- Shop for Plans show Shop for Plans menu
- I'm a Member show I'm a Member menu
-
Pharmacy Benefits
show Pharmacy Benefits menu
-
- Find a Doctor or Pharmacy
- List of Drugs (Formulary)
- Medication Therapy Management (MTMP)
- Mail Order Service
- Specialty Pharmacy
- Coverage Determinations and Redeterminations
- Prior Authorization, Step Therapy & Quantity Limitations
- Out-of-Network Pharmacies
- Medication (Drug) Management and Safety
- Drug Transition Policy
- Pharmacy Forms
- Medicare Prescription Payment Plan
-
- Shop for Plans show Shop for Plans menu
- I'm a Member show I'm a Member menu
-
Pharmacy Benefits
show Pharmacy Benefits menu
-
- Find a Doctor or Pharmacy
- List of Drugs (Formulary)
- Medication Therapy Management (MTMP)
- Mail Order Service
- Specialty Pharmacy
- Coverage Determinations and Redeterminations
- Prior Authorization, Step Therapy & Quantity Limitations
- Out-of-Network Pharmacies
- Medication (Drug) Management and Safety
- Drug Transition Policy
- Pharmacy Forms
- Medicare Prescription Payment Plan
-
Plan Benefit Materials | Allwell from PA Health and Wellness
Plan Benefit Materials
Learn about your plan and all that it has to offer by reviewing helpful plan documents such as the Annual Notice of Change (ANOC), Summary of Benefits, and Evidence of Coverage.
To get started, locate your plan in the list of plans below and select “Plan Benefits.”
HMO
Additional Forms
Plan Benefit Materials
Learn about your plan and all that it has to offer by reviewing helpful plan documents such as the Annual Notice of Change (ANOC), Summary of Benefits, and Evidence of Coverage.
To get started, locate your plan in the list of plans below and select “Plan Benefits.”
HMO
Wellcare Simple (HMO) H2915-003
Counties: Allegheny, Armstrong, Beaver, Bedford, Blair, Butler, Cambria, Cameron, Carbon, Clarion, Clearfield, Clinton, Crawford, Elk, Erie, Fayette, Forest, Greene, Indiana, Jefferson, Lawrence, Lehigh, Luzerne, McKean, Mercer, Monroe, Northampton, Potter, Schuylkill, Somerset, Venango, Warren, Washington, Westmoreland
Annual Notice of Changes
Summary of Benefits
Evidence of Coverage
Wellcare Assist (HMO) H2915-011
Counties: Adams, Allegheny, Armstrong, Beaver, Bedford, Berks, Blair, Bradford, Bucks, Butler, Cambria, Cameron, Carbon, Centre, Chester, Clarion, Clearfield, Clinton, Crawford, Cumberland, Dauphin, Delaware, Elk, Erie, Fayette, Forest, Franklin, Fulton, Greene, Huntingdon, Indiana, Jefferson, Juniata, Lackawanna, Lancaster, Lawrence, Lebanon, Lehigh, Luzerne, Lycoming, McKean, Mercer, Mifflin, Monroe, Montgomery, Montour, Northampton, Perry, Philadelphia, Pike, Potter, Schuylkill, Snyder, Somerset, Sullivan, Susquehanna, Tioga, Union, Venango, Warren, Washington, Wayne, Westmoreland, Wyoming, York
Annual Notice of Changes
Summary of Benefits
Evidence of Coverage
Wellcare Patriot Giveback (HMO) H2915-013
Counties: Adams, Allegheny, Armstrong, Beaver, Bedford, Berks, Blair, Bradford, Bucks, Butler, Cambria, Cameron, Carbon, Centre, Chester, Clarion, Clearfield, Clinton, Crawford, Cumberland, Dauphin, Delaware, Elk, Erie, Fayette, Forest, Franklin, Fulton, Greene, Huntingdon, Indiana, Jefferson, Juniata, Lackawanna, Lancaster, Lawrence, Lebanon, Lehigh, Luzerne, Lycoming, McKean, Mercer, Mifflin, Monroe, Montgomery, Montour, Northampton, Perry, Philadelphia, Pike, Potter, Schuylkill, Snyder, Somerset, Sullivan, Susquehanna, Tioga, Union, Venango, Warren, Washington, Wayne, Westmoreland, Wyoming, York
Annual Notice of Changes
Summary of Benefits
Evidence of Coverage
Wellcare Simple (HMO) H2915-016
Counties: Adams, Allegheny, Armstrong, Beaver, Bedford, Berks, Blair, Bradford, Bucks, Butler, Cambria, Cameron, Carbon, Centre, Chester, Clarion, Clearfield, Clinton, Crawford, Cumberland, Dauphin, Delaware, Elk, Erie, Fayette, Forest, Franklin, Fulton, Greene, Huntingdon, Indiana, Jefferson, Juniata, Lackawanna, Lancaster, Lawrence, Lebanon, Lehigh, Luzerne, Lycoming, McKean, Mercer, Mifflin, Monroe, Montgomery, Montour, Northampton, Perry, Philadelphia, Pike, Potter, Schuylkill, Snyder, Somerset, Sullivan, Susquehanna, Tioga, Union, Venango, Warren, Washington, Wayne, Westmoreland, Wyoming, York
Annual Notice of Changes
Summary of Benefits
Evidence of Coverage
HMO D-SNP
Wellcare Dual Access (HMO D-SNP) H2915-002
Counties: Allegheny, Armstrong, Beaver, Bedford, Blair, Bucks, Butler, Cambria, Cameron, Chester, Clarion, Clearfield, Crawford, Delaware, Elk, Erie, Fayette, Forest, Greene, Indiana, Jefferson, Lawrence, McKean, Mercer, Montgomery, Philadelphia, Potter, Somerset, Venango, Warren, Washington, Westmoreland
Annual Notice of Changes
- Annual Notice of Change – English (PDF)
- Annual Notice of Change – Spanish (PDF)
- Annual Notice of Change - Chinese (PDF)
- Annual Notice of Change - Vietnamese (PDF)
Summary of Benefits
- Summary of Benefits – English (PDF)
- Summary of Benefits – Spanish (PDF)
- Summary of Benefits - Vietnamese (PDF)
Evidence of Coverage
- Evidence of Coverage – English (PDF)
- Evidence of Coverage – Spanish (PDF)
- Evidence of Coverage - Chinese (PDF)
- Evidence of Coverage - Vietnamese (PDF)
- Dental Benefit Details – English (PDF)
- Dental Benefit Details - Arabic (PDF)
- Dental Benefit Details - Chinese (PDF)
- Dental Benefit Details - Russian (PDF)
- Dental Benefit Details - Creole (PDF)
- Dental Benefit Details - Spanish (PDF)
- Dental Benefit Details - Vietnamese (PDF)
- Dental Benefit Details - Bengali (PDF)
- Dental Benefit Details - Nepali (PDF)
- Dental Benefit Details - Swahili (PDF)
- Dental Benefit Details - Tamil (PDF)
Wellcare Dual Access (HMO D-SNP) H2915-007
Counties: Adams, Berks, Bradford, Carbon, Centre, Clinton, Cumberland, Dauphin, Franklin, Fulton, Huntingdon, Juniata, Lackawanna, Lancaster, Lebanon, Lehigh, Luzerne, Lycoming, Mifflin, Monroe, Montour, Northampton, Perry, Pike, Schuylkill, Snyder, Sullivan, Susquehanna, Tioga, Union, Wayne, Wyoming, York
Annual Notice of Changes
- Annual Notice of Change – English (PDF)
- Annual Notice of Change – Spanish (PDF)
- Annual Notice of Change - Chinese (PDF)
Summary of Benefits
- Summary of Benefits – English (PDF)
- Summary of Benefits – Spanish (PDF)
- Summary of Benefits - Chinese (PDF)
- Summary of Benefits - Vietnamese (PDF)
Evidence of Coverage
- Evidence of Coverage – English (PDF)
- Evidence of Coverage – Spanish (PDF)
- Evidence of Coverage - Chinese (PDF)
- Dental Benefit Details – English (PDF)
- Dental Benefit Details - Arabic (PDF)
- Dental Benefit Details - Chinese (PDF)
- Dental Benefit Details - Russian (PDF)
- Dental Benefit Details - Creole (PDF)
- Dental Benefit Details - Spanish (PDF)
- Dental Benefit Details - Vietnamese (PDF)
- Dental Benefit Details - Bengali (PDF)
- Dental Benefit Details - Nepali (PDF)
- Dental Benefit Details - Swahili (PDF)
- Dental Benefit Details - Tamil (PDF)
PPO
Wellcare Simple Open (PPO) H2128-002
Counties: Adams, Allegheny, Armstrong, Beaver, Bedford, Berks, Blair, Bradford, Bucks, Butler, Cambria, Cameron, Carbon, Centre, Chester, Clarion, Clearfield, Clinton, Crawford, Cumberland, Dauphin, Delaware, Elk, Erie, Fayette, Forest, Franklin, Fulton, Greene, Huntingdon, Indiana, Jefferson, Juniata, Lackawanna, Lancaster, Lawrence, Lebanon, Lehigh, Luzerne, Lycoming, McKean, Mercer, Mifflin, Monroe, Montgomery, Montour, Northampton, Perry, Philadelphia, Potter, Schuylkill, Snyder, Somerset, Sullivan, Susquehanna, Tioga, Union, Venango, Warren, Washington, Wayne, Westmoreland, Wyoming, York
Annual Notice of Changes
Summary of Benefits
Evidence of Coverage
Wellcare Giveback Open (PPO) H2128-004
Counties: Adams, Allegheny, Armstrong, Beaver, Bedford, Berks, Blair, Bradford, Bucks, Butler, Cambria, Cameron, Carbon, Centre, Chester, Clarion, Clearfield, Clinton, Crawford, Cumberland, Dauphin, Delaware, Elk, Erie, Fayette, Forest, Franklin, Fulton, Greene, Huntingdon, Indiana, Jefferson, Juniata, Lackawanna, Lancaster, Lawrence, Lebanon, Lehigh, Luzerne, Lycoming, McKean, Mercer, Mifflin, Monroe, Montgomery, Montour, Northampton, Perry, Philadelphia, Potter, Schuylkill, Snyder, Somerset, Sullivan, Susquehanna, Tioga, Union, Venango, Warren, Washington, Wayne, Westmoreland, Wyoming, York
Annual Notice of Changes
Summary of Benefits
Evidence of Coverage
PPO D-SNP
Wellcare Dual Access Open (PPO D-SNP) H2128-005
Counties: Adams, Allegheny, Armstrong, Beaver, Bedford, Berks, Blair, Bradford, Bucks, Butler, Cambria, Cameron, Carbon, Centre, Chester, Clarion, Clearfield, Clinton, Crawford, Cumberland, Dauphin, Delaware, Elk, Erie, Fayette, Forest, Franklin, Fulton, Greene, Huntingdon, Indiana, Jefferson, Juniata, Lackawanna, Lancaster, Lawrence, Lebanon, Lehigh, Luzerne, Lycoming, McKean, Mercer, Mifflin, Monroe, Montgomery, Montour, Northampton, Perry, Philadelphia, Potter, Schuylkill, Snyder, Somerset, Sullivan, Susquehanna, Tioga, Union, Venango, Warren, Washington, Wayne, Westmoreland, Wyoming, York
Annual Notice of Changes
Summary of Benefits
Evidence of Coverage
Wellcare Dual Reserve Open (PPO D-SNP) H2128-006
Counties: Adams, Allegheny, Armstrong, Beaver, Bedford, Berks, Blair, Bradford, Bucks, Butler, Cambria, Cameron, Carbon, Centre, Chester, Clarion, Clearfield, Clinton, Crawford, Cumberland, Dauphin, Delaware, Elk, Erie, Fayette, Forest, Franklin, Fulton, Greene, Huntingdon, Indiana, Jefferson, Juniata, Lackawanna, Lancaster, Lawrence, Lebanon, Lehigh, Luzerne, Lycoming, McKean, Mercer, Mifflin, Monroe, Montgomery, Montour, Northampton, Perry, Philadelphia, Potter, Schuylkill, Snyder, Somerset, Sullivan, Susquehanna, Tioga, Union, Venango, Warren, Washington, Wayne, Westmoreland, Wyoming, York
Summary of Benefits
Evidence of Coverage
Additional Forms
If you have questions please, contact Member Services.
Please Note
By clicking on this link you will be leaving the plan website.