Plan Benefit Materials | Allwell from PA Health and Wellness

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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