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:

PLAN NAME	CMS #	County	Summary of Benefits
Wellcare No Premium (HMO)	H6446-001	Clark, Nye	Summary of Benefits, H6446-001 - English (PDF) Summary of Benefits, H6446-001 - Spanish (PDF)
Wellcare No Premium (HMO)	H6446-010	Carson City, Churchill, Douglas, Lyon, Storey, Washoe	Summary of Benefits, H6446-010 - English (PDF) Summary of Benefits, H6446-010 - Spanish (PDF)

PLAN NAME

CMS #

County

Summary of Benefits

Wellcare No Premium (HMO)

H6446-001

Clark, Nye

Summary of Benefits, H6446-001 - English (PDF)

Summary of Benefits, H6446-001 - Spanish (PDF)

Wellcare No Premium (HMO)

H6446-010

Carson City, Churchill, Douglas, Lyon, Storey, Washoe

Summary of Benefits, H6446-010 - English (PDF)

Summary of Benefits, H6446-010 - Spanish (PDF)

For HMO D-SNP Members:

Plan Name	CMS #	County	Summary of Benefits
Wellcare Dual Access (HMO D-SNP)	H6446-014	Clark, Nye	Summary of Benefits, H6446-014 - English (PDF) Summary of Benefits, H6446-014 - Spanish (PDF)
Wellcare Dual Access (HMO D-SNP)	H6446-016	Carson City, Churchill, Douglas, Lyon, Storey, Washoe	Summary of Benefits, H6446-016 - English (PDF) Summary of Benefits, H6446-016 - Spanish (PDF)

Plan Name

CMS #

County

Summary of Benefits

Wellcare Dual Access (HMO D-SNP)

H6446-014

Clark, Nye

Summary of Benefits, H6446-014 - English (PDF)

Summary of Benefits, H6446-014 - Spanish (PDF)

Wellcare Dual Access (HMO D-SNP)

H6446-016

Carson City, Churchill, Douglas, Lyon, Storey, Washoe

Summary of Benefits, H6446-016 - English (PDF)

Summary of Benefits, H6446-016 - Spanish (PDF)

For HMO C-SNP Members:

Plan Name	CMS #	County	Summary of Benefits
Wellcare Specialty No Premium (HMO C-SNP)	H6446-017	Clark, Nye	Summary of Benefits, H6446-017 - English (PDF) Summary of Benefits, H6446-017 - Spanish (PDF)

Plan Name

CMS #

County

Summary of Benefits

Wellcare Specialty No Premium (HMO C-SNP)

H6446-017

Clark, Nye

Summary of Benefits, H6446-017 - English (PDF)

Summary of Benefits, H6446-017 - Spanish (PDF)

For PPO Members:

Plan Name	CMS #	County	Summary of Benefits
Wellcare No Premium Open (PPO)	H8458-003	Carson City, Clark, Churchill, Douglas, Lyon, Storey, Washoe	Summary of Benefits, H8458-003 - English (PDF) Summary of Benefits, H8458-003 - Spanish (PDF)

Plan Name

CMS #

County

Summary of Benefits

Wellcare No Premium Open (PPO)

H8458-003

Carson City, Clark, Churchill, Douglas, Lyon, Storey, Washoe

Summary of Benefits, H8458-003 - English (PDF)

Summary of Benefits, H8458-003 - 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:

Plan Name	CMS #	County	Evidence of Changes
Wellcare No Premium (HMO)	H6446-001	Clark, Nye	Evidence of Coverage, H6446-001 - English (PDF) Evidence of Coverage, H6446-001 - Spanish (PDF) Dental Benefit Details - English (PDF) Dental Benefit Details - Spanish (PDF)
Wellcare No Premium (HMO)	H6446-010	Carson City, Churchill, Douglas, Lyon, Storey, Washoe	Evidence of Coverage, H6446-010 - English (PDF) Evidence of Coverage, H6446-010 - Spanish (PDF) Dental Benefit Details - English (PDF) Dental Benefit Details - Spanish (PDF)

Plan Name

CMS #

County

Evidence of Changes

Wellcare No Premium (HMO)

H6446-001

Clark, Nye

Evidence of Coverage, H6446-001 - English (PDF)

Evidence of Coverage, H6446-001 - Spanish (PDF)

Dental Benefit Details - English (PDF)

Dental Benefit Details - Spanish (PDF)

Wellcare No Premium (HMO)

H6446-010

Carson City, Churchill, Douglas, Lyon, Storey, Washoe

Evidence of Coverage, H6446-010 - English (PDF)

Evidence of Coverage, H6446-010 - Spanish (PDF)

Dental Benefit Details - English (PDF)

Dental Benefit Details - Spanish (PDF)

For HMO D-SNP Members:

Plan Name	CMS #	County	Evidence of Changes
Wellcare Dual Access (HMO D-SNP)	H6446-014	Clark, Nye	Evidence of Coverage, H6446-014 - English (PDF) Evidence of Coverage, H6446-014 - Spanish (PDF) Dental Benefit Details - English (PDF) Dental Benefit Details - Spanish (PDF)
Wellcare Dual Access (HMO D-SNP)	H6446-016	Carson City, Churchill, Douglas, Lyon, Storey, Washoe	Evidence of Coverage, H6446-016 - English (PDF) Evidence of Coverage, H6446-016 - Spanish (PDF) Dental Benefit Details - English (PDF) Dental Benefit Details - Spanish (PDF)

Plan Name

CMS #

County

Evidence of Changes

Wellcare Dual Access (HMO D-SNP)

H6446-014

Clark, Nye

Evidence of Coverage, H6446-014 - English (PDF)

Evidence of Coverage, H6446-014 - Spanish (PDF)

Dental Benefit Details - English (PDF)

Dental Benefit Details - Spanish (PDF)

Wellcare Dual Access (HMO D-SNP)

H6446-016

Carson City, Churchill, Douglas, Lyon, Storey, Washoe

Evidence of Coverage, H6446-016 - English (PDF)

Evidence of Coverage, H6446-016 - Spanish (PDF)

Dental Benefit Details - English (PDF)

Dental Benefit Details - Spanish (PDF)

For HMO C-SNP Members:

Plan Name	CMS #	County	Evidence of Changes
Wellcare Specialty No Premium (HMO C-SNP)	H6446-017	Clark, Nye	Evidence of Coverage, H6446-017 - English (PDF) Evidence of Coverage, H6446-017 - Spanish (PDF) Dental Benefit Details - English (PDF) Dental Benefit Details - Spanish (PDF)

Plan Name

CMS #

County

Evidence of Changes

Wellcare Specialty No Premium (HMO C-SNP)

H6446-017

Clark, Nye

Evidence of Coverage, H6446-017 - English (PDF)

Evidence of Coverage, H6446-017 - Spanish (PDF)

Dental Benefit Details - English (PDF)

Dental Benefit Details - Spanish (PDF)

For PPO Members:

Plan Name	CMS #	County	Evidence of Changes
Wellcare No Premium Open (PPO)	H8458-003	Carson City, Clark, Churchill, Douglas, Lyon, Storey, Washoe	Evidence of Coverage, H8458-003 - English (PDF) Evidence of Coverage, H8458-003 - Spanish (PDF) Dental Benefit Details - English (PDF) Dental Benefit Details - Spanish (PDF)

Plan Name

CMS #

County

Evidence of Changes

Wellcare No Premium Open (PPO)

H8458-003

Carson City, Clark, Churchill, Douglas, Lyon, Storey, Washoe

Evidence of Coverage, H8458-003 - English (PDF)

Evidence of Coverage, H8458-003 - Spanish (PDF)

Dental Benefit Details - English (PDF)

Dental Benefit Details - Spanish (PDF)

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 No Premium (HMO)	H6446-001	Clark, Nye	Annual Notice of Changes, H6446-001 to H6446-001 - English (PDF) Annual Notice of Changes, H6446-001- Spanish (PDF)
Wellcare Giveback (HMO) to Wellcare No Premium (HMO)	H6446-003 to H6446-001	Clark, Nye	Annual Notice of Changes, H6446-003 to H6446-001 - English (PDF) Annual Notice of Changes, H6446-003 to H6446-001 - Spanish (PDF)
Wellcare Assist (HMO) to Wellcare No Premium (HMO)	H6446-011 to H6446-001	Clark, Nye	Annual Notice of Changes, H6446-011 to H6446-001 - English (PDF) Annual Notice of Changes, H6446-011 to H6446-001 - Spanish (PDF)
Wellcare Giveback (HMO) to Wellcare No Premium (HMO)	H6446-005 to H6446-010	Carson City, Churchill, Douglas, Lyon, Storey, Washoe	Annual Notice of Changes, H6446-005 to H6446-010 - English (PDF) Annual Notice of Changes, H6446-005 to H6446-010 Spanish (PDF)
Wellcare No Premium (HMO)	H6446-010	Carson City, Churchill, Douglas, Lyon, Storey, Washoe	Annual Notice of Changes, H6446-010 to H6446-010 - English (PDF) Annual Notice of Changes, H6446-010 to H6446-010 - Spanish (PDF)
Wellcare Assist (HMO) to Wellcare No Premium (HMO)	H6446-013 to H6446-010	Carson City, Churchill, Douglas, Lyon, Storey, Washoe	Annual Notice of Changes, H6446-013 to H6446-010 - English (PDF) Annual Notice of Changes, H6446-013 to H6446-010 - Spanish (PDF)

For HMO D-SNP and C-SNP Members:

Plan Name	CMS #	County	Annual Notice of Changes
Wellcare Dual Access (HMO D-SNP)	H6446-014	Clark, Nye	Annual Notice of Changes, H6446-014 to H6446-014 - English (PDF) Annual Notice of Changes, H6446-014 Spanish (PDF)
Wellcare Dual Access (HMO D-SNP)	H6446-016	Carson City, Churchill, Douglas, Lyon, Storey, Washoe	Annual Notice of Changes, H6446-016- English (PDF) Annual Notice of Changes, H6446-016 - Spanish (PDF)
Wellcare Specialty No Premium (HMO C-SNP)	H6446-017	Clark, Nye	Annual Notice of Changes, H6446-017 - English (PDF) Annual Notice of Changes, H6446-017 - Spanish (PDF)

Plan Name

CMS #

County

Annual Notice of Changes

Wellcare Dual Access (HMO D-SNP)

H6446-014

Clark, Nye

Annual Notice of Changes, H6446-014 to H6446-014 - English (PDF)

Annual Notice of Changes, H6446-014 Spanish (PDF)

Wellcare Dual Access (HMO D-SNP)

H6446-016

Carson City, Churchill, Douglas, Lyon, Storey, Washoe

Annual Notice of Changes, H6446-016- English (PDF)

Annual Notice of Changes, H6446-016 - Spanish (PDF)

Wellcare Specialty No Premium (HMO C-SNP)

H6446-017

Clark, Nye

Annual Notice of Changes, H6446-017 - English (PDF)

Annual Notice of Changes, H6446-017 - Spanish (PDF)

For PPO Members:

Plan Name	CMS #	County	Annual Notice of Changes
Wellcare No Premium Open (PPO)	H8458-003	Carson City, Churchill, Clark, Douglas, Lyon, Nye, Storey, Washoe	Annual Notice of Changes, H8458-003 - English (PDF) Annual Notice of Changes, H8458-003 - Spanish (PDF)
Wellcare No Premium Open (PPO) to Wellcare No Premium Open (PPO)	H8458-001 to H8458-003	Carson City, Churchill, Clark, Douglas, Lyon, Nye, Storey, Washoe	Annual Notice of Changes, H8458-001 to H8458-003 - English (PDF) Annual Notice of Changes, H8458-001 to H8458-003 - Spanish (PDF)

Plan Name

CMS #

County

Annual Notice of Changes

Wellcare No Premium Open (PPO)

H8458-003

Carson City, Churchill, Clark, Douglas, Lyon, Nye, Storey, Washoe

Annual Notice of Changes, H8458-003 - English (PDF)

Annual Notice of Changes, H8458-003 - Spanish (PDF)

Wellcare No Premium Open (PPO) to Wellcare No Premium Open (PPO)

H8458-001 to H8458-003

Carson City, Churchill, Clark, Douglas, Lyon, Nye, Storey, Washoe

Annual Notice of Changes, H8458-001 to H8458-003 - English (PDF)

Annual Notice of Changes, H8458-001 to H8458-003 - 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 from Silver Summit Health

Plan Materials and Forms

For HMO D-SNP Members:

For HMO C-SNP Members:

For PPO Members:

For HMO D-SNP Members:

For HMO C-SNP Members:

For PPO Members:

For HMO D-SNP and C-SNP Members:

For PPO Members:

HMO

Wellcare Simple (HMO-POS) H0351-067

Wellcare Simple (HMO-POS) H0351-070

HMO D-SNP

Wellcare Dual Access (HMO-POS D-SNP) H0351-066

Wellcare Dual Access (HMO-POS D-SNP) H0351-068

HMO C-SNP

Wellcare Specialty Simple (HMO-POS C-SNP) H0351-069

Additional Forms

Plan Benefit Materials | Allwell from Silver Summit Health

Plan Materials and Forms

Summary of Benefits (SB)

For HMO D-SNP Members:

For HMO C-SNP Members:

For PPO Members:

Evidence Of Coverage (EOC)

For HMO D-SNP Members:

For HMO C-SNP Members:

For PPO Members:

Annual Notice of Changes (ANOC)

For HMO D-SNP and C-SNP Members:

For PPO 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-POS) H0351-067

Plan Benefits

Wellcare Simple (HMO-POS) H0351-070

Plan Benefits

HMO D-SNP

Wellcare Dual Access (HMO-POS D-SNP) H0351-066

Plan Benefits

Wellcare Dual Access (HMO-POS D-SNP) H0351-068

Plan Benefits

HMO C-SNP

Wellcare Specialty Simple (HMO-POS C-SNP) H0351-069

Plan Benefits

Additional Forms

Step Therapy Part B

Covered Diabetes Testing Supplies

Over-the Counter Catalog and Healthy Food

2025 AHIP Flyer