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Plan Benefit Materials | Allwell from PA Health and Wellness

Plan Materials and Forms
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
- Annual Notice of Change – English (PDF) - Coming soon
Summary of Benefits
- Summary of Benefits – English (PDF) - Coming soon
Evidence of Coverage
- Evidence of Coverage – English (PDF) - Coming soon
- Dental Benefit Details – English (PDF) - Coming soon
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
- Annual Notice of Change – English (PDF) - Coming soon
Summary of Benefits
- Summary of Benefits – English (PDF) - Coming soon
Evidence of Coverage
- Evidence of Coverage – English (PDF) - Coming soon
- Dental Benefit Details – English (PDF) - Coming soon
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
- Annual Notice of Change – English (PDF) - Coming soon
Summary of Benefits
- Summary of Benefits – English (PDF) - Coming soon
Evidence of Coverage
- Evidence of Coverage – English (PDF) - Coming soon
- Dental Benefit Details – English (PDF) - Coming soon
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
- Annual Notice of Change – English (PDF) - Coming soon
Summary of Benefits
- Summary of Benefits – English (PDF) - Coming soon
Evidence of Coverage
- Evidence of Coverage – English (PDF) - Coming soon
- Dental Benefit Details – English (PDF) - Coming soon
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) - Coming soon
- Annual Notice of Change – Spanish (PDF) - Coming soon
- Annual Notice of Change - Chinese (PDF) - Coming soon
- Annual Notice of Change - Vietnamese (PDF) - Coming soon
Summary of Benefits
- Summary of Benefits – English (PDF) - Coming soon
- Summary of Benefits – Spanish (PDF) - Coming soon
- Summary of Benefits - Vietnamese (PDF) - Coming soon
Evidence of Coverage
- Evidence of Coverage – English (PDF) - Coming soon
- Evidence of Coverage – Spanish (PDF) - Coming soon
- Evidence of Coverage - Chinese (PDF) - Coming soon
- Evidence of Coverage - Vietnamese (PDF) - Coming soon
- Dental Benefit Details – English (PDF) - Coming soon
- Dental Benefit Details - Arabic (PDF) - Coming soon
- Dental Benefit Details - Chinese (PDF) - Coming soon
- Dental Benefit Details - Russian (PDF) - Coming soon
- Dental Benefit Details - Creole (PDF) - Coming soon
- Dental Benefit Details - Spanish (PDF) - Coming soon
- Dental Benefit Details - Vietnamese (PDF) - Coming soon
- Dental Benefit Details - Bengali (PDF) - Coming soon
- Dental Benefit Details - Nepali (PDF) - Coming soon
- Dental Benefit Details - Swahili (PDF) - Coming soon
- Dental Benefit Details - Tamil (PDF) - Coming soon
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) - Coming soon
- Annual Notice of Change – Spanish (PDF) - Coming soon
- Annual Notice of Change - Chinese (PDF) - Coming soon
Summary of Benefits
- Summary of Benefits – English (PDF) - Coming soon
- Summary of Benefits – Spanish (PDF) - Coming soon
- Summary of Benefits - Chinese (PDF) - Coming soon
- Summary of Benefits - Vietnamese (PDF) - Coming soon
Evidence of Coverage
- Evidence of Coverage – English (PDF) - Coming soon
- Evidence of Coverage – Spanish (PDF) - Coming soon
- Evidence of Coverage - Chinese (PDF) - Coming soon
- Dental Benefit Details – English (PDF) - Coming soon
- Dental Benefit Details - Arabic (PDF) - Coming soon
- Dental Benefit Details - Chinese (PDF) - Coming soon
- Dental Benefit Details - Russian (PDF) - Coming soon
- Dental Benefit Details - Creole (PDF) - Coming soon
- Dental Benefit Details - Spanish (PDF) - Coming soon
- Dental Benefit Details - Vietnamese (PDF) - Coming soon
- Dental Benefit Details - Bengali (PDF) - Coming soon
- Dental Benefit Details - Nepali (PDF) - Coming soon
- Dental Benefit Details - Swahili (PDF) - Coming soon
- Dental Benefit Details - Tamil (PDF) - Coming soon
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
- Annual Notice of Change – English (PDF) - Coming soon
Summary of Benefits
- Summary of Benefits – English (PDF) - Coming soon
Evidence of Coverage
- Evidence of Coverage – English (PDF) - Coming soon
- Dental Benefit Details – English (PDF) - Coming soon
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
- Annual Notice of Change – English (PDF) - Coming soon
Summary of Benefits
- Summary of Benefits – English (PDF) - Coming soon
Evidence of Coverage
- Evidence of Coverage – English (PDF) - Coming soon
- Dental Benefit Details – English (PDF) - Coming soon
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
- Annual Notice of Change – English (PDF) - Coming soon
Summary of Benefits
- Summary of Benefits – English (PDF) - Coming soon
Evidence of Coverage
- Evidence of Coverage – English (PDF) - Coming soon
- Dental Benefit Details – English (PDF) - Coming soon
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
- Summary of Benefits – English (PDF) - Coming soon
Evidence of Coverage
- Evidence of Coverage – English (PDF) - Coming soon
- Dental Benefit Details – English (PDF) - Coming soon
Additional Forms
- Medicare Step Therapy Part B (PDF) - Coming soon
- Covered Diabetes Testing Supplies - Coming soon
- Over-the-Counter Catalog (PDF) - Coming soon
- Over-the-Counter Catalog and Healthy Food (PDF) - Coming soon
- 2026 Original Medicare Defined Cost Share Amounts and Premiums (PDF) - Coming soon