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	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, 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, 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, Sandoval, Santa Fe, Torrance, Valencia	Summary of Benefits, H2134-004-000 - 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, Luna, McKinley, Quay, Rio Arriba, Roosevelt, San Juan, 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, Luna, McKinley, Quay, Rio Arriba, Roosevelt, San Juan, 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, Luna, McKinley, Quay, Rio Arriba, Roosevelt, Sandoval, Santa Fe, Taos, Torrance, Valencia	Summary of Benefits, H9976-002-000 - English (PDF) Summary of Benefits, H9976-002-000 - Spanish (PDF)
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	Summary of Benefits, H9976-003-000 - English (PDF) Summary of Benefits, H9976-003-000 - Spanish (PDF)
Wellcare Assist Open (PPO)	H9976-001	Bernalillo, Chaves, Cibola, Curry, Dona Ana, Luna, McKinley, Quay, Rio Arriba, Roosevelt, 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, Luna, McKinley, Quay, Rio Arriba, Roosevelt, 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:

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	Evidence of Coverage, H2134-006 English (PDF) Evidence of Coverage, H2134-006 Spanish (PDF)
Wellcare Giveback (HMO) MAPD	H2134-002	Bernalillo, Dona Ana, Rio Arriba, 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, Sandoval, Santa Fe, Torrance, Valencia	Evidence of Coverage, H2134-004 - English (PDF) Evidence of Coverage, H2134-004 - Spanish (PDF)
Wellcare No Premium (HMO) MAPD	H2134-005	Bernalillo, Dona Ana, Rio Arriba, Sandoval, Santa Fe, Torrance, Valencia	Evidence of Coverage, H2134-005-000 - English (PDF) Evidence of Coverage, H2134-005-000 - 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, Luna, McKinley, Quay, Rio Arriba, Roosevelt, San Juan, Sandoval, Santa Fe, Taos, Torrance, Valencia	Evidence of Coverage, H2134-001-000 - English (PDF) Evidence of Coverage, H2134-001-000 - Spanish (PDF)
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	Evidence of Coverage, H2134-003-000 - English (PDF) Evidence of Coverage, H2134-003-000 - Spanish (PDF)

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	Evidence of Coverage, H9976-001-000 - English (PDF) Evidence of Coverage, H9976-001-000 - Spanish (PDF)
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	Evidence of Coverage, H9976-002-000 - English (PDF) Evidence of Coverage, H9976-002-000 - Spanish (PDF)
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	Evidence of Coverage, H9976-003-000 - English (PDF) Evidence of Coverage, H9976-003 Spanish (PDF)
Wellcare Giveback Open (PPO)	H9976-004	Bernalillo, Chaves, Cibola, Curry, Dona Ana, Luna, McKinley, Quay, Rio Arriba, Roosevelt, Sandoval, Santa Fe, Taos, Torrance, Valencia	Evidence of Coverage, H9976-004- English (PDF) Evidence of Coverage, H9976-004-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:

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	Annual Notice of Change (ANOC), H2134-001 - English (PDF) Annual Notice of Change (ANOC), H2134-001 - Spanish (PDF)
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 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	Annual Notice of Change (ANOC), H2134-003 - English (PDF) Annual Notice of Change (ANOC), H2134-003 - Spanish (PDF)
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	Annual Notice of Change (ANOC), H2134-001 - H2134-003 - English (PDF) Annual Notice of Change (ANOC), H2134-001 - H2134-003 - Spanish (PDF)
Wellcare Assist (HMO)	H2134-004	Bernalillo, Dona Ana, Rio Arriba, 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, 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, Sandoval, Santa Fe, Torrance, Valencia	Annual Notice of Change (ANOC), H2134-006 - English (PDF) Annual Notice of Change (ANOC), H2134-006 - Spanish (PDF)

Plan Benefit Materials | Allwell from Western Sky Community Care

Plan Materials and Forms

For HMO Members:

For HMO D-SNP Members:

For PPO Members:

For HMO Members:

For HMO D-SNP Members:

For PPO Members:

Wellcare Giveback (HMO)

Wellcare Giveback Open (PPO)

Plan Benefit Materials

For HMO Members:

For HMO D-SNP Members:

For PPO Members:

For HMO Members:

For HMO D-SNP Members:

For PPO Members:

For HMO Members:

For HMO-DSNP Members:

For PPO 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)

Plan Benefit Materials | Allwell from Western Sky Community Care

Plan Materials and Forms

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)

Optional Supplemental Benefits Flyer

Wellcare Giveback (HMO)

Wellcare Giveback Open (PPO)

Over-The-Counter Benefits

Optional Benefit Individual Enrollment Form

Plan Benefit Materials

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:

Over-the-Counter Catalog

2023 AHIP Flyer