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Materiales de los beneficios del plan | Allwell de PA Health and Wellness
Plan Materials and Forms
Information about plan benefits, services, and drug costs can be found in your plan materials.
You can also look for plan materials based on the plan name and the county you live in.
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 |
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| 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 |
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| 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 |
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| 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 |
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| 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 |
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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 |
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| 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 |
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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 |
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| 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 |
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| 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 |
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| 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 |
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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 |
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| 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 |
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| 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 |
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| 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 |
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| 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 |
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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 |
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| 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 |
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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 |
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| 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 |
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| 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 |
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| 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 |
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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 |
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| 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 |
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| 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 |
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| 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 |
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| 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 |
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| 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 |
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| 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 |
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| 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 |
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 | |
| 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 |
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| 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 |
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- Medicare Step Therapy Part B (PDF)