Plan Benefit Materials

Plan Name	CMS #	County	Summary of Benefits
Wellcare No Premium (HMO)	H2134-005	Bernalillo, Chaves, Cibola, Curry, Dona Ana, Eddy, Grant, Lea, Lincoln, Los Alamos, Luna, McKinley, Otero, Quay, Rio Arriba, Roosevelt, San Juan, San Miguel, Sandoval, Santa Fe, Taos, Torrance, Valencia	Summary of Benefits, H2134-005-000 - English (PDF) Summary of Benefits, H2134-005-000 - Spanish (PDF) - coming soon

Plan Name	CMS #	County	Summary of Benefits
Wellcare Dual Liberty (HMO D-SNP)	H2134-001	Bernalillo, Chaves, Cibola, Curry, Dona Ana, Eddy, Grant, Lea, Lincoln, Los Alamos, Luna, McKinley, Otero, Quay, Rio Arriba, Roosevelt, San Juan, San Miguel, Sandoval, Santa Fe, Taos, Torrance, Valencia	Summary of Benefits, H2134-001-000 English (PDF) Summary of Benefits, H2134-001-000 Spanish (PDF)- coming soon
Wellcare Dual Access (HMO D-SNP)	H2134-003	Bernalillo, Chaves, Cibola, Curry, Dona Ana, Eddy, Grant, Lea, Lincoln, Los Alamos, Luna, McKinley, Otero, Quay, Rio Arriba, Roosevelt, San Juan, San Miguel, Sandoval, Santa Fe, Taos, Torrance, Valencia	Summary of Benefits, H2134-003-000 English (PDF) Summary of Benefits, H2134-003-000 Spanish (PDF) - coming soon

Plan Name	CMS #	County	Summary of Benefits
Wellcare No Premium Open (PPO)	H9976-002	Bernalillo, Chaves, Cibola, Curry, Dona Ana, Eddy, Grant, Lea, Lincoln, Los Alamos, Luna, McKinley, Otero, Quay, Rio Arriba, Roosevelt, San Miguel, Sandoval, Santa Fe, Taos, Torrance, Valencia	Summary of Benefits, H9976-002-000 - English (PDF) Summary of Benefits, H9976-002-000 - Spanish (PDF) - coming soon

Plan Name	CMS #	County	Evidence of Coverage
Wellcare No Premium (HMO)	H2134-005	Bernalillo, Chaves, Cibola, Curry, Dona Ana, Eddy, Grant, Lea, Lincoln, Los Alamos, Luna, McKinley, Otero, Quay, Rio Arriba, Roosevelt, San Juan, San Miguel, Sandoval, Santa Fe, Taos, Torrance, Valencia	Evidence of Coverage, H2134-005 - English (PDF) Evidence of Coverage, H2134-005 - Spanish (PDF) - coming soon Dental Benefit Details, H2134-005 - English (PDF) - coming soon Dental Benefit Details, H2134-005 - Spanish (PDF) - coming soon

Plan Name	CMS #	County	Evidence of Coverage
Wellcare Dual Liberty (HMO D-SNP)	H2134-001	Bernalillo, Chaves, Cibola, Curry, Dona Ana, Eddy, Grant, Lea, Lincoln, Los Alamos, Luna, McKinley, Otero, Quay, Rio Arriba, Roosevelt, San Juan, San Miguel, Sandoval, Santa Fe, Taos, Torrance, Valencia	Evidence of Coverage, H2134-001 - English (PDF) Evidence of Coverage, H2134-001 - Spanish (PDF) - coming soon Dental Benefit Details, H2134-001 - English (PDF) - coming soon Dental Benefit Details, H2134-001 - Spanish (PDF) - coming soon
Wellcare All Dual (HMO D-SNP)	H2134-003	Bernalillo, Chaves, Cibola, Curry, Dona Ana, Eddy, Grant, Lea, Lincoln, Los Alamos, Luna, McKinley, Otero, Quay, Rio Arriba, Roosevelt, San Juan, San Miguel, Sandoval, Santa Fe, Taos, Torrance, Valencia	Evidence of Coverage, H2134-003 - English (PDF) Evidence of Coverage, H2134-003 - Spanish (PDF) - coming soon Dental Benefit Details, H2134-003 - English (PDF) - coming soon Dental Benefit Details, H2134-003 - Spanish (PDF) - coming soon

Plan Name	CMS #	County	Evidence of Coverage
Wellcare No Premium Open (PPO)	H9976-002	Bernalillo, Chaves, Cibola, Curry, Dona Ana, Eddy, Grant, Lea, Lincoln, Los Alamos, Luna, McKinley, Otero, Quay, Rio Arriba, Roosevelt, San Miguel, Sandoval, Santa Fe, Taos, Torrance, Valencia	Evidence of Coverage, H9976-002 - English (PDF) Evidence of Coverage, H9976-002 - Spanish (PDF) - coming soon Dental Benefit Details, H9976-002 - English (PDF) - coming soon Dental Benefit Details, H9976-002 - Spanish (PDF) - coming soon

Plan Name	CMS #	County	Annual Notice of Change (ANOC)
Wellcare Assist (HMO) to Wellcare No Premium (HMO)	H2134-004 to H2134-005	Bernalillo, Chaves, Cibola, Curry, Dona Ana, Eddy, Grant, Lea, Lincoln, Los Alamos, Luna, McKinley, Otero, Quay, Rio Arriba, Roosevelt, San Juan, San Miguel, Sandoval, Santa Fe, Taos, Torrance, Valencia	Annual Notice of Change (ANOC), H2134-004 to H2134-005 - English (PDF) Annual Notice of Change (ANOC), H2134-004 to H2134-005 - Spanish (PDF)
Wellcare No Premium (HMO)	H2134-005	Bernalillo, Chaves, Cibola, Curry, Dona Ana, Eddy, Grant, Lea, Lincoln, Los Alamos, Luna, McKinley, Otero, Quay, Rio Arriba, Roosevelt, San Juan, San Miguel, Sandoval, Santa Fe, Taos, Torrance, Valencia	Annual Notice of Change (ANOC), H2134-005 - English (PDF) Annual Notice of Change (ANOC), H2134-005 - Spanish (PDF)

Plan Name	CMS #	County	Annual Notice of Change (ANOC)
Wellcare No Premium Open (PPO)	H9976-002	Bernalillo, Chaves, Cibola, Curry, Dona Ana, Eddy, Grant, Lea, Lincoln, Los Alamos, Luna, McKinley, Otero, Quay, Rio Arriba, Roosevelt, San Miguel, Sandoval, Santa Fe, Taos, Torrance, Valencia	Annual Notice of Change (ANOC), H9976-002 - English (PDF) Annual Notice of Change (ANOC), H9976-002 - Spanish (PDF)
Wellcare Assist Open (PPO) to Wellcare No Premium Open (PPO)	H9976-001 to H9976- 002	Bernalillo, Chaves, Cibola, Curry, Dona Ana, Eddy, Grant, Lea, Lincoln, Los Alamos, Luna, McKinley, Otero, Quay, Rio Arriba, Roosevelt, San Miguel, Sandoval, Santa Fe, Taos, Torrance, Valencia	Annual Notice of Change (ANOC), H9976-001 - H9976-002- English (PDF) Annual Notice of Change (ANOC), H9976-001 - H9976-002- Spanish (PDF)

This booklet gives you a summary of costs and coverage in your plan.

Please select the document for your plan and county:

**Refer to Addendum to 2023 Medicare Advantage Benefits for additional information**

For HMO Members:

Plan Name	CMS #	County	Summary of Benefits
Wellcare No Premium (HMO)	H2134-005	Bernalillo, Dona Ana, Rio Arriba, San Miguel, Sandoval, Santa Fe, Torrance, Valencia	Summary of Benefits, H2134-005-000 - English (PDF) Summary of Benefits, H2134-005-000 - Spanish (PDF)
Wellcare Patriot No Premium (HMO)	H2134-006	Bernalillo, Dona Ana, Rio Arriba, San Miguel, Sandoval, Santa Fe, Torrance, Valencia	Summary of Benefits, H2134-006-000 - English (PDF) Summary of Benefits, H2134-006-000 - Spanish (PDF)
Wellcare Giveback (HMO)	H2134-002	Bernalillo, Dona Ana, Rio Arriba, San Miguel, Sandoval, Santa Fe, Torrance, Valencia	Summary of Benefits, H2134-002-000 English (PDF) Summary of Benefits, H2134-002-000 - Spanish (PDF)
Wellcare Assist (HMO)	H2134-004	Bernalillo, Dona Ana, Rio Arriba, San Miguel, Sandoval, Santa Fe, Torrance, Valencia	Summary of Benefits, H2134-004 - English (PDF) Summary of Benefits, H2134-004-000 - Spanish (PDF)

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, Eddy, Grant, Lea, Lincoln, Los Alamos, Luna, McKinley, Otero, Quay, Rio Arriba, Roosevelt, San Juan, San Miguel, Sandoval, Santa Fe, Taos, Torrance, Valencia	Summary of Benefits, H2134-001-000 English (PDF) Summary of Benefits, H2134-001-000 Spanish (PDF)
Wellcare Dual Access (HMO D-SNP)	H2134-003	Bernalillo, Chaves, Cibola, Curry, Dona Ana, Eddy, Grant, Lea, Lincoln, Los Alamos, Luna, McKinley, Otero, Quay, Rio Arriba, Roosevelt, San Juan, San Miguel, Sandoval, Santa Fe, Taos, Torrance, Valencia	Summary of Benefits, H2134-003-000 English (PDF) Summary of Benefits, H2134-003-000 Spanish (PDF)

For PPO Members:

Plan Name	CMS #	County	Summary of Benefits
Wellcare No Premium Open (PPO)	H9976-002	Bernalillo, Chaves, Cibola, Curry, Dona Ana, Eddy, Grant, Lea, Lincoln, Los Alamos, Luna, McKinley, Otero, Quay, Rio Arriba, Roosevelt, San Miguel, Sandoval, Santa Fe, Taos, Torrance, Valencia	Summary of Benefits, H9976-002-000 - English (PDF) Summary of Benefits, H9976-002-000 - Spanish (PDF)
Wellcare Assist Open (PPO)	H9976-001	Bernalillo, Chaves, Cibola, Curry, Dona Ana, Eddy, Grant, Lea, Lincoln, Los Alamos, Luna, McKinley, Otero, Quay, Rio Arriba, Roosevelt, San Miguel, Sandoval, Santa Fe, Taos, Torrance, Valencia	Summary of Benefits, H9976-001-000 - English (PDF) Summary of Benefits, H9976-001-000 - Spanish (PDF)
Wellcare Giveback Open (PPO)	H9976-004	Bernalillo, Chaves, Cibola, Curry, Dona Ana, Eddy, Grant, Lea, Lincoln, Los Alamos, Luna, McKinley, Otero, Quay, Rio Arriba, Roosevelt, San Miguel, Sandoval, Santa Fe, Taos, Torrance, Valencia	Summary of Benefits, H9976-004-000 - English (PDF) Summary of Benefits, H9976-004-000 - 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:

**Refer to Addendum to 2023 Medicare Advantage Benefits for additional information**

For HMO Members:

Plan Name	CMS #	County	Evidence of Coverage
Wellcare Patriot No Premium (HMO) MA Only	H2134-006	Bernalillo, Dona Ana, Rio Arriba, San Miguel, Sandoval, Santa Fe, Torrance, Valencia	Evidence of Coverage, H2134-006 English (PDF) Evidence of Coverage, H2134-006 Spanish (PDF) Dental Benefit Details - English (PDF) Dental Benefit Details - Spanish (PDF)
Wellcare Giveback (HMO) MAPD	H2134-002	Bernalillo, Dona Ana, Rio Arriba, San Miguel, Sandoval, Santa Fe, Torrance, Valencia	Evidence of Coverage, H2134-002 - English (PDF) Evidence of Coverage, H2134-002 - Spanish (PDF)
Wellcare Assist (HMO) MAPD	H2134-004	Bernalillo, Dona Ana, Rio Arriba, San Miguel, Sandoval, Santa Fe, Torrance, Valencia	Evidence of Coverage, H2134-004 - English (PDF) Evidence of Coverage, H2134-004 - Spanish (PDF) Dental Benefit Details - English (PDF) Dental Benefit Details - Spanish (PDF)
Wellcare No Premium (HMO) MAPD	H2134-005	Bernalillo, Dona Ana, Rio Arriba, San Miguel, Sandoval, Santa Fe, Torrance, Valencia	Evidence of Coverage, H2134-005 - English (PDF) Evidence of Coverage, H2134-005 - Spanish (PDF) Dental Benefit Details - English (PDF)

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, Eddy, Grant, Lea, Lincoln, Los Alamos, Luna, McKinley, Otero, Quay, Rio Arriba, Roosevelt, San Juan, San Miguel, Sandoval, Santa Fe, Taos, Torrance, Valencia	Evidence of Coverage, H2134-001 - English (PDF) Evidence of Coverage, H2134-001 - Spanish (PDF) Dental Benefit Details - English (PDF) Dental Benefit Details - Spanish (PDF)
Wellcare Dual Access (HMO D-SNP)	H2134-003	Bernalillo, Chaves, Cibola, Curry, Dona Ana, Eddy, Grant, Lea, Lincoln, Los Alamos, Luna, McKinley, Otero, Quay, Rio Arriba, Roosevelt, San Juan, San Miguel, Sandoval, Santa Fe, Taos, Torrance, Valencia	Evidence of Coverage, H2134-003 - English (PDF) Evidence of Coverage, H2134-003 - Spanish (PDF) Dental Benefit Details - English (PDF) Dental Benefit Details - Spanish (PDF)

Plan Name

CMS #

County

Summary of Benefits

Wellcare Dual Liberty (HMO D-SNP)

H2134-001

Bernalillo, Chaves, Cibola, Curry, Dona Ana, Eddy, Grant, Lea, Lincoln, Los Alamos, Luna, McKinley, Otero, Quay, Rio Arriba, Roosevelt, San Juan, San Miguel, Sandoval, Santa Fe, Taos, Torrance, Valencia

Wellcare Dual Access (HMO D-SNP)

H2134-003

Bernalillo, Chaves, Cibola, Curry, Dona Ana, Eddy, Grant, Lea, Lincoln, Los Alamos, Luna, McKinley, Otero, Quay, Rio Arriba, Roosevelt, San Juan, San Miguel, 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, Eddy, Grant, Lea, Lincoln, Los Alamos, Luna, McKinley, Otero, Quay, Rio Arriba, Roosevelt, San Miguel, Sandoval, Santa Fe, Taos, Torrance, Valencia	Evidence of Coverage, H9976-001 - English (PDF) Evidence of Coverage, H9976-001 - Spanish (PDF) Dental Benefit Details - English (PDF) Dental Benefit Details - Spanish (PDF)
Wellcare No Premium Open (PPO)	H9976-002	Bernalillo, Chaves, Cibola, Curry, Dona Ana, Eddy, Grant, Lea, Lincoln, Los Alamos, Luna, McKinley, Otero, Quay, Rio Arriba, Roosevelt, San Miguel, Sandoval, Santa Fe, Taos, Torrance, Valencia	Evidence of Coverage, H9976-002 - English (PDF) Evidence of Coverage, H9976-002 - Spanish (PDF) Dental Benefit Details - English (PDF) Dental Benefit Details - Spanish (PDF)
Wellcare Giveback Open (PPO)	H9976-004	Bernalillo, Chaves, Cibola, Curry, Dona Ana, Eddy, Grant, Lea, Lincoln, Los Alamos, Luna, McKinley, Otero, Quay, Rio Arriba, Roosevelt, San Miguel, Sandoval, Santa Fe, Taos, Torrance, Valencia	Evidence of Coverage, H9976-004- English (PDF) Evidence of Coverage, H9976-004-Spanish (PDF)

Plan Name

CMS #

County

Evidence of Coverage

Wellcare Assist Open (PPO)

H9976-001

Bernalillo, Chaves, Cibola, Curry, Dona Ana, Eddy, Grant, Lea, Lincoln, Los Alamos, Luna, McKinley, Otero, Quay, Rio Arriba, Roosevelt, San Miguel, Sandoval, Santa Fe, Taos, Torrance, Valencia

Wellcare No Premium Open (PPO)

H9976-002

Bernalillo, Chaves, Cibola, Curry, Dona Ana, Eddy, Grant, Lea, Lincoln, Los Alamos, Luna, McKinley, Otero, Quay, Rio Arriba, Roosevelt, San Miguel, Sandoval, Santa Fe, Taos, Torrance, Valencia

Wellcare Giveback Open (PPO)

H9976-004

Bernalillo, Chaves, Cibola, Curry, Dona Ana, Eddy, Grant, Lea, Lincoln, Los Alamos, Luna, McKinley, Otero, Quay, Rio Arriba, Roosevelt, San Miguel, 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:

**Refer to Addendum to 2023 Medicare Advantage Benefits for additional information**

For HMO Members:

Plan Name	CMS #	County	Annual Notice of Change (ANOC)
Wellcare Giveback (HMO)	H2134-002	Bernalillo, Dona Ana, Rio Arriba, Sandoval, Santa Fe, Torrance, Valencia	Annual Notice of Change (ANOC), H2134-002 - English (PDF) Annual Notice of Change (ANOC), H2134-002 - Spanish (PDF)
Wellcare Assist (HMO)	H2134-004	Bernalillo, Dona Ana, Rio Arriba, San Miguel, Sandoval, Santa Fe, Torrance, Valencia	Annual Notice of Change (ANOC), H2134-004 - English (PDF) Annual Notice of Change (ANOC), H2134-004 - Spanish (PDF)
Wellcare No Premium (HMO)	H2134-005	Bernalillo, Dona Ana, Rio Arriba, San Miguel, Sandoval, Santa Fe, Torrance, Valencia	Annual Notice of Change (ANOC), H2134-005 - English (PDF) Annual Notice of Change (ANOC), H2134-005 - Spanish (PDF)
Wellcare Patriot No Premium (HMO)	H2134-006	Bernalillo, Dona Ana, Rio Arriba, San Miguel, Sandoval, Santa Fe, Torrance, Valencia	Annual Notice of Change (ANOC), H2134-006 - English (PDF) Annual Notice of Change (ANOC), H2134-006 - Spanish (PDF)

For HMO-DSNP Members:

Plan Name	CMS #	County	Annual Notice of Change (ANOC)
Wellcare Dual Liberty (HMO D-SNP)	H2134-001	Bernalillo, Chaves, Cibola, Curry, Dona Ana, Eddy, Grant, Lea, Lincoln, Los Alamos, Luna, McKinley, Otero, Quay, Rio Arriba, Roosevelt, San Juan, San Miguel, Sandoval, Santa Fe, Taos, Torrance, Valencia	Annual Notice of Change (ANOC), H2134-001 - English (PDF) Annual Notice of Change (ANOC), H2134-001 - Spanish (PDF)
Wellcare Dual Access (HMO D-SNP)	H2134-003	Bernalillo, Chaves, Cibola, Curry, Dona Ana, Eddy, Grant, Lea, Lincoln, Los Alamos, Luna, McKinley, Otero, Quay, Rio Arriba, Roosevelt, San Juan, San Miguel, Sandoval, Santa Fe, Taos, Torrance, Valencia	Annual Notice of Change (ANOC), H2134-003 - English (PDF) Annual Notice of Change (ANOC), H2134-003 - Spanish (PDF)

For PPO Members:

Plan Name	CMS #	County	Annual Notice of Change (ANOC)
Wellcare Assist Open (PPO)	H9976-001	Bernalillo, Chaves, Cibola, Curry, Dona Ana, Eddy, Grant, Lea, Lincoln, Los Alamos, Luna, McKinley, Otero, Quay, Rio Arriba, Roosevelt, San Miguel, Sandoval, Santa Fe, Taos, Torrance, Valencia	Annual Notice of Change (ANOC), H9976-001 - English (PDF) Annual Notice of Change (ANOC), H9976-001 - Spanish (PDF)
Wellcare No Premium Open (PPO)	H9976-002	Bernalillo, Chaves, Cibola, Curry, Dona Ana, Eddy, Grant, Lea, Lincoln, Los Alamos, Luna, McKinley, Otero, Quay, Rio Arriba, Roosevelt, San Miguel, Sandoval, Santa Fe, Taos, Torrance, Valencia	Annual Notice of Change (ANOC), H9976-002 - English (PDF) Annual Notice of Change (ANOC), H9976-002 - Spanish (PDF)
Wellcare No Premium Open (PPO)	H9976-002 and H9976- 003	Bernalillo, Chaves, Cibola, Curry, Dona Ana, Eddy, Grant, Lea, Lincoln, Los Alamos, Luna, McKinley, Otero, Quay, Rio Arriba, Roosevelt, San Miguel, Sandoval, Santa Fe, Taos, Torrance, Valencia	Annual Notice of Change (ANOC), H9976-002 - H9976-003- English (PDF) Annual Notice of Change (ANOC), H9976-002 - H9976-003- Spanish (PDF)
Wellcare Giveback Open (PPO)	H9976-004	Bernalillo, Chaves, Cibola, Curry, Dona Ana, Eddy, Grant, Lea, Lincoln, Los Alamos, Luna, McKinley, Otero, Quay, Rio Arriba, Roosevelt, San Miguel, Sandoval, Santa Fe, Taos, Torrance, Valencia	Annual Notice of Change (ANOC), H9976-004 - English (PDF) Annual Notice of Change (ANOC), H9976-004 - Spanish (PDF)

This document is an addendum to the 2023 Evidence of Coverage (EOC), Annual Notice of Change (ANOC) and Summary of Benefits (SB) for the plan(s) listed below. It describes the member cost sharing protections provided under the Inflation Reduction Act (IRA) for certain Part B drugs.

Addendum to 2023 Medicare Advantage Benefits - English (PDF)
Addendum to 2023 Medicare Advantage Benefits - Spanish (PDF)
- H2134-002 Wellcare Giveback (HMO)
- H2134-004 Wellcare Assist (HMO)
- H2134-005 Wellcare No Premium (HMO)
- H2134-006 Wellcare Patriot No Premium (HMO)
- H9976-001 Wellcare Assist Open (PPO)
- H9976-002 Wellcare No Premium Open (PPO)
- H9976-004 Wellcare Giveback Open (PPO)

Mid-Year Change Notification - English (PDF)
Mid-Year Change Notification - Spanish (PDF)
- H9976-001 Wellcare Assist Open (PPO)
- H9976-002 Wellcare No Premium Open (PPO)
- H9976-002 Wellcare No Premium Open (PPO)
- H9976-004 Wellcare Giveback Open (PPO)

AHIP Flyer (PDF)

Plan Benefit Materials | Allwell from Western Sky Community Care

Plan Materials and Forms

Summary of Benefits (SB)

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)

For HMO-DSNP Members:

For PPO Members:

Step Therapy Part B

Summary of Benefits (SB)

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)

For HMO Members:

For HMO-DSNP Members:

For PPO Members:

Addendum To 2023 Medicare Advantage Benefits

Mid-Year Change Notification

Over-the-Counter Catalog

2023 AHIP Flyer