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.

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 P3 (HMO)	H6446- 001	Clark, Nye	Summary of Benefits, H6446-001 - English (PDF) Summary of Benefits, H6446-001 - Spanish (PDF)
Wellcare Giveback P3 (HMO)	H6446- 003	Clark, Nye	Summary of Benefits, H6446-003 - English (PDF) Summary of Benefits, H6446-003 - Spanish (PDF)
Wellcare Giveback USHS (HMO)	H6446- 004	Clark, Nye	Summary of Benefits, H6446-004 - English (PDF) Summary of Benefits, H6446-004 - Spanish (PDF)
Wellcare Giveback (HMO)	H6446- 005	Carson City, Lyon, Washoe	Summary of Benefits, H6446-005 - English (PDF) Summary of Benefits, H6446-005 - Spanish (PDF)
Wellcare No Premium USHS (HMO)	H6446- 009	Clark, Nye	Summary of Benefits, H6446-009 - English (PDF) Summary of Benefits, H6446-009 - Spanish (PDF)
Wellcare No Premium (HMO)	H6446- 010	Carson City, Lyon, Washoe	Summary of Benefits, H6446-010 - English (PDF) Summary of Benefits, H6446-010 - Spanish (PDF)
Wellcare Assist P3 (HMO)	H6446- 011	Clark, Nye	Summary of Benefits, H6446-011 - English (PDF) Summary of Benefits, H6446-011 - Spanish (PDF)
Wellcare Assist USHS (HMO)	H6446- 012	Clark, Nye	Summary of Benefits, H6446-012 - English (PDF) Summary of Benefits, H6446-012 - Spanish (PDF)
Wellcare Assist (HMO)	H6446- 013	Carson City, Lyon, Washoe	Summary of Benefits, H6446-013 - English (PDF) Summary of Benefits, H6446-013 - Spanish (PDF)

For HMO SNP Members:

Plan Name	CMS #	County	Summary of Benefits
Wellcare Dual Access P3 (HMO D-SNP)	H6446- 014	Clark, Nye	Summary of Benefits, H6446-014-MA - English (PDF) Summary of Benefits, H6446-014-MA - Spanish (PDF)
Wellcare Dual Access USHS (HMO D-SNP)	H6446- 015	Clark, Nye	Summary of Benefits, H6446-015 - English (PDF) Summary of Benefits, H6446-015 - Spanish (PDF)
Wellcare Dual Access (HMO D-SNP)	H6446- 016	Carson City, Lyon, Washoe	Summary of Benefits, H6446-016 - English (PDF) Summary of Benefits, H6446-016 - Spanish (PDF)
Wellcare Specialty No Premium P3 (HMO C-SNP)	H6446- 017	Clark	Summary of Benefits, H6446-017 - English (PDF) Summary of Benefits, H6446-017 - Spanish (PDF)
Wellcare Specialty No Premium USHS (HMO C-SNP)	H6446- 018	Clark	Summary of Benefits, H6446-018 - English (PDF) Summary of Benefits, H6446-018 - Spanish (PDF)

For PPO Members:

Plan Name	CMS #	County	Summary of Benefits
Wellcare No Premium Open (PPO)	H8458-001	Clark	Summary of Benefits, H8458-001 - English (PDF) Summary of Benefits, H8458-001 - Spanish (PDF)
Wellcare Patriot Giveback Open (PPO)	H8458-002	Clark	Summary of Benefits, H8458-002 - English (PDF) Summary of Benefits, H8458-002 - Spanish (PDF)
Wellcare No Premium Open (PPO)	H8458-003	Lyon and Washoe	Summary of Benefits, H8458-003 - English (PDF) Summary of Benefits, H8458-003 - Spanish (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 (EOC)
Wellcare No Premium P3 (HMO)	H6446- 001	Clark, Nye	Evidence of Coverage, H6446-001 - English (PDF) Evidence of Coverage, H6446-001 - Spanish (PDF)
Wellcare Giveback P3 (HMO)	H6446- 003	Clark, Nye	Evidence of Coverage, H6446-003 - English (PDF) Evidence of Coverage, H6446-003 - Spanish (PDF)
Wellcare Giveback USHS (HMO)	H6446- 004	Clark, Nye	Evidence of Coverage, H6446-004 - English (PDF) Evidence of Coverage, H6446-004 - Spanish (PDF)
Wellcare Giveback (HMO)	H6446- 005	Carson City, Lyon, Washoe	Evidence of Coverage, H6446-005 - English (PDF) Evidence of Coverage, H6446-005 - Spanish (PDF)
Wellcare No Premium USHS (HMO)	H6446- 009	Clark, Nye	Evidence of Coverage, H6446-009 - English (PDF) Evidence of Coverage, H6446-009 - Spanish (PDF)
Wellcare No Premium (HMO)	H6446- 010	Carson City, Lyon, Washoe	Evidence of Coverage, H6446-010 - English (PDF) Evidence of Coverage, H6446-010 - Spanish (PDF)
Wellcare Assist P3 (HMO)	H6446- 011	Clark, Nye	Evidence of Coverage, H6446-011 - English (PDF) Evidence of Coverage, H6446-011 - Spanish (PDF)
Wellcare Assist USHS (HMO)	H6446- 012	Clark, Nye	Evidence of Coverage, H6446-012 - English (PDF) Evidence of Coverage, H6446-012 - Spanish (PDF)
Wellcare Assist (HMO)	H6446- 013	Carson City, Lyon, Washoe	Evidence of Coverage, H6446-013 - English (PDF) Evidence of Coverage, H6446-013 - Spanish (PDF)

For HMO D-SNP & HMO C-SNP Members:

Plan Name	CMS #	County	Evidence of Coverage (EOC)
Wellcare Dual Access P3 (HMO D-SNP)	H6446- 014	Clark, Nye	Evidence of Coverage, H6446-014 - English (PDF) Evidence of Coverage, H6446-014 - Spanish (PDF)
Wellcare Dual Access USHS (HMO D-SNP)	H6446- 015	Clark, Nye	Evidence of Coverage, H6446-015 - English (PDF) Evidence of Coverage, H6446-015 - Spanish (PDF)
Wellcare Dual Access (HMO D-SNP)	H6446- 016	Carson City, Lyon, Washoe	Evidence of Coverage, H6446-016 - English (PDF) Evidence of Coverage, H6446-016 - Spanish (PDF)
Wellcare Specialty No Premium P3 (HMO C-SNP)	H6446- 017	Clark	Evidence of Coverage, H6446-017 - English (PDF) Evidence of Coverage, H6446-017 - Spanish (PDF)
Wellcare Specialty No Premium USHS (HMO C-SNP)	H6446- 018	Clark	Evidence of Coverage, H6446-018 - English (PDF) Evidence of Coverage, H6446-018 - English (PDF)

For PPO Members:

Plan Name	CMS #	County	Evidence of Coverage
Wellcare No Premium Open (PPO)	H8458-001	Clark	Evidence of Coverage, H8458-001 - English (PDF) Evidence of Coverage, H8458-001- Spanish (PDF)
Wellcare Patriot Giveback Open (PPO)	H8458-002	Clark	Evidence of Coverage, H8458-002 - English (PDF) Evidence of Coverage, H8458-002 - Spanish (PDF)
Wellcare No Premium Open (PPO)	H8458-003	Lyon and Washoe	Evidence of Coverage, H8458-003 - English (PDF) Evidence of Coverage, H8458-003 - Spanish (PDF)

If you were enrolled in Wellcare By Allwell 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 (ANOC)
Wellcare No Premium P3 (HMO)	H6446-001	Clark, Nye	Annual Notice of Changes, H6446-001 - English (PDF) Annual Notice of Changes, H6446-001 - Spanish (PDF)
Wellcare Giveback P3 (HMO)	H6446-003		Annual Notice of Changes, H6446-003 - English (PDF) Annual Notice of Changes, H6446-003 - Spanish (PDF)
Wellcare Giveback USHS (HMO)	H6446-004		Annual Notice of Changes, H6446-004 - English (PDF) Annual Notice of Changes, H6446-004 - Spanish (PDF)
Wellcare Giveback (HMO)	H6446-005		Annual Notice of Changes, H6446-005 - English (PDF) Annual Notice of Changes, H6446-005 - Spanish (PDF)
Wellcare No Premium USHS (HMO)	H6446-009		Annual Notice of Changes, H6446-009 - English (PDF) Annual Notice of Changes, H6446-009 - Spanish (PDF)
Wellcare No Premium (HMO)	H6446-010		Annual Notice of Changes, H6446-010 - English (PDF) Annual Notice of Changes, H6446-010 - Spanish (PDF)
Wellcare Assist P3 (HMO)	H6446-011		Annual Notice of Changes, H6446-011 - English (PDF) Annual Notice of Changes, H6446-011 - Spanish (PDF)
Wellcare Assist USHS (HMO)	H6446-012		Annual Notice of Changes, H6446-012 - English (PDF) Annual Notice of Changes, H6446-012 - Spanish (PDF)
Wellcare Assist (HMO)	H6446-013		Annual Notice of Changes, H6446-013 - English (PDF) Annual Notice of Changes, H6446-013 - Spanish (PDF)

For HMO D-SNP Members:

Plan Name	CMS #	Annual Notice of Changes (ANOC)
Wellcare Dual Access P3 (HMO D-SNP)	H6446-014	Annual Notice of Changes, H6446-014 - English (PDF) Annual Notice of Changes, H6446-014 - Spanish (PDF)
Wellcare Dual Access USHS (HMO D-SNP)	H6446-015	Annual Notice of Changes, H6446-015 - English (PDF) Annual Notice of Changes, H6446-015 - Spanish (PDF)
Wellcare Dual Access (HMO D-SNP)	H6446-016	Annual Notice of Changes, H6446-016 - English (PDF) Annual Notice of Changes, H6446-016 - Spanish (PDF)

Plan Benefit Materials | Allwell from Silver Summit Health

Plan Materials and Forms

For HMO Members:

For HMO SNP Members:

For PPO Members:

For HMO Members:

For HMO D-SNP & HMO C-SNP Members:

For PPO Members:

Plan Benefit Materials

For HMO Members:

For HMO SNP Members:

For HMO Members:

For HMO SNP Members:

For HMO Members:

Plan Name	CMS #	County	Summary of Benefits
Wellcare By Allwell Medicare Select P3 (HMO)	H6446- 001	Clark and Nye counties	Summary of Benefits, H6446-001 - English (PDF) Summary of Benefits, H6446-001 - Spanish (PDF)
Wellcare By Allwell Medicare Boost P3 (HMO)	H6446- 003	Clark and Nye counties	Summary of Benefits, H6446-003 - English (PDF) Summary of Benefits, H6446-003 - Spanish (PDF)
Wellcare By Allwell Medicare Boost USHS (HMO)	H6446- 004	Clark and Nye counties	Summary of Benefits, H6446-004 - English (PDF) Summary of Benefits, H6446-004 - Spanish (PDF)
Wellcare By Allwell Medicare Boost (HMO)	H6446- 005	Carson City and Washoe counties	Summary of Benefits, H6446-005 - English (PDF) Summary of Benefits, H6446-005 - Spanish (PDF)
Wellcare By Allwell Medicare Select USHS (HMO)	H6446- 009	Clark and Nye counties	Summary of Benefits, H6446-009 - English (PDF) Summary of Benefits, H6446-009 - Spanish (PDF)
Wellcare By Allwell Medicare (HMO)	H6446- 010	Carson City and Washoe counties	Summary of Benefits, H6446-010 - English (PDF) Summary of Benefits, H6446-010 - Spanish (PDF)
Wellcare By Allwell Medicare Complement P3 (HMO)	H6446- 011	Clark and Nye counties	Summary of Benefits, H6446-011 - English (PDF) Summary of Benefits, H6446-011 - Spanish (PDF)
Wellcare By Allwell Medicare Complement USHS (HMO)	H6446- 012	Clark and Nye counties	Summary of Benefits, H6446-012 - English (PDF) Summary of Benefits, H6446-012 - Spanish (PDF)
Wellcare By Allwell Medicare Complement (HMO)	H6446- 013	Carson City and Washoe counties	Summary of Benefits, 2021-NV-SB-H6446-013 - English (PDF) Summary of Benefits, 2021-NV-SB-H6446-013 - Spanish (PDF)

Plan Name	CMS #	County	Summary of Benefits
Wellcare By Allwell Dual Medicare Harmony P3 (HMO D-SNP)	H6446- 014	Clark and Nye counties	Summary of Benefits, H6446-014-MA - English (PDF) Summary of Benefits, H6446-014-MA - Spanish (PDF)
Wellcare By Allwell Dual Medicare Harmony USHS (HMO D-SNP)	H6446- 015	Clark and Nye counties	Summary of Benefits, H6446-015 - English (PDF) Summary of Benefits, H6446-015 - Spanish (PDF)
Wellcare By Allwell Dual Medicare Harmony (HMO D-SNP)	H6446- 016	Carson City and Washoe counties	Summary of Benefits, H6446-016 - English (PDF) Summary of Benefits, H6446-016 - Spanish (PDF)

Plan Benefit Materials | Allwell from Silver Summit Health

Plan Materials and Forms

Summary of Benefits (SB)

For HMO Members:

For HMO SNP Members:

For PPO Members:

Evidence Of Coverage (EOC)

For HMO Members:

For HMO D-SNP & HMO C-SNP Members:

For PPO Members:

Annual Notice of Changes (ANOC)

Over-The-Counter Benefits

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:

Acupuncture National Coverage

Over-The-Counter Benefits