Plan Materials and Forms

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

Look at your Wellcare By Allwell member ID card for your plan number and type to view materials for your plan.

View a sample of an Wellcare By 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 Wellcare By Allwell ID card or have questions about plan materials, give us a call. We’re here to help.

For HMO Members

Plans	CMS#	County	Summary of Benefits
Wellcare No Premium (HMO)	H0351 - 052	Maricopa, Pima, Pinal, Yavapai	Summary of Benefits, H0351 - 052 - English (PDF) Summary of Benefits, H0351 - 052 - Spanish (PDF)
Wellcare No Premium (HMO)	H0351 - 053	Cochise, Mohave, Santa Cruz, Yuma	Summary of Benefits, H0351 - 053 - English (PDF) Summary of Benefits, H0351 - 053 - Spanish (PDF)
Wellcare Giveback (HMO)	H0351 - 054	Cochise, Mohave, Santa Cruz, Yuma	Summary of Benefits, H0351 - 054 - English (PDF) Summary of Benefits, H0351 - 054 - Spanish (PDF)
Wellcare Assist (HMO)	H0351 - 055	Maricopa, Pima, Pinal, Yavapai	Summary of Benefits, H0351 - 055 - English (PDF) Summary of Benefits, H0351 - 055 - Spanish (PDF)
Wellcare Giveback (HMO)	H0351 - 056	Maricopa, Pima, Pinal, Yavapai	Summary of Benefits, H0351 - 056 - English (PDF) Summary of Benefits, H0351 - 056 - Spanish (PDF)
Wellcare No Premium Essentials (HMO)	H5590-0005	Maricopa and Pinal	Summary of Benefits, H5590 - 005 - English (PDF) Summary of Benefits, H5590 - 005 - Spanish (PDF)
Wellcare Assist (HMO)	H5590 - 007	Cochise, Mohave, Santa Cruz, Yuma	Summary of Benefits, H5590 - 007 - English (PDF) Summary of Benefits, H5590 - 007 - Spanish (PDF)

For HMO D-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)

For HMO Members

Plans	CMS#	County	Evidence of Coverage
Wellcare No Premium (HMO)	H0351 - 052	Maricopa, Pima, Pinal, Yavapai	Evidence of Coverage, H0351 - 052 - English (PDF) Evidence of Coverage, H0351 - 052 - Spanish (PDF)
Wellcare No Premium (HMO)	H0351 - 053	Cochise, Mohave, Santa Cruz, Yuma	Evidence of Coverage, H0351 - 053 - English (PDF) Evidence of Coverage, H0351 - 053 - Spanish (PDF)
Wellcare Giveback (HMO)	H0351 - 054	Cochise, Mohave, Santa Cruz, Yuma	Evidence of Coverage, H0351 - 054 - English (PDF) Evidence of Coverage, H0351 - 054 - Spanish (PDF)
Wellcare Assist (HMO)	H0351 - 055	Maricopa, Pima, Pinal, Yavapai	Evidence of Coverage, H0351 - 055 - English (PDF) Evidence of Coverage, H0351 - 055 - Spanish (PDF)
Wellcare Giveback (HMO)	H0351 - 056	Maricopa, Pima, Pinal, Yavapai	Evidence of Coverage, H0351 - 056 - English (PDF) Evidence of Coverage, H0351 - 056 - Spanish (PDF)
Wellcare No Premium Essentials (HMO)	H5590-0005	Maricopa and Pinal	Evidence of Coverage, H5590 - 005 - English (PDF) Evidence of Coverage, H5590 - 005 - Spanish (PDF)
Wellcare Assist (HMO)	H5590 - 007	Cochise, Mohave, Santa Cruz, Yuma	Evidence of Coverage, H5590 - 007 - English (PDF) Evidence of Coverage, H5590 - 007 - Spanish (PDF)

For HMO D-SNP Members

Plans	CMS#	County	Evidence of Coverage
Wellcare Dual Liberty (HMO D-SNP)	H5590 - 008	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)
Wellcare Dual Liberty (HMO D-SNP)	H5590 - 009	Apache, Coconino, Mohave, Navajo, Yavapai	Evidence of Coverage, H5590 - 009 - English (PDF) Evidence of Coverage, H5590 - 009 - Spanish (PDF)
Wellcare Specialty No Premium (HMO C-SNP)	H0351 - 038	Maricopa, Pima and Pinal	Evidence of Coverage, H0351 - 038 - English (PDF) Evidence of Coverage, H0351 - 038 - 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)

For PPO Members

Plans	CMS#	County	Evidence of Coverage
Wellcare No Premium Open (PPO)	H8553 - 001	Maricopa, Pima	Evidence of Coverage, H8553 - 001 - English (PDF)
Wellcare Patriot Giveback Open (PPO)	H8553 - 002	Maricopa, Pima	Evidence of Coverage, H8553 - 002 - English (PDF)
Wellcare No Premium Rx Plus Open (PPO)	H8553 - 003	Maricopa, Pima	Evidence of Coverage, H8553 - 003 - English (PDF)

For HMO Members

Plans	CMS#	County	Annual Notice of Changes
Wellcare No Premium (HMO)	H0351-052	Maricopa, Pima, Pinal, Yavapai	Annual Notice of Changes, H0351-052 - English (PDF) Annual Notice of Changes, H0351-052 - Spanish (PDF)
WellCare Value (HMO) to WellCare No Premium (HMO)	H6439-002 to H0351-052	Maricopa, Pima, Pinal, Yavapai	Annual Notice of Changes, H6439-002 to H0351-052 - English (PDF) Annual Notice of Changes, H6439-002 to H0351-052 - Spanish (PDF)
Wellcare No Premium (HMO)	H0351 - 053	Cochise, 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, Mohave, Santa Cruz, Yuma	Annual Notice of Changes, H0351-054 - English (PDF) Annual Notice of Changes, H0351-054 - Spanish (PDF)
WellCare Compass (HMO) to Wellcare Assist (HMO)	H6439-003 - H0351-055	Maricopa, Pima, Pinal, Yavapai	Annual Notice of Changes, H6439-003 - H0351-055 - English (PDF) Annual Notice of Changes, H6439-003 - H0351-055 - Spanish (PDF)
WellCare Dividend (HMO) to Wellcare Giveback (HMO)	H6439-004 - H0351-056	Maricopa, Pima, Pinal, Yavapai	Annual Notice of Changes, H6439-004 - H0351-056 - English (PDF) Annual Notice of Changes, H6439-004 - H0351-056 - Spanish (PDF)
Wellcare No Premium Essentials (HMO)	H5590-0005	Maricopa and Pinal	Annual Notice of Changes, H5590-005 - English (PDF) Annual Notice of Changes, H5590-005 - Spanish (PDF)
Wellcare Assist (HMO)	H5590 - 007	Cochise, Mohave, Santa Cruz, Yuma	Annual Notice of Changes, H5590-007 - English (PDF) Annual Notice of Changes, H5590-007 - Spanish (PDF)
Allwell Medicare (HMO) to Wellcare Assist (HMO)	H5590-004 - H5590-007	Cochise, Mohave, Santa Cruz, Yuma	Annual Notice of Changes, H5590-004 - H5590-007 - English (PDF) Annual Notice of Changes, H5590-004 - H5590-007 - Spanish (PDF)

For HMO D-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 Specialty No Premium (HMO C-SNP)	H0351 - 038	Maricopa, Pima and Pinal	Annual Notice of Changes, H0351 - 038 - English (PDF) Annual Notice of Changes, H0351 - 038 - Spanish (PDF)

Plan Name	CMS #	County	Summary of Benefits
Allwell Medicare Premier II (HMO)	H0351-052	Maricopa, Pima and Pinal counties	Summary of Benefits - H0351-052 - English (PDF) Summary of Benefits H0351-052- Spanish (PDF)
Allwell Medicare Premier II (HMO)	H0351-053	Cochise, Santa Cruz, Yavapai and Yuma counties	Summary of Benefits - H0351-053 - English (PDF) Summary of Benefits H0351-053 - Spanish (PDF)
Allwell Medicare Boost (HMO)	H0351-054	Cochise, Santa Cruz and Yuma counties	Summary of Benefits - H0351-054 - English (PDF) Summary of Benefits H0351-054 - Spanish (PDF)
Allwell Medicare (HMO)	H5590-004	Yavapai and Yuma Counties	Summary of Benefits - H5590-004 - English (PDF) Summary of Benefits H5590-004 - Spanish (PDF)
Allwell Medicare Essentials (HMO)	H5590-005	Maricopa and Pinal counties	Summary of Benefits - H5590-005 - English (PDF) Summary of Benefits H5590-005 - Spanish (PDF)
Allwell Medicare Essentials I (HMO)	H5590-007	Cochise, Santa Cruz and Yuma counties	Summary of Benefits - H5590-007 - English (PDF) Summary of Benefits H5590-007 - Spanish (PDF)

Plan Name	CMS #	County	Summary of Benefits
Allwell CHF/Diabetes Medicare (HMO C-SNP)	H0351-038	Maricopa and Pinal counties	Summary of Benefits - H0351-038 - English (PDF) Summary of Benefits H0351-038 - Spanish (PDF)
Allwell Dual Medicare (HMO D-SNP)	H5590-008	Cochise, Gila, Graham, Greenlee, La Paz, Maricopa, Pima, Pinal, Santa Cruz and Yuma counties	Summary of Benefits - H5590-008 - English (PDF) Summary of Benefits H5590-008 - Spanish (PDF)

Plan Name	CMS #	County	Evidence of Coverage
Allwell Medicare Premier II (HMO)	H0351-052	Maricopa, Pima and Pinal counties	Evidence of Coverage - H0351-052 - English (PDF) Evidence of Coverage, H0351-052 - Spanish (PDF)
Allwell Medicare Premier II (HMO)	H0351-053	Cochise, Santa Cruz, Yavapai and Yuma counties	Evidence of Coverage - H0351-053 - English (PDF) Evidence of Coverage, H0351-053 - Spanish (PDF)
Allwell Medicare Boost (HMO)	H0351-054	Cochise, Santa Cruz and Yuma counties	Evidence of Coverage - H0351-054 - English (PDF) Evidence of Coverage, H0351-054 - Spanish (PDF)
Allwell Medicare (HMO)	H5590-004	Yavapai and Yuma Counties	Evidence of Coverage - H5590-004 - English (PDF) Evidence of Coverage, H5590-004 - Spanish (PDF)
Allwell Medicare Essentials (HMO)	H5590-005	Maricopa and Pinal counties	Evidence of Coverage - H5590-005 - English (PDF) Evidence of Coverage, H5590-005 - Spanish (PDF)
Allwell Medicare Essentials I (HMO)	H5590-007	Cochise, Santa Cruz and Yuma counties	Evidence of Coverage - H5590-007 - English (PDF) Evidence of Coverage, H5590-007 - Spanish (PDF)

Plan Name	CMS #	County	Evidence of Coverage
Allwell CHF/Diabetes Medicare (HMO C-SNP)	H0351-038	Maricopa and Pinal counties	Evidence of Coverage - H0351-038 - English (PDF) Evidence of Coverage, H0351-038 - Spanish (PDF)
Allwell Dual Medicare (HMO D-SNP)	H5590-008	Cochise, Gila, Graham, Greenlee, La Paz, Maricopa, Pima, Pinal, Santa Cruz and Yuma counties	Evidence of Coverage - H5590-008 - English (PDF) Evidence of Coverage, H5590-008 - Spanish (PDF)

Plan Name	CMS #	County	Annual Notice of Changes
Allwell Medicare Premier II (HMO)	H0351-52 H0351-004-001 H0351-050-52 H9287-001	Maricopa, Pima and Pinal counties	Annual Notice of Changes H0351-044-001-052 - English (PDF) Annual Notice of Changes H0351-044-001-052 - Spanish (PDF) Annual Notice of Changes H0351-050-052 - English (PDF) Annual Notice of Changes H0351-050-052 - Spanish (PDF) Annual Notice of Changes H0351-051-052 - English (PDF) Annual Notice of Changes H0351-051-052 - Spanish (PDF) Annual Notice of Changes H9287-001 -H0351-052 - English (PDF) Annual Notice of Changes H9287-001 -H0351-052 - Spanish (PDF)
Allwell Medicare Premier II (HMO)	H0351-053 H0351-044 H0351-002	Cochise, Santa Cruz, Yavapai and Yuma counties	Annual Notice of Changes H0351-044-002-053 - English (PDF) Annual Notice of Changes H0351-044-002-0053- Spanish (PDF)
Allwell Medicare (HMO)	H5590-004	Yavapai and Yuma Counties	Annual Notice of Changes H5590-004- English (PDF) Annual Notice of Changes H5590-004- Spanish (PDF)
Allwell Medicare Essentials (HMO)	H5590-005	Maricopa and Pinal counties	Annual Notice of Changes H5590-005 - English (PDF) Annual Notice of Changes H5590-005 - Spanish (PDF)
Allwell Medicare Essentials I (HMO)	H5590-007	Cochise, Santa Cruz and Yuma counties	Annual Notice of Changes H5590-007- English (PDF) Annual Notice of Changes H5590-007 - Spanish (PDF)

Plan Benefit Materials | Allwell at Arizona Complete Health

Plan Materials and Forms

For HMO Members

For HMO D-SNP Members

For HMO Members

For HMO D-SNP Members

For PPO Members

For HMO Members

For HMO D-SNP Members

Plan Benefit Materials

For HMO Members:

For HMO SNP Members:

For HMO Members:

For HMO SNP Members:

For HMO Members:

For HMO SNP Members:

Plan Benefit Materials | Allwell at Arizona Complete Health

Plan Materials and Forms

Summary of Benefits (SB)

For HMO Members

For HMO D-SNP 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

Optional Supplemental Benefits Flyers

Newsletters

Over-The-Counter Benefits

Optional Benefit Individual Enrollment Form

Plan Benefit Materials

Summary of Benefits (SB)

For HMO Members:

For HMO SNP Members:

Evidence Of Coverage (EOC)

For HMO Members:

For HMO SNP Members:

Annual Notice of Changes (ANOC)

For HMO Members:

For HMO SNP Members:

Optional Supplemental Benefits Flyers

Optional Benefit Enrollment Form

Dental

Diabetes Pre-Qualifying Questionnaire

Acupuncture National Coverage

myStrength

Newsletters

Over-The-Counter Benefits