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 from Home State Health 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 from Home State Health 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)	H1664-001	Barry, Christian, Dallas, Greene, Jasper, Laclede, Lawrence, McDonald, Newton, Polk, Stone, Taney, Webster and Wright	Summary of Benefits H1664- 001 - English (PDF)
Wellcare No Premium (HMO)	H1664-004	Crawford, Franklin, Jefferson, Lincoln, St. Charles, St. Louis, St. Louis City, Warren and Washington	Summary of Benefits H1664 - 004 - English (PDF)
Wellcare Giveback (HMO)	H1664-006	Barry, Cass, Christian, Clay, Crawford, Dade, Dallas, Douglas, Franklin, Greene, Jackson, Jasper, Jefferson, Laclede, Lawrence, Lincoln, McDonald, Newton, Platte, Polk, St. Charles, St. Louis, St. Louis City, Stone, Taney, Warren, Washington, Webster, Wright	Summary of Benefits H1664 - 006 - English (PDF)
Wellcare Assist (HMO)	H1664-007	Barry, Cass, Christian, Clay, Crawford, Dade, Dallas, Douglas, Franklin, Greene, Jackson, Jasper, Jefferson, Laclede, Lawrence, Lincoln, McDonald, Newton, Platte, Polk, St. Charles, St. Louis, St. Louis City, Stone, Taney, Warren, Washington, Webster, Wright	Summary of Benefits H1664 - 007 - English (PDF)

For HMO D-SNP Members:

Plan Name	CMS#	County	Summary of Benefits
Wellcare Dual Access (HMO D-SNP)	H1664 - 005	Barry, Cass, Christian, Clay, Crawford, Dade, Dallas, Douglas, Franklin, Greene, Jackson, Jasper, Jefferson, Laclede, Lawrence, Lincoln, McDonald, Newton, Platte, Polk, St. Charles, St. Louis, St. Louis City, Stone, Taney, Warren, Washington, Webster, Wright	Summary of Benefits -H1664 - 005 - English (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
Wellcare No Premium (HMO)	H1664-001	Barry, Cass, Christian, Clay, Dade, Dallas, Douglas, Greene, Jackson, Jasper, Laclede, Lawrence, McDonald, Newton, Platte, Polk, Stone, Taney, Webster, Wright	Evidence of Coverage H1664 - 001- English (PDF)
Wellcare No Premium (HMO)	H1664-004	Crawford, Franklin, Jefferson, Lincoln, St. Charles, St. Louis, St. Louis City, Warren and Washington	Evidence of Coverage H1664 - 004 - English (PDF)
Wellcare Giveback (HMO)	H1664-006	Barry, Cass, Christian, Clay, Crawford, Dade, Dallas, Douglas, Franklin, Greene, Jackson, Jasper, Jefferson, Laclede, Lawrence, Lincoln, McDonald, Newton, Platte, Polk, St. Charles, St. Louis, St. Louis City, Stone, Taney, Warren, Washington, Webster, Wright	Evidence of Coverage H1664 - 006 - English (PDF)
Wellcare Assist (HMO)	H1664-007	Barry, Cass, Christian, Clay, Crawford, Dade, Dallas, Douglas, Franklin, Greene, Jackson, Jasper, Jefferson, Laclede, Lawrence, Lincoln, McDonald, Newton, Platte, Polk, St. Charles, St. Louis, St. Louis City, Stone, Taney, Warren, Washington, Webster, Wright	Evidence of Coverage H1664 - 007 - English (PDF)

For HMO D-SNP Members:

Plan Name	CMS#	County	Evidence of Coverage
Wellcare Dual Access (HMO D-SNP)	H1664 - 005	Barry, Cass, Christian, Clay, Crawford, Dade, Dallas, Douglas, Franklin, Greene, Jackson, Jasper, Jefferson, Laclede, Lawrence, Lincoln, McDonald, Newton, Platte, Polk, St. Charles, St. Louis, St. Louis City, Stone, Taney, Warren, Washington, Webster, Wright	Evidence of Coverage -H1664 - 005 - English (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
Wellcare No Premium (HMO)	H1664-001	Barry, Christian, Dallas, Greene, Jasper, Laclede, Lawrence, McDonald, Newton, Polk, Stone, Taney, Webster and Wright	Annual Notice of Changes, H1664-001 - English (PDF)
Allwell Medicare (HMO) to Wellcare No Premium (HMO)	H1664-002 - H1664-001	Barry, Christian, Dallas, Greene, Jasper, Laclede, Lawrence, McDonald, Newton, Polk, Stone, Taney, Webster and Wright	Annual Notice of Changes, H1664-002 - H1664-001 - English (PDF)
Wellcare No Premium (HMO)	H1664-004	Crawford, Franklin, Jefferson, Lincoln, St. Charles, St. Louis, St. Louis City, Warren and Washington	Annual Notice of Changes H1664-004 - English (PDF)
Wellcare Giveback (HMO)	H1664-006	Barry, Cass, Christian, Clay, Crawford, Dade, Dallas, Douglas, Franklin, Greene, Jackson, Jasper, Jefferson, Laclede, Lawrence, Lincoln, McDonald, Newton, Platte, Polk, St. Charles, St. Louis, St. Louis City, Stone, Taney, Warren, Washington, Webster, Wright	Annual Notice of Changes H1664-006 - English (PDF)
Allwell Medicare Boost (HMO) to Wellcare Giveback (HMO)	H1664-08 - H1664-006	Barry, Cass, Christian, Clay, Crawford, Dade, Dallas, Douglas, Franklin, Greene, Jackson, Jasper, Jefferson, Laclede, Lawrence, Lincoln, McDonald, Newton, Platte, Polk, St. Charles, St. Louis, St. Louis City, Stone, Taney, Warren, Washington, Webster, Wright	Annual Notice of Changes H1664-08 - H1664-006 - English (PDF)
Allwell Medicare Boost (HMO) to Wellcare Giveback (HMO)	H1664-10 - H1664-006	Barry, Cass, Christian, Clay, Crawford, Dade, Dallas, Douglas, Franklin, Greene, Jackson, Jasper, Jefferson, Laclede, Lawrence, Lincoln, McDonald, Newton, Platte, Polk, St. Charles, St. Louis, St. Louis City, Stone, Taney, Warren, Washington, Webster, Wright	Annual Notice of Changes H1664-10 - H1664-006 - English (PDF)
Wellcare Assist (HMO)	H1664-007	Barry, Cass, Christian, Clay, Crawford, Dade, Dallas, Douglas, Franklin, Greene, Jackson, Jasper, Jefferson, Laclede, Lawrence, Lincoln, McDonald, Newton, Platte, Polk, St. Charles, St. Louis, St. Louis City, Stone, Taney, Warren, Washington, Webster, Wright	Annual Notice of Changes H1664-007 - English (PDF)
Allwell Medicare Complement (HMO) to Wellcare Assist (HMO)	H1664-009 - H1664-007	Barry, Cass, Christian, Clay, Crawford, Dade, Dallas, Douglas, Franklin, Greene, Jackson, Jasper, Jefferson, Laclede, Lawrence, Lincoln, McDonald, Newton, Platte, Polk, St. Charles, St. Louis, St. Louis City, Stone, Taney, Warren, Washington, Webster, Wright	Annual Notice of Changes H1664-009 - H1664-007 - English (PDF)
Allwell Medicare Complement (HMO) to Wellcare Assist (HMO)	H1664-011 - H1664-007	Barry, Cass, Christian, Clay, Crawford, Dade, Dallas, Douglas, Franklin, Greene, Jackson, Jasper, Jefferson, Laclede, Lawrence, Lincoln, McDonald, Newton, Platte, Polk, St. Charles, St. Louis, St. Louis City, Stone, Taney, Warren, Washington, Webster, Wright	Annual Notice of Changes H1664-011 - H1664-007 - English (PDF)

For HMO D-SNP Members:

Plan Name	CMS#	County	Annual Notice Of Changes
Wellcare Dual Access (HMO D-SNP)	H1664 - 005	Barry, Cass, Christian, Clay, Crawford, Dallas, Franklin, Greene, Jackson, Jasper, Jefferson, Laclede, Lawrence, Lincoln, McDonald, Newton, Platte, Polk, St. Charles, St. Louis, St. Louis City, Stone, Taney, Warren, Washington, Webster and Wright	Annual Notice of Changes H1664-005 - English (PDF)

Over-The-Counter Catalog - English (PDF)

Plan Benefit Materials |

Plan Materials and Forms

For HMO Members:

For HMO D-SNP Members:

For HMO Members:

For HMO D-SNP Members:

For HMO D-SNP Members:

Plan Benefit Materials

For HMO Members:

For HMO D-SNP Members:

For HMO Members:

For HMO D-SNP Members:

For HMO Members:

For HMO D-SNP Members:

Plan Name	CMS#	County	Summary of Benefits
Allwell Medicare (HMO)	H1664-001	Barry, Christian, Dade, Dallas, Greene, Jasper, Laclede, Lawrence, McDonald, Newton, Polk, Stone, Taney, Webster and Wright	Summary of Benefits H1664- 001 - English (PDF)
Allwell Medicare (HMO)	H1664-002	Cass, Clay, Jackson, and Platte	Summary of Benefits H1664 - 002 - English (PDF)
Allwell Medicare (HMO)	H1664-004	Crawford, Franklin, Jefferson, Lincoln, St. Charles, St. Louis, St. Louis City, Warren and Washington	Summary of Benefits H1664 - 004 - English (PDF)
Allwell Medicare Boost (HMO)	H1664-006	Barry, Christian, Dade, Dallas, Douglas, Greene, Jasper, Laclede, Lawrence, McDonald, Newton, Polk, Stone, Taney, Webster and Wright counties	Summary of Benefits H1664 - 006 - English (PDF)
Allwell Medicare Complement (HMO)	H1664-007	Barry, Christian, Dade, Dallas, Douglas, Greene, Jasper, Laclede, Lawrence, McDonald, Newton, Polk, Stone, Taney, Webster and Wright counties	Summary of Benefits H1664 - 007 - English (PDF)
Allwell Medicare Boost (HMO)	H1664-008	Cass, Clay, Jackson and Platte counties	Summary of Benefits H1664 - 008 - English (PDF)
Allwell Medicare Complement (HMO)	H1664-009	Cass, Clay, Jackson and Platte counties	Summary of Benefits H1664 - 009 - English (PDF)
Allwell Medicare Boost (HMO)	H1664-010	Crawford, Franklin, Jefferson, Lincoln, St. Charles, St. Louis, St. Louis City, Warren and Washington counties	Summary of Benefits H1664 - 010 - English (PDF)
Allwell Medicare Complement (HMO)	H1664-011	Crawford, Franklin, Jefferson, Lincoln, St. Charles, St. Louis, St. Louis City, Warren and Washington counties	Summary of Benefits H1664 - 011 - English (PDF)

Plan Benefit Materials |

Plan Materials and Forms

Summary of Benefits (SB)

For HMO Members:

For HMO D-SNP Members:

Evidence Of Coverage (EOC)

For HMO Members:

For HMO D-SNP Members:

Annual Notice of Changes (ANOC)

For HMO D-SNP Members:

Over-The-Counter Benefits

Plan Benefit Materials

Summary of Benefits (SB)

For HMO Members:

For HMO D-SNP Members:

Evidence Of Coverage (EOC)

For HMO Members:

For HMO D-SNP Members:

Annual Notice of Changes (ANOC)

For HMO Members:

For HMO D-SNP Members:

Acupuncture National Coverage

Over-The-Counter Benefits