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 (HMO)	H2915-003	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	Summary of Benefits, H2915-003 - English (PDF) Summary of Benefits, H2915-003 - Spanish (PDF)
Wellcare No Premium (HMO)	H2915-016	Berks, Bradford, Bucks, Centre, Chester, Cumberland, Dauphin, Delaware, Fulton, Huntingdon, Juniata, Lackawanna, Lancaster, Lebanon, Lycoming, Mifflin, Montgomery, Perry, Philadelphia, Snyder, Sullivan, Susquehanna, Tioga, Union, Wayne, Wyoming	Summary of Benefits, H2915-016 - English (PDF) Summary of Benefits, H2915-016 - Spanish (PDF)
Wellcare Assist (HMO)	H2915-011	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, Fulton, Greene, Huntingdon, Indiana, Jefferson, Juniata, Lackawanna, Lancaster, Lawrence, Lebanon, Lehigh, Luzerne, Lycoming, McKean, Mercer, Mifflin, Monroe, Montgomery, Northampton, Perry, Philadelphia, Potter, Schuylkill, Snyder, Somerset, Sullivan, Susquehanna, Tioga, Union, Venango, Warren, Washington, Wayne, Westmoreland, Wyoming	Summary of Benefits, H2915-011 - English (PDF) Summary of Benefits, H2915-011 - Spanish (PDF)
Wellcare Giveback (HMO)	H2915-012	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, Fulton, Greene, Huntingdon, Indiana, Jefferson, Juniata, Lackawanna, Lancaster, Lawrence, Lebanon, Lehigh, Luzerne, Lycoming, McKean, Mercer, Mifflin, Monroe, Montgomery, Northampton, Perry, Philadelphia, Potter, Schuylkill, Snyder, Somerset, Sullivan, Susquehanna, Tioga, Union, Venango, Warren, Washington, Wayne, Westmoreland, Wyoming	Summary of Benefits, H2915-012 - English (PDF) Summary of Benefits, H2915-012 - Spanish (PDF)
Wellcare Patriot Giveback (HMO)	H2915-013	Allegheny, Armstrong, Beaver, Bedford, Berks, Blair, Bradford, Bucks, Butler, Cambria, Cameron, Centre, Chester, Clarion, Clearfield, Crawford, Cumberland, Dauphin, Delaware, Elk, Erie, Fayette, Huntingdon, Indiana, Jefferson, Lackawanna, Lancaster, Lawrence, Lebanon, Lycoming, McKean, Mercer, Mifflin, Montgomery, Perry, Philadelphia, Potter, Snyder, Somerset, Sullivan, Susquehanna, Tioga, Union, Venango, Warren, Washington, Wayne, Westmoreland, Wyoming	Summary of Benefits, H2915-013 - English (PDF) Summary of Benefits, H2915-013 - Spanish (PDF)

For HMO D-SNP Members:

Plan Name	CMS #	County	Summary of Benefits
Wellcare Dual Access (HMO D-SNP)	H2915-002	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	Summary of Benefits H2915-002 - English (PDF) Summary of Benefits H2915-002 - Spanish (PDF)
Wellcare Dual Access (HMO D-SNP)	H2915-007	Adams, Berks, Bradford, Carbon, Centre, Clinton, Cumberland, Dauphin, Franklin, Fulton, Huntingdon, Juniata, Lackawanna, Lancaster, Lebanon, Lehigh, Luzerne, Lycoming, Mifflin, Monroe, Northampton, Perry, Pike, Schuylkill, Snyder, Sullivan, Susquehanna, Tioga, Union, Wayne, Wyoming, York	Summary of Benefits H2915-007 - English (PDF) Summary of Benefits H2915-007 - Spanish (PDF)

Plan Name

CMS #

County

Summary of Benefits

Wellcare Dual Access (HMO D-SNP)

H2915-002

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

Summary of Benefits H2915-002 - English (PDF)

Summary of Benefits H2915-002 - Spanish (PDF)

Wellcare Dual Access (HMO D-SNP)

H2915-007

Adams, Berks, Bradford, Carbon, Centre, Clinton, Cumberland, Dauphin, Franklin, Fulton, Huntingdon, Juniata, Lackawanna, Lancaster, Lebanon, Lehigh, Luzerne, Lycoming, Mifflin, Monroe, Northampton, Perry, Pike, Schuylkill, Snyder, Sullivan, Susquehanna, Tioga, Union, Wayne, Wyoming, York

Summary of Benefits H2915-007 - English (PDF)

Summary of Benefits H2915-007 - Spanish (PDF)

For PPO Members:

Plan Name	CMS #	County	Summary of Benefits
Wellcare Assist Open (PPO)	H2128-001	Armstrong, Beaver, Bedford, Berks, Blair, Bradford, Bucks, Butler, Cambria, Cameron, Carbon, Centre, Chester, Clarion, Clearfield, Clinton, Crawford, Cumberland, Dauphin, Delaware, Elk, Erie, Fayette, Forest, Fulton, Greene, Huntingdon, Indiana, Jefferson, Juniata, Lackawanna, Lancaster, Lawrence, Lebanon, Lehigh, Luzerne, Lycoming, McKean, Mifflin, Monroe, Montgomery, Northampton, Perry, Philadelphia, Potter, Schuylkill, Snyder, Somerset, Sullivan, Susquehanna, Tioga, Union, Venango, Warren, Washington, Wayne, Westmoreland, Wyoming	Summary of Benefits, H2128-001 - English (PDF) Summay of Benefits, H2128-001 - Spanish (PDF)
Wellcare No Premium Open (PPO)	H2128-002	Armstrong, Beaver, Bedford, Berks, Blair, Bradford, Bucks, Butler, Cambria, Cameron, Carbon, Centre, Chester, Clarion, Clearfield, Clinton, Crawford, Cumberland, Dauphin, Delaware, Elk, Erie, Fayette, Forest, Fulton, Greene, Huntingdon, Indiana, Jefferson, Juniata, Lackawanna, Lancaster, Lawrence, Lebanon, Lehigh, Luzerne, Lycoming, McKean, Mifflin, Monroe, Montgomery, Northampton, Perry, Philadelphia, Potter, Schuylkill, Snyder, Somerset, Sullivan, Susquehanna, Tioga, Union, Venango, Warren, Washington, Wayne, Westmoreland, Wyoming	Summary of Benefits H2128-002 - English (PDF) Summary of Benefits H2128-002 - Spanish (PDF)
Wellcare Low Premium Open (PPO)	H2128-003	Armstrong, Beaver, Bedford, Berks, Blair, Bradford, Bucks, Butler, Cambria, Cameron, Carbon, Centre, Chester, Clarion, Clearfield, Clinton, Crawford, Cumberland, Dauphin, Delaware, Elk, Erie, Fayette, Forest, Fulton, Greene, Huntingdon, Indiana, Jefferson, Juniata, Lackawanna, Lancaster, Lawrence, Lebanon, Lehigh, Luzerne, Lycoming, McKean, Mifflin, Monroe, Montgomery, Northampton, Perry, Philadelphia, Potter, Schuylkill, Snyder, Somerset, Sullivan, Susquehanna, Tioga, Union, Venango, Warren, Washington, Wayne, Westmoreland, Wyoming	Summary of Benefits H2128-003 - English (PDF) Summary of Benefits H2128-003 - Spanish (PDF)
Wellcare Giveback Open (PPO)	H2128-004	Armstrong, Beaver, Bedford, Berks, Blair, Bradford, Bucks, Butler, Cambria, Cameron, Carbon, Centre, Chester, Clarion, Clearfield, Clinton, Crawford, Cumberland, Dauphin, Delaware, Elk, Erie, Fayette, Forest, Fulton, Greene, Huntingdon, Indiana, Jefferson, Juniata, Lackawanna, Lancaster, Lawrence, Lebanon, Lehigh, Luzerne, Lycoming, McKean, Mifflin, Monroe, Montgomery, Northampton, Perry, Philadelphia, Potter, Schuylkill, Snyder, Somerset, Sullivan, Susquehanna, Tioga, Union, Venango, Warren, Washington, Wayne, Westmoreland, Wyoming	Summary of Benefits H2128-004 - English (PDF) Summary of Benefits H2128-004 - 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 (HMO)	H2915-003	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	Evidence of Coverage, H2915-003 - English (PDF) Evidence of Coverage, H2915-003 - Spanish (PDF)
Wellcare No Premium (HMO)	H2915-016	Berks, Bradford, Bucks, Centre, Chester, Cumberland, Dauphin, Delaware, Fulton, Huntingdon, Juniata, Lackawanna, Lancaster, Lebanon, Lycoming, Mifflin, Montgomery, Perry, Philadelphia, Snyder, Sullivan, Susquehanna, Tioga, Union, Wayne, Wyoming	Evidence of Coverage, H2915-016 - English (PDF) Evidence of Coverage, H2915-016 - Spanish (PDF)
Wellcare Assist (HMO)	H2915-011	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, Fulton, Greene, Huntingdon, Indiana, Jefferson, Juniata, Lackawanna, Lancaster, Lawrence, Lebanon, Lehigh, Luzerne, Lycoming, McKean, Mercer, Mifflin, Monroe, Montgomery, Northampton, Perry, Philadelphia, Potter, Schuylkill, Snyder, Somerset, Sullivan, Susquehanna, Tioga, Union, Venango, Warren, Washington, Wayne, Westmoreland, Wyoming	Evidence of Coverage, H2915-011 - English (PDF) Evidence of Coverage, H2915-011 - Spanish (PDF)
Wellcare Giveback (HMO)	H2915-012	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, Fulton, Greene, Huntingdon, Indiana, Jefferson, Juniata, Lackawanna, Lancaster, Lawrence, Lebanon, Lehigh, Luzerne, Lycoming, McKean, Mercer, Mifflin, Monroe, Montgomery, Northampton, Perry, Philadelphia, Potter, Schuylkill, Snyder, Somerset, Sullivan, Susquehanna, Tioga, Union, Venango, Warren, Washington, Wayne, Westmoreland, Wyoming	Evidence of Coverage, H2915-012 - English (PDF) Evidence of Coverage, H2915-012 - Spanish (PDF)
Wellcare Patriot Giveback (HMO)	H2915-013	Allegheny, Armstrong, Beaver, Bedford, Berks, Blair, Bradford, Bucks, Butler, Cambria, Cameron, Centre, Chester, Clarion, Clearfield, Crawford, Cumberland, Dauphin, Delaware, Elk, Erie, Fayette, Huntingdon, Indiana, Jefferson, Lackawanna, Lancaster, Lawrence, Lebanon, Lycoming, McKean, Mercer, Mifflin, Montgomery, Perry, Philadelphia, Potter, Snyder, Somerset, Sullivan, Susquehanna, Tioga, Union, Venango, Warren, Washington, Wayne, Westmoreland, Wyoming	Evidence of Coverage, H2915-013 - English (PDF) Evidence of Coverage, H2915-013 - Spanish (PDF)

For HMO D-SNP Members:

Plan Name	CMS #	County	Evidence of Coverage (EOC)
Wellcare Dual Access (HMO D-SNP)	H2915-002	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	Evidence of Coverage, H2915-002 - English (PDF) Evidence of Coverage, H2915-002 - Spanish (PDF)
Wellcare Dual Access (HMO D-SNP)	H2915-007	Adams, Berks, Bradford, Carbon, Centre, Clinton, Cumberland, Dauphin, Franklin, Fulton, Huntingdon, Juniata, Lackawanna, Lancaster, Lebanon, Lehigh, Luzerne, Lycoming, Mifflin, Monroe, Northampton, Perry, Pike, Schuylkill, Snyder, Sullivan, Susquehanna, Tioga, Union, Wayne, Wyoming, York	Evidence of Coverage, H2915-007 - English (PDF) Evidence of Coverage, H2915-007 - Spanish (PDF)

Plan Name

CMS #

County

Evidence of Coverage (EOC)

Wellcare Dual Access (HMO D-SNP)

H2915-002

Evidence of Coverage, H2915-002 - English (PDF)

Evidence of Coverage, H2915-002 - Spanish (PDF)

Wellcare Dual Access (HMO D-SNP)

H2915-007

Evidence of Coverage, H2915-007 - English (PDF)

Evidence of Coverage, H2915-007 - Spanish (PDF)

For PPO Members:

Plan Name	CMS #	County	Evidence of Coverage (EOC)
Wellcare Assist Open (PPO)	H2128-001	Armstrong, Beaver, Bedford, Berks, Blair, Bradford, Bucks, Butler, Cambria, Cameron, Carbon, Centre, Chester, Clarion, Clearfield, Clinton, Crawford, Cumberland, Dauphin, Delaware, Elk, Erie, Fayette, Forest, Fulton, Greene, Huntingdon, Indiana, Jefferson, Juniata, Lackawanna, Lancaster, Lawrence, Lebanon, Lehigh, Luzerne, Lycoming, McKean, Mifflin, Monroe, Montgomery, Northampton, Perry, Philadelphia, Potter, Schuylkill, Snyder, Somerset, Sullivan, Susquehanna, Tioga, Union, Venango, Warren, Washington, Wayne, Westmoreland, Wyoming	Evidence of Coverage, H2128-001 - English (PDF) Evidence of Coverage, H2128-001 - Spanish (PDF)
Wellcare No Premium Open (PPO)	H2128-002	Armstrong, Beaver, Bedford, Berks, Blair, Bradford, Bucks, Butler, Cambria, Cameron, Carbon, Centre, Chester, Clarion, Clearfield, Clinton, Crawford, Cumberland, Dauphin, Delaware, Elk, Erie, Fayette, Forest, Fulton, Greene, Huntingdon, Indiana, Jefferson, Juniata, Lackawanna, Lancaster, Lawrence, Lebanon, Lehigh, Luzerne, Lycoming, McKean, Mifflin, Monroe, Montgomery, Northampton, Perry, Philadelphia, Potter, Schuylkill, Snyder, Somerset, Sullivan, Susquehanna, Tioga, Union, Venango, Warren, Washington, Wayne, Westmoreland, Wyoming	Evidence of Coverage, H2128-002 - English (PDF) Evidence of Coverage, H2128-002 - Spanish (PDF)
Wellcare Low Premium Open (PPO)	H2128-003	Armstrong, Beaver, Bedford, Berks, Blair, Bradford, Bucks, Butler, Cambria, Cameron, Carbon, Centre, Chester, Clarion, Clearfield, Clinton, Crawford, Cumberland, Dauphin, Delaware, Elk, Erie, Fayette, Forest, Fulton, Greene, Huntingdon, Indiana, Jefferson, Juniata, Lackawanna, Lancaster, Lawrence, Lebanon, Lehigh, Luzerne, Lycoming, McKean, Mifflin, Monroe, Montgomery, Northampton, Perry, Philadelphia, Potter, Schuylkill, Snyder, Somerset, Sullivan, Susquehanna, Tioga, Union, Venango, Warren, Washington, Wayne, Westmoreland, Wyoming	Evidence of Coverage, H2128-003 - English (PDF) Evidence of Coverage, H2128-003 - Spanish (PDF) - coming soon
Wellcare Giveback Open (PPO)	H2128-004	Armstrong, Beaver, Bedford, Berks, Blair, Bradford, Bucks, Butler, Cambria, Cameron, Carbon, Centre, Chester, Clarion, Clearfield, Clinton, Crawford, Cumberland, Dauphin, Delaware, Elk, Erie, Fayette, Forest, Fulton, Greene, Huntingdon, Indiana, Jefferson, Juniata, Lackawanna, Lancaster, Lawrence, Lebanon, Lehigh, Luzerne, Lycoming, McKean, Mifflin, Monroe, Montgomery, Northampton, Perry, Philadelphia, Potter, Schuylkill, Snyder, Somerset, Sullivan, Susquehanna, Tioga, Union, Venango, Warren, Washington, Wayne, Westmoreland, Wyoming	Evidence of Coverage, H2128-004 - English (PDF) Evidence of Coverage, H2128-004 - 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 (ANOC)
Wellcare No Premium (HMO)	H2915-003	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, H2915-003 - English (PDF) Annual Notice of Changes, H2915-003 - Spanish (PDF) coming soon
Wellcare Assist (HMO)	H2915-011	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, Fulton, Greene, Huntingdon, Indiana, Jefferson, Juniata, Lackawanna, Lancaster, Lawrence, Lebanon, Lehigh, Luzerne, Lycoming, McKean, Mercer, Mifflin, Monroe, Montgomery, Northampton, Perry, Philadelphia, Potter, Schuylkill, Snyder, Somerset, Sullivan, Susquehanna, Tioga, Union, Venango, Warren, Washington, Wayne, Westmoreland, Wyoming	Annual Notice of Changes H2915-011 - English (PDF) Annual Notice of Changes H2915-011 - Spanish (PDF) coming soon
Wellcare Giveback (HMO)	H2915-012	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, Fulton, Greene, Huntingdon, Indiana, Jefferson, Juniata, Lackawanna, Lancaster, Lawrence, Lebanon, Lehigh, Luzerne, Lycoming, McKean, Mercer, Mifflin, Monroe, Montgomery, Northampton, Perry, Philadelphia, Potter, Schuylkill, Snyder, Somerset, Sullivan, Susquehanna, Tioga, Union, Venango, Warren, Washington, Wayne, Westmoreland, Wyoming	Annual Notice of Changes H2915-012 - English (PDF) Annual Notice of Changes H2915-012 - Spanish (PDF) coming soon
Allwell Medicare Boost (HMO) to Wellcare Giveback (HMO)	H2915-014 - H2915-012	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, Fulton, Greene, Huntingdon, Indiana, Jefferson, Juniata, Lackawanna, Lancaster, Lawrence, Lebanon, Lehigh, Luzerne, Lycoming, McKean, Mercer, Mifflin, Monroe, Montgomery, Northampton, Perry, Philadelphia, Potter, Schuylkill, Snyder, Somerset, Sullivan, Susquehanna, Tioga, Union, Venango, Warren, Washington, Wayne, Westmoreland, Wyoming	Annual Notice of Changes H2915-014 - H2915-012 - English (PDF) Annual Notice of Changes H2915-014 - H2915-012 - Spanish (PDF) coming soon
Wellcare Patriot Giveback (HMO)	H2915-013	Allegheny, Armstrong, Beaver, Bedford, Berks, Blair, Bradford, Bucks, Butler, Cambria, Cameron, Centre, Chester, Clarion, Clearfield, Crawford, Cumberland, Dauphin, Delaware, Elk, Erie, Fayette, Huntingdon, Indiana, Jefferson, Lackawanna, Lancaster, Lawrence, Lebanon, Lycoming, McKean, Mercer, Mifflin, Montgomery, Perry, Philadelphia, Potter, Snyder, Somerset, Sullivan, Susquehanna, Tioga, Union, Venango, Warren, Washington, Wayne, Westmoreland, Wyoming	Annual Notice of Changes H2915-013 - English (PDF) Annual Notice of Changes H2915-013 - Spanish (PDF) - coming soon
Allwell Medicare Simple (HMO) to Wellcare Patriot Giveback (HMO)	H2915-010 - H2915-013	Allegheny, Armstrong, Beaver, Bedford, Berks, Blair, Bradford, Bucks, Butler, Cambria, Cameron, Centre, Chester, Clarion, Clearfield, Crawford, Cumberland, Dauphin, Delaware, Elk, Erie, Fayette, Huntingdon, Indiana, Jefferson, Lackawanna, Lancaster, Lawrence, Lebanon, Lycoming, McKean, Mercer, Mifflin, Montgomery, Perry, Philadelphia, Potter, Snyder, Somerset, Sullivan, Susquehanna, Tioga, Union, Venango, Warren, Washington, Wayne, Westmoreland, Wyoming	Annual Notice of Changes H2915-010 - H2915-013 - English (PDF) Annual Notice of Changes H2915-010 - H2915-013 - Spanish (PDF) coming soon
Allwell Medicare (HMO) to Wellcare No Premium (HMO)	H2915-015-002 - H2915-016	Berks, Bradford, Bucks, Centre, Chester, Cumberland, Dauphin, Delaware, Fulton, Huntingdon, Juniata, Lackawanna, Lancaster, Lebanon, Lycoming, Mifflin, Montgomery, Perry, Philadelphia, Snyder, Sullivan, Susquehanna, Tioga, Union, Wayne, Wyoming	Annual Notice of Changes H2915-015-002 - H2915-016 - English (PDF) Annual Notice of Changes H2915-015-002 - H2915-016 - Spanish (PDF) coming soon
Allwell Medicare (HMO) to Wellcare No Premium (HMO)	H2915-015-003 - H2915-016	Berks, Bradford, Bucks, Centre, Chester, Cumberland, Dauphin, Delaware, Fulton, Huntingdon, Juniata, Lackawanna, Lancaster, Lebanon, Lycoming, Mifflin, Montgomery, Perry, Philadelphia, Snyder, Sullivan, Susquehanna, Tioga, Union, Wayne, Wyoming	Annual Notice of Changes H2915-015-003 - H2915-016 - English (PDF) Annual Notice of Changes H2915-015-003 - H2915-016 - Spanish (PDF)

For HMO D-SNP Members:

Plan Name	CMS #	County	Annual Notice Of Changes (ANOC)
Wellcare Dual Access (HMO D-SNP)	H2915-002	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, H2915-002 - English (PDF)
Allwell Dual Medicare (HMO D-SNP) to Wellcare Dual Access (HMO D-SNP)	H2915-001 - H2915-002	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, H2915-001 - H2915-002 - English (PDF) Annual Notice of Changes, H2915-001 - H2915-002 - Spanish (PDF) - coming soon
Wellcare Dual Access (HMO D-SNP)	H2915-007	Adams, Berks, Bradford, Carbon, Centre, Clinton, Cumberland, Dauphin, Franklin, Fulton, Huntingdon, Juniata, Lackawanna, Lancaster, Lebanon, Lehigh, Luzerne, Lycoming, Mifflin, Monroe, Northampton, Perry, Pike, Schuylkill, Snyder, Sullivan, Susquehanna, Tioga, Union, Wayne, Wyoming, York	Annual Notice of Changes, H2915-007 - English (PDF) Annual Notice of Changes, H2915-007 - Spanish (PDF) coming soon

Plan Name

CMS #

County

Annual Notice Of Changes (ANOC)

Wellcare Dual Access (HMO D-SNP)

H2915-002

Annual Notice of Changes, H2915-002 - English (PDF)

Allwell Dual Medicare (HMO D-SNP) to Wellcare Dual Access (HMO D-SNP)

H2915-001 - H2915-002

Annual Notice of Changes, H2915-001 - H2915-002 - English (PDF)
Annual Notice of Changes, H2915-001 - H2915-002 - Spanish (PDF) - coming soon

Wellcare Dual Access (HMO D-SNP)

H2915-007

Annual Notice of Changes, H2915-007 - English (PDF)

Annual Notice of Changes, H2915-007 - Spanish (PDF) coming soon

Plan Benefit Materials | Allwell from PA Health and Wellness

Plan Materials and Forms

For HMO Members:

For HMO D-SNP Members:

For PPO Members:

For HMO Members:

For HMO D-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:

For HMO SNP Members:

Plan Name	CMS #	County	Summary of Benefits
Allwell Medicare (HMO)	H2915-003	Allegheny, Armstrong, Beaver, Bedford, Blair, Butler, Cambria, Cameron, Clarion, Clearfield, Crawford, Elk, Erie, Fayette, Forest, Greene, Indiana, Jefferson, Lawrence, McKean, Mercer, Potter, Somerset, Venango, Warren, Washington and Westmoreland counties	Summary of Benefits, H2915-003 - English (PDF)
Allwell Medicare Simple (HMO)	H2915-010	Allegheny, Armstrong, Beaver, Bedford, Berks, Blair, Bradford, Butler, Cambria, Cameron, Centre, Clarion, Clearfield, Crawford, Cumberland, Dauphin, Elk, Erie, Fayette, Forest, Fulton, Greene, Huntingdon, Indiana, Jefferson, Juniata, Lackawanna, Lancaster, Lawrence, Lebanon, Lycoming, McKean, Mercer, Mifflin, Perry, Potter, Snyder, Somerset, Sullivan, Susquehanna, Tioga, Union, Venango, Warren, Washington, Wayne, Westmoreland and Wyoming counties	Summary of Benefits, H2915-010 - English (PDF)
Allwell Medicare Complement (HMO)	H2915-011	Allegheny, Armstrong, Beaver, Bedford, Berks, Blair, Bradford, Bucks, Butler, Cambria, Cameron, Centre, Chester, Clarion, Clearfield, Crawford, Cumberland, Dauphin, Delaware, Elk, Erie, Fayette, Forest, Fulton, Greene, Huntingdon, Indiana, Jefferson, Juniata, Lackawanna, Lancaster, Lawrence, Lebanon, Lycoming, McKean, Mercer, Mifflin, Montgomery, Perry, Philadelphia, Potter, Snyder, Somerset, Sullivan, Susquehanna, Tioga, Union, Venango, Warren, Washington, Wayne, Westmoreland and Wyoming counties	Summary of Benefits, H2915-011 - English (PDF)
Allwell Medicare Boost (HMO)	H2915-012	Allegheny, Armstrong, Beaver, Bedford, Berks, Blair, Bradford, Butler, Cambria, Cameron, Centre, Clarion, Clearfield, Crawford, Cumberland, Dauphin, Elk, Erie, Fayette, Forest, Fulton, Greene, Huntingdon, Indiana, Jefferson, Juniata, Lackawanna, Lancaster, Lawrence, Lebanon, Lycoming, McKean, Mercer, Mifflin, Perry, Potter, Snyder, Somerset, Sullivan, Susquehanna, Tioga, Union, Venango, Warren, Washington, Wayne, Westmoreland and Wyoming counties	Summary of Benefits, H2915-012 - English (PDF)
Allwell Medicare Simple (HMO)	H2915-013	Bucks, Chester, Delaware, Montgomery and Philadelphia counties	Summary of Benefits, H2915-013 - English (PDF)
Allwell Medicare Boost (HMO)	H2915-014	Bucks, Chester, Delaware, Montgomery and Philadelphia counties	Summary of Benefits, H2915-014 - English (PDF)
Allwell Medicare (HMO)	H2915-015-002	Berks, Bradford, Centre, Cumberland, Dauphin, Fulton, Huntingdon, Juniata, Lackawanna, Lancaster, Lebanon, Lycoming, Mifflin, Perry, Snyder, Sullivan, Susquehanna, Tioga, Union, Wayne and Wyoming counties	Summary of Benefits, H2915-015-002 - English (PDF)
Allwell Medicare (HMO)	H2915-015-003	Bucks, Chester, Delaware, Montgomery and Philadelphia counties	Summary of Benefits, H2915-015-003 - English (PDF)

Plan Name	CMS #	County	Summary of Benefits
Allwell Dual Medicare (HMO D-SNP)	H2915-001	Allegheny, Armstrong, Beaver, Bedford, Blair, Butler, Cambria, Cameron, Clarion, Clearfield, Crawford, Elk, Erie, Fayette, Forest, Greene, Indiana, Jefferson, Lawrence, McKean, Mercer, Potter, Somerset, Venango, Warren, Washington and Westmoreland counties	Summary of Benefits, H2915-001 - English (PDF)
Allwell Dual Medicare (HMO D-SNP)	H2915-002	Bucks, Chester, Delaware, Montgomery and Philadelphia counties	Summary of Benefits, H2915-002 - English (PDF) Summary of Benefits, H2915 - 002 - Spanish (PDF)
Allwell Dual Medicare (HMO D-SNP)	H2915-007	Adams, Berks, Bradford, Carbon, Centre, Clinton, Cumberland, Dauphin, Franklin, Fulton, Huntingdon, Juniata, Lackawanna, Lancaster, Lebanon, Lehigh, Luzerne, Lycoming, Mifflin, Monroe, Northampton, Perry, Pike, Schuylkill, Snyder, Sullivan, Susquehanna, Tioga, Union, Wayne, Wyoming and York counties	Summary of Benefits, H2915-007 - English (PDF) Summary of Benefits, H2915-007 - Spanish (PDF)

Plan Benefit Materials | Allwell from PA Health and Wellness

Plan Materials and Forms

Summary of Benefits

For HMO Members:

For HMO D-SNP Members:

For PPO Members:

Evidence Of Coverage (EOC)

For HMO Members:

For HMO D-SNP Members:

For PPO Members:

Annual Notice of Changes (ANOC)

Over-The-Counter Benefits

Plan Benefit Materials

Summary of Benefits

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:

For HMO SNP Members:

Optional Supplemental Benefits Brochure

Optional Individual Benefit Enrollment Form

Acupuncture National Coverage

Over-The-Counter Benefits