yuma	Annual Notice of Changes, H0351-059-001 to H5590-008 - English (PDF) Annual Notice of Changes, H0351-059-001 to H5590-008 - Spanish (PDF)
Wellcare Dual Liberty (HMO D-SNP)	H5590 - 009	Apache, Coconino, Mohave, Navajo, Yavapai	Annual Notice of Changes, H5590 - 009 - English (PDF)
Wellcare Specialty No Premium (HMO C-SNP)	H0351 - 038	Maricopa, Pima, Pinal	Annual Notice of Changes, H0351 - 038 - English (PDF) Annual Notice of Changes, H0351 - 038 - Spanish (PDF)
Wellcare Specialty No Premium (HMO C-SNP)	H0351 - 057	Cochise, Mohave, Santa Cruz, Yavapai, Yuma	Annual Notice of Changes, H0351 - 057 - English (PDF) Annual Notice of Changes, H0351 - 057 - Spanish (PDF)

Medicare Step Therapy Part B (PDF)

Covered Diabetes Testing Supplies

2024 Original Medicare Defined Cost Share Amounts and Premiums (PDF)

Plan Benefit Materials | Allwell at Arizona Complete Health

Plan Materials and Forms

For HMO Members

For HMO D-SNP and C-SNP Members

For HMO Members

For HMO D-SNP and C-SNP Members

For HMO Members

For HMO D-SNP and C-SNP Members

HMO

Wellcare Simple (HMO) H0351-053

Wellcare Giveback (HMO) H0351-054

Wellcare Simple (HMO) H0351-063

Wellcare Giveback (HMO) H0351-064

Wellcare Simple Value (HMO) H0351-065

HMO C-SNP

Wellcare Specialty Simple (HMO C-SNP) H0351-038

Wellcare Specialty Simple (HMO C-SNP) H0351-057

HMO D-SNP

Wellcare Dual Liberty (HMO D-SNP) H5590-008

Additional Forms

Plan Benefit Materials | Allwell at Arizona Complete Health

Plan Materials and Forms

Summary of Benefits (SB)

For HMO Members

For HMO D-SNP and C-SNP Members

Evidence Of Coverage (EOC)

For HMO Members

For HMO D-SNP and C-SNP Members

Annual Notice of Changes (ANOC)

For HMO Members

For HMO D-SNP and C-SNP Members

Step Therapy Part B

Covered Diabetes Testing Supplies

Over-the Counter Catalog and Healthy Food

2024 AHIP Flyer

Plan Benefit Materials

HMO

Wellcare Simple (HMO) H0351-053

Plan Benefits

Wellcare Giveback (HMO) H0351-054

Plan Benefits

Wellcare Simple (HMO) H0351-063

Plan Benefits

Wellcare Giveback (HMO) H0351-064

Plan Benefits

Wellcare Simple Value (HMO) H0351-065

Plan Benefits

HMO C-SNP

Wellcare Specialty Simple (HMO C-SNP) H0351-038

Plan Benefits

Wellcare Specialty Simple (HMO C-SNP) H0351-057

Plan Benefits

HMO D-SNP

Wellcare Dual Liberty (HMO D-SNP) H5590-008

Plan Benefits

Additional Forms

Step Therapy Part B

Covered Diabetes Testing Supplies

Over-the Counter Catalog and Healthy Food

2025 AHIP Flyer