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Plan Benefit Materials |
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.”
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, Barton, Bates, Cass, Christian, Clay, Clinton, Dade, Dallas, Douglas, Greene, Henry, Jackson, Jasper, Johnson, Laclede, Lafayette, Lawrence, McDonald, Newton, Platte, Polk, Ray, Stone, Taney, Vernon, Webster, Wright | |
Wellcare No Premium (HMO) | H1664-004 | Audrain, Boone, Callaway, Cole, Cooper, Crawford, Franklin, Gasconade, Jefferson, Lincoln, Maries, Miller, Moniteau, Montgomery, Morgan, Osage, St. Charles, St. Louis, St. Louis City, Warren, Washington | |
Wellcare Giveback (HMO) | H1664-006 | Audrain, Barry, Barton, Bates, Boone, Callaway, Cass, Christian, Clay, Clinton, Cole, Cooper, Crawford, Dade, Dallas, Douglas, Franklin, Gasconade, Greene, Henry, Jackson, Jasper, Jefferson, Johnson, Laclede, Lafayette, Lawrence, Lincoln, Maries, McDonald, Miller, Moniteau, Montgomery, Morgan, Newton, Osage, Platte, Polk, Ray, St. Charles, St. Louis, St. Louis City, Stone, Taney, Vernon, Warren, Washington, Webster, Wright | |
Wellcare Assist (HMO) | H1664-007 | Audrain, Barry, Barton, Bates, Boone, Callaway, Cass, Christian, Clay, Clinton, Cole, Cooper, Crawford, Dade, Dallas, Douglas, Franklin, Gasconade, Greene, Henry, Jackson, Jasper, Jefferson, Johnson, Laclede, Lafayette, Lawrence, Lincoln, Maries, McDonald, Miller, Moniteau, Montgomery, Morgan, Newton, Osage, Platte, Polk, Ray, St. Charles, St. Louis, St. Louis City, Stone, Taney, Vernon, Warren, Washington, Webster, Wright |
For HMO D-SNP Members:
| Plan Name | CMS# | County | Summary of Benefits |
|---|---|---|---|
Wellcare Dual Access (HMO D-SNP) | H1664 - 005 | Audrain, Barry, Barton, Bates, Boone, Callaway, Cass, Christian, Clay, Clinton, Cole, Cooper, Crawford, Dade, Dallas, Douglas, Franklin, Gasconade, Greene, Henry, Jackson, Jasper, Jefferson, Johnson, Laclede, Lafayette, Lawrence, Lincoln, Maries, McDonald, Miller, Moniteau, Montgomery, Morgan, Newton, Osage, Platte, Polk, Ray, St. Charles, St. Louis, St. Louis City, Stone, Taney, Vernon, Warren, Washington, Webster, Wright |
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, Barton, Bates, Cass, Christian, Clay, Clinton, Dade, Dallas, Douglas, Greene, Henry, Jackson, Jasper, Johnson, Laclede, Lafayette, Lawrence, McDonald, Newton, Platte, Polk, Ray, Stone, Taney, Vernon, Webster, Wright | |
Wellcare No Premium (HMO) | H1664-004 | Audrain, Boone, Callaway, Cole, Cooper, Crawford, Franklin, Gasconade, Jefferson, Lincoln, Maries, Miller, Moniteau, Montgomery, Morgan, Osage, St. Charles, St. Louis, St. Louis City, Warren, Washington | |
Wellcare Giveback (HMO) | H1664-006 | Audrain, Barry, Barton, Bates, Boone, Callaway, Cass, Christian, Clay, Clinton, Cole, Cooper, Crawford, Dade, Dallas, Douglas, Franklin, Gasconade, Greene, Henry, Jackson, Jasper, Jefferson, Johnson, Laclede, Lafayette, Lawrence, Lincoln, Maries, McDonald, Miller, Moniteau, Montgomery, Morgan, Newton, Osage, Platte, Polk, Ray, St. Charles, St. Louis, St. Louis City, Stone, Taney, Vernon, Warren, Washington, Webster, Wright | |
Wellcare Assist (HMO) | H1664-007 | Audrain, Barry, Barton, Bates, Boone, Callaway, Cass, Christian, Clay, Clinton, Cole, Cooper, Crawford, Dade, Dallas, Douglas, Franklin, Gasconade, Greene, Henry, Jackson, Jasper, Jefferson, Johnson, Laclede, Lafayette, Lawrence, Lincoln, Maries, McDonald, Miller, Moniteau, Montgomery, Morgan, Newton, Osage, Platte, Polk, Ray, St. Charles, St. Louis, St. Louis City, Stone, Taney, Vernon, Warren, Washington, Webster, Wright |
For HMO D-SNP Members:
| Plan Name | CMS# | County | Evidence of Coverage |
|---|---|---|---|
Wellcare Dual Access (HMO D-SNP) | H1664 - 005 | Audrain, Barry, Barton, Bates, Boone, Callaway, Cass, Christian, Clay, Clinton, Cole, Cooper, Crawford, Dade, Dallas, Douglas, Franklin, Gasconade, Greene, Henry, Jackson, Jasper, Jefferson, Johnson, Laclede, Lafayette, Lawrence, Lincoln, Maries, McDonald, Miller, Moniteau, Montgomery, Morgan, Newton, Osage, Platte, Polk, Ray, St. Charles, St. Louis, St. Louis City, Stone, Taney, Vernon, Warren, Washington, Webster, Wright |
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, Barton, Bates, Cass, Christian, Clay, Clinton, Dade, Dallas, Douglas, Greene, Henry, Jackson, Jasper, Johnson, Laclede, Lafayette, Lawrence, McDonald, Newton, Platte, Polk, Ray, Stone, Taney, Vernon, Webster, Wright | |
| Wellcare No Premium (HMO) | H1664-004 | Audrain, Boone, Callaway, Cole, Cooper, Crawford, Franklin, Gasconade, Jefferson, Lincoln, Maries, Miller, Moniteau, Montgomery, Morgan, Osage, St. Charles, St. Louis, St. Louis City, Warren, Washington | |
| Wellcare Giveback (HMO) | H1664-006 | Audrain, Barry, Barton, Bates, Boone, Callaway, Cass, Christian, Clay, Clinton, Cole, Cooper, Crawford, Dade, Dallas, Douglas, Franklin, Gasconade, Greene, Henry, Jackson, Jasper, Jefferson, Johnson, Laclede, Lafayette, Lawrence, Lincoln, Maries, McDonald, Miller, Moniteau, Montgomery, Morgan, Newton, Osage, Platte, Polk, Ray, St. Charles, St. Louis, St. Louis City, Stone, Taney, Vernon, Warren, Washington, Webster, Wright | |
| Wellcare Assist (HMO) | H1664-007 | Audrain, Barry, Barton, Bates, Boone, Callaway, Cass, Christian, Clay, Clinton, Cole, Cooper, Crawford, Dade, Dallas, Douglas, Franklin, Gasconade, Greene, Henry, Jackson, Jasper, Jefferson, Johnson, Laclede, Lafayette, Lawrence, Lincoln, Maries, McDonald, Miller, Moniteau, Montgomery, Morgan, Newton, Osage, Platte, Polk, Ray, St. Charles, St. Louis, St. Louis City, Stone, Taney, Vernon, Warren, Washington, Webster, Wright |
For HMO D-SNP Members:
| Plan Name | CMS# | County | Annual Notice Of Changes |
|---|---|---|---|
| Wellcare Dual Access (HMO D-SNP) | H1664 - 005 | Audrain, Barry, Barton, Bates, Boone, Callaway, Cass, Christian, Clay, Clinton, Cole, Cooper, Crawford, Dade, Dallas, Douglas, Franklin, Gasconade, Greene, Henry, Jackson, Jasper, Jefferson, Johnson, Laclede, Lafayette, Lawrence, Lincoln, Maries, McDonald, Miller, Moniteau, Montgomery, Morgan, Newton, Osage, Platte, Polk, Ray, St. Charles, St. Louis, St. Louis City, Stone, Taney, Vernon, Warren, Washington, Webster, Wright |