Plan Benefit Materials | Allwell from Western Sky Community Care

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) H2134-005 Bernalillo, Dona Ana, Rio Arriba, Sandoval, Santa Fe, Torrance, Valencia
Wellcare Patriot No Premium (HMO) H2134-006 Bernalillo, Dona Ana, Rio Arriba, Sandoval, Santa Fe, Torrance, Valencia
Wellcare Giveback (HMO) H2134-002 Bernalillo, Dona Ana, Rio Arriba, Sandoval, Santa Fe, Torrance, Valencia
Wellcare Assist (HMO) H2134-004 Bernalillo, Dona Ana, Rio Arriba, Sandoval, Santa Fe, Torrance, Valencia

For HMO D-SNP Members:

Plan Name  CMS # County Summary of Benefits
Wellcare Dual Liberty (HMO D-SNP) H2134-001 Bernalillo, Chaves, Cibola, Curry, Dona Ana, Luna, McKinley, Quay, Rio Arriba, Roosevelt, San Juan, Sandoval, Santa Fe, Taos, Torrance, Valencia
Wellcare Dual Access (HMO D-SNP) H2134-003 Bernalillo, Chaves, Cibola, Curry, Dona Ana, Luna, McKinley, Quay, Rio Arriba, Roosevelt, San Juan, Sandoval, Santa Fe, Taos, Torrance, Valencia

For PPO Members:

Plan Name CMS # County Summary of Benefits
Wellcare No Premium Open (PPO) H9976-002 Bernalillo, Chaves, Cibola, Curry, Dona Ana, Luna, McKinley, Quay, Rio Arriba, Roosevelt, Sandoval, Santa Fe, Taos, Torrance, Valencia
Wellcare Low Premium Open (PPO) H9976-003 Bernalillo, Chaves, Cibola, Curry, Dona Ana, Luna, McKinley, Quay, Rio Arriba, Roosevelt, Sandoval, Santa Fe, Taos, Torrance, Valencia
Wellcare Assist Open (PPO) H9976-001 Bernalillo, Chaves, Cibola, Curry, Dona Ana, Luna, McKinley, Quay, Rio Arriba, Roosevelt, Sandoval, Santa Fe, Taos, Torrance, Valencia
Wellcare Giveback Open (PPO) H9976-004 Bernalillo, Chaves, Cibola, Curry, Dona Ana, Luna, McKinley, Quay, Rio Arriba, Roosevelt, Sandoval, Santa Fe, Taos, Torrance, Valencia

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 Patriot No Premium (HMO) MA Only H2134-006 Bernalillo, Dona Ana, Rio Arriba, Sandoval, Santa Fe, Torrance, Valencia
Wellcare Giveback (HMO) MAPD H2134-002 Bernalillo, Dona Ana, Rio Arriba, Sandoval, Santa Fe, Torrance, Valencia
Wellcare Assist (HMO) MAPD H2134-004 Bernalillo, Dona Ana, Rio Arriba, Sandoval, Santa Fe, Torrance, Valencia
Wellcare No Premium (HMO) MAPD H2134-005 Bernalillo, Dona Ana, Rio Arriba, Sandoval, Santa Fe, Torrance, Valencia

For HMO D-SNP Members:

Plan Name  CMS # County Summary of Benefits
Wellcare Dual Liberty (HMO D-SNP) H2134-001 Bernalillo, Chaves, Cibola, Curry, Dona Ana, Luna, McKinley, Quay, Rio Arriba, Roosevelt, San Juan, Sandoval, Santa Fe, Taos, Torrance, Valencia
Wellcare Dual Access (HMO D-SNP) H2134-003 Bernalillo, Chaves, Cibola, Curry, Dona Ana, Luna, McKinley, Quay, Rio Arriba, Roosevelt, San Juan, Sandoval, Santa Fe, Taos, Torrance, Valencia

For PPO Members:

Plan Name  CMS # County Evidence of Coverage
Wellcare Assist Open (PPO) H9976-001 Bernalillo, Chaves, Cibola, Curry, Dona Ana, Luna, McKinley, Quay, Rio Arriba, Roosevelt, Sandoval, Santa Fe, Taos, Torrance, Valencia
Wellcare No Premium Open (PPO) H9976-002 Bernalillo, Chaves, Cibola, Curry, Dona Ana, Luna, McKinley, Quay, Rio Arriba, Roosevelt, Sandoval, Santa Fe, Taos, Torrance, Valencia
Wellcare Low Premium Open (PPO) H9976-003 Bernalillo, Chaves, Cibola, Curry, Dona Ana, Luna, McKinley, Quay, Rio Arriba, Roosevelt, Sandoval, Santa Fe, Taos, Torrance, Valencia
Wellcare Giveback Open (PPO) H9976-004 Bernalillo, Chaves, Cibola, Curry, Dona Ana, Luna, McKinley, Quay, Rio Arriba, Roosevelt, Sandoval, Santa Fe, Taos, Torrance, Valencia

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:

Plan Name  CMS # County Annual Notice of Change (ANOC)
Wellcare Dual Liberty (HMO D-SNP) H2134-001 Bernalillo, Chaves, Cibola, Curry, Dona Ana, Luna, McKinley, Quay, Rio Arriba, Roosevelt, San Juan, Sandoval, Santa Fe, Taos, Torrance, Valencia
Wellcare Giveback (HMO) H2134-002 Bernalillo, Dona Ana, Rio Arriba, Sandoval, Santa Fe, Torrance, Valencia
Wellcare Dual Access (HMO D-SNP) H2134-003 Bernalillo, Chaves, Cibola, Curry, Dona Ana, Luna, McKinley, Quay, Rio Arriba, Roosevelt, San Juan, Sandoval, Santa Fe, Taos, Torrance, Valencia
Allwell Dual Medicare (HMO D-SNP) to Wellcare Dual Access (HMO D-SNP) H2134-001 - H2134-003 Bernalillo, Chaves, Cibola, Curry, Dona Ana, Luna, McKinley, Quay, Rio Arriba, Roosevelt, San Juan, Sandoval, Santa Fe, Taos, Torrance, Valencia
Wellcare Assist (HMO) H2134-004 Bernalillo, Dona Ana, Rio Arriba, Sandoval, Santa Fe, Torrance, Valencia
Wellcare No Premium (HMO) H2134-005 Bernalillo, Dona Ana, Rio Arriba, Sandoval, Santa Fe, Torrance, Valencia
Wellcare Patriot No Premium (HMO) H2134-006 Bernalillo, Dona Ana, Rio Arriba, Sandoval, Santa Fe, Torrance, Valencia