Plan Benefit Materials and Forms

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 Giveback (HMO)	H9900-001	Adair, Caddo, Canadian, Cherokee, Cleveland, Comanche, Creek, Delaware, Garfield, Garvin, Grady, Kay, Le Flore, Lincoln, Logan, Mayes, McClain, McIntosh, Muskogee, Oklahoma, Okmulgee, Osage, Ottawa, Payne, Pittsburg, Pottawatomie, Rogers, Seminole, Sequoyah, Tulsa, Wagoner	Summary of Benefits, H9900-001 - English (PDF) - coming soon
Wellcare No Premium (HMO)	H9900-004	Adair, Cherokee, Creek, Delaware, Le Flore, Mayes, McIntosh, Muskogee, Okmulgee, Osage, Ottawa, Payne, Pittsburg, Rogers, Sequoyah, Tulsa, Wagoner	Summary of Benefits, H9900-004 - English (PDF) - coming soon
Wellcare No Premium (HMO)	H9900-005	Caddo, Canadian, Cleveland, Comanche, Garfield, Garvin, Grady, Kay, Lincoln, Logan, McClain, Oklahoma, Pottawatomie, Seminole	Summary of Benefits, H9900-005 - English (PDF) - coming soon
Wellcare Assist (HMO)	H9900-006	Adair, Cherokee, Creek, Delaware, Le Flore, Mayes, McIntosh, Muskogee, Okmulgee, Osage, Ottawa, Payne, Pittsburg, Rogers, Sequoyah, Tulsa, Wagoner	Summary of Benefits, H9900-006 - English (PDF) - coming soon
Wellcare Assist (HMO)	H9900-007	Caddo, Canadian, Cleveland, Comanche, Garfield, Garvin, Grady, Kay, Lincoln, Logan, McClain, Oklahoma, Pottawatomie, Seminole	Summary of Benefits, H9900-007 - English (PDF) - coming soon
Wellcare Patriot No Premium (HMO)	H9900-008	Adair, Caddo, Canadian, Cherokee, Cleveland, Comanche, Creek, Delaware, Garfield, Garvin, Grady, Kay, Le Flore, Lincoln, Logan, Mayes, McClain, McIntosh, Muskogee, Oklahoma, Okmulgee, Osage, Ottawa, Payne, Pittsburg, Pottawatomie, Rogers, Seminole, Sequoyah, Tulsa, Wagoner	Summary of Benefits, H9900-008 - English (PDF) - coming soon

For HMO D-SNP Members:

Plan Name	CMS #	County	Summary of Benefits
Wellcare Dual Access (HMO D-SNP)	H9900-002	Adair, Caddo, Canadian, Cherokee, Cleveland, Comanche, Creek, Delaware, Garfield, Garvin, Grady, Kay, Le Flore, Lincoln, Logan, Mayes, McClain, McIntosh, Muskogee, Oklahoma, Okmulgee, Osage, Ottawa, Payne, Pittsburg, Pottawatomie, Rogers, Seminole, Sequoyah, Tulsa, Wagoner	Summary of Benefits, H9900-002 - English (PDF)
Wellcare Dual Liberty (HMO D-SNP)	H9900-003	Adair, Caddo, Canadian, Cherokee, Cleveland, Comanche, Creek, Delaware, Garfield, Garvin, Grady, Kay, Le Flore, Lincoln, Logan, Mayes, McClain, McIntosh, Muskogee, Oklahoma, Okmulgee, Osage, Ottawa, Payne, Pittsburg, Pottawatomie, Rogers, Seminole, Sequoyah, Tulsa, Wagoner	Summary of Benefits, H9900-003 - English (PDF)
Wellcare All Dual Assure (HMO D-SNP)	H9909-009	Adair, Caddo, Canadian, Cherokee, Cleveland, Comanche, Creek, Delaware, Garfield, Garvin, Grady, Kay, Le Flore, Lincoln, Logan, Mayes, McClain, McIntosh, Muskogee, Oklahoma, Okmulgee, Osage, Ottawa, Payne, Pittsburg, Pottawatomie, Rogers, Seminole, Sequoyah, Tulsa, Wagoner	Summary of Benefits, H9900-009 - English (PDF)

For PPO and PPO D-SNP Members:

Plan Name	CMS #	County	Summary of Benefits
Wellcare No Premium Open (PPO)	H4537-001	Adair, Cherokee, Creek, Delaware, Le Flore, Mayes, McIntosh, Muskogee, Okmulgee, Osage, Ottawa, Payne, Pittsburg, Rogers, Sequoyah, Tulsa, Wagoner	Summary of Benefits, H4537-001 - English (PDF)
Wellcare No Premium Open (PPO)	H4537-002	Caddo, Canadian, Cleveland, Comanche, Garfield, Garvin, Grady, Kay, Lincoln, Logan, McClain, Oklahoma, Pottawatomie, Seminole	Summary of Benefits, H4537-002 - English (PDF)
Wellcare Low Premium Open (PPO)	H4537-003	Adair, Caddo, Canadian, Cherokee, Cleveland, Comanche, Creek, Delaware, Garfield, Garvin, Grady, Kay, Le Flore, Lincoln, Logan, Mayes, McClain, McIntosh, Muskogee, Oklahoma, Okmulgee, Osage, Ottawa, Payne, Pittsburg, Pottawatomie, Rogers, Seminole, Sequoyah, Tulsa, Wagoner	Summary of Benefits, H4537-003 - English (PDF)
Wellcare Dual Access Open (PPO D-SNP)	H4537-004	Adair, Caddo, Canadian, Cherokee, Cleveland, Comanche, Creek, Delaware, Garfield, Garvin, Grady, Kay, Le Flore, Lincoln, Logan, Mayes, McClain, McIntosh, Muskogee, Oklahoma, Okmulgee, Osage, Ottawa, Payne, Pittsburg, Pottawatomie, Rogers, Seminole, Sequoyah, Tulsa, Wagoner	Summary of Benefits, H4537-004 - English (PDF)

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	Evidence of Coverage
Wellcare Giveback (HMO)	H9900-001	Adair, Caddo, Canadian, Cherokee, Cleveland, Comanche, Creek, Delaware, Garfield, Garvin, Grady, Kay, Le Flore, Lincoln, Logan, Mayes, McClain, McIntosh, Muskogee, Oklahoma, Okmulgee, Osage, Ottawa, Payne, Pittsburg, Pottawatomie, Rogers, Seminole, Sequoyah, Tulsa, Wagoner	Evidence of Coverage, H9900-001 - English (PDF) Dental Benefit Details - English (PDF) - coming soon
Wellcare No Premium (HMO)	H9900-004	Adair, Cherokee, Creek, Delaware, Le Flore, Mayes, McIntosh, Muskogee, Okmulgee, Osage, Ottawa, Payne, Pittsburg, Rogers, Sequoyah, Tulsa, Wagoner	Evidence of Coverage, H9900-004 - English (PDF) Dental Benefit Details - English (PDF) - coming soon
Wellcare No Premium (HMO)	H9900-005	Caddo, Canadian, Cleveland, Comanche, Garfield, Garvin, Grady, Kay, Lincoln, Logan, McClain, Oklahoma, Pottawatomie, Seminole	Evidence of Coverage, H9900-005 - English (PDF) Dental Benefit Details - English (PDF) - coming soon
Wellcare Assist (HMO)	H9900-006	Adair, Cherokee, Creek, Delaware, Le Flore, Mayes, McIntosh, Muskogee, Okmulgee, Osage, Ottawa, Payne, Pittsburg, Rogers, Sequoyah, Tulsa, Wagoner	Evidence of Coverage, H9900-006 - English (PDF) Dental Benefit Details - English (PDF) - coming soon
Wellcare Assist (HMO)	H9900-007	Caddo, Canadian, Cleveland, Comanche, Garfield, Garvin, Grady, Kay, Lincoln, Logan, McClain, Oklahoma, Pottawatomie, Seminole	Evidence of Coverage, H9900-007 - English (PDF) Dental Benefit Details - English (PDF) - coming soon
Wellcare Patriot No Premium (HMO)	H9900-008	Adair, Caddo, Canadian, Cherokee, Cleveland, Comanche, Creek, Delaware, Garfield, Garvin, Grady, Kay, Le Flore, Lincoln, Logan, Mayes, McClain, McIntosh, Muskogee, Oklahoma, Okmulgee, Osage, Ottawa, Payne, Pittsburg, Pottawatomie, Rogers, Seminole, Sequoyah, Tulsa, Wagoner	Evidence of Coverage, H9900-008 - English (PDF) Dental Benefit Details - English (PDF) - coming soon

For HMO D-SNP Members:

Plan Name	CMS #	County	Evidence of Coverage
Wellcare Dual Access (HMO D-SNP)	H9900-002	Adair, Caddo, Canadian, Cherokee, Cleveland, Comanche, Creek, Delaware, Garfield, Garvin, Grady, Kay, Le Flore, Lincoln, Logan, Mayes, McClain, McIntosh, Muskogee, Oklahoma, Okmulgee, Osage, Ottawa, Payne, Pittsburg, Pottawatomie, Rogers, Seminole, Sequoyah, Tulsa, Wagoner	Evidence of Coverage, H9900-002 - English (PDF) Dental Benefit Details - English (PDF) - coming soon
Wellcare Dual Liberty (HMO D-SNP)	H9900-003	Adair, Caddo, Canadian, Cherokee, Cleveland, Comanche, Creek, Delaware, Garfield, Garvin, Grady, Kay, Le Flore, Lincoln, Logan, Mayes, McClain, McIntosh, Muskogee, Oklahoma, Okmulgee, Osage, Ottawa, Payne, Pittsburg, Pottawatomie, Rogers, Seminole, Sequoyah, Tulsa, Wagoner	Evidence of Coverage, H9900-003 - English (PDF) Dental Benefit Details - English (PDF) - coming soon
Wellcare All Dual Assure (HMO D-SNP)	H9900-009	Adair, Caddo, Canadian, Cherokee, Cleveland, Comanche, Creek, Delaware, Garfield, Garvin, Grady, Kay, Le Flore, Lincoln, Logan, Mayes, McClain, McIntosh, Muskogee, Oklahoma, Okmulgee, Osage, Ottawa, Payne, Pittsburg, Pottawatomie, Rogers, Seminole, Sequoyah, Tulsa, Wagoner	Evidence of Coverage, H9900-009 - English (PDF) Dental Benefit Details - English (PDF) - coming soon

Plan Name

CMS #

County

Evidence of Coverage

Wellcare Dual Access (HMO D-SNP)

H9900-002

Adair, Caddo, Canadian, Cherokee, Cleveland, Comanche, Creek, Delaware, Garfield, Garvin, Grady, Kay, Le Flore, Lincoln, Logan, Mayes, McClain, McIntosh, Muskogee, Oklahoma, Okmulgee, Osage, Ottawa, Payne, Pittsburg, Pottawatomie, Rogers, Seminole, Sequoyah, Tulsa, Wagoner

Evidence of Coverage, H9900-002 - English (PDF)

Dental Benefit Details - English (PDF) - coming soon

Wellcare Dual Liberty (HMO D-SNP)

H9900-003

Adair, Caddo, Canadian, Cherokee, Cleveland, Comanche, Creek, Delaware, Garfield, Garvin, Grady, Kay, Le Flore, Lincoln, Logan, Mayes, McClain, McIntosh, Muskogee, Oklahoma, Okmulgee, Osage, Ottawa, Payne, Pittsburg, Pottawatomie, Rogers, Seminole, Sequoyah, Tulsa, Wagoner

Evidence of Coverage, H9900-003 - English (PDF)

Dental Benefit Details - English (PDF) - coming soon

Wellcare All Dual Assure (HMO D-SNP)

H9900-009

Adair, Caddo, Canadian, Cherokee, Cleveland, Comanche, Creek, Delaware, Garfield, Garvin, Grady, Kay, Le Flore, Lincoln, Logan, Mayes, McClain, McIntosh, Muskogee, Oklahoma, Okmulgee, Osage, Ottawa, Payne, Pittsburg, Pottawatomie, Rogers, Seminole, Sequoyah, Tulsa, Wagoner

Evidence of Coverage, H9900-009 - English (PDF)

Dental Benefit Details - English (PDF) - coming soon

For PPO and PPO D-SNP Members:

Plan Name	CMS #	County	Evidence of Coverage
Wellcare No Premium Open (PPO)	H4537-001	Adair, Cherokee, Creek, Delaware, Le Flore, Mayes, McIntosh, Muskogee, Okmulgee, Osage, Ottawa, Payne, Pittsburg, Rogers, Sequoyah, Tulsa, Wagoner	Evidence of Coverage, H4537-001 - English (PDF) Dental Benefit Details - English (PDF) - coming soon
Wellcare No Premium Open (PPO)	H4537-002	Caddo, Canadian, Cleveland, Comanche, Garfield, Garvin, Grady, Kay, Lincoln, Logan, McClain, Oklahoma, Pottawatomie, Seminole	Evidence of Coverage, H4537-002 - English (PDF) Dental Benefit Details - English (PDF) - coming soon
Wellcare Low Premium Open (PPO)	H4537-003	Adair, Caddo, Canadian, Cherokee, Cleveland, Comanche, Creek, Delaware, Garfield, Garvin, Grady, Kay, Le Flore, Lincoln, Logan, Mayes, McClain, McIntosh, Muskogee, Oklahoma, Okmulgee, Osage, Ottawa, Payne, Pittsburg, Pottawatomie, Rogers, Seminole, Sequoyah, Tulsa, Wagoner	Evidence of Coverage, H4537-003 - English (PDF) Dental Benefit Details - English (PDF) - coming soon
Wellcare Dual Access Open (PPO D-SNP)	H4537-004	Adair, Caddo, Canadian, Cherokee, Cleveland, Comanche, Creek, Delaware, Garfield, Garvin, Grady, Kay, Le Flore, Lincoln, Logan, Mayes, McClain, McIntosh, Muskogee, Oklahoma, Okmulgee, Osage, Ottawa, Payne, Pittsburg, Pottawatomie, Rogers, Seminole, Sequoyah, Tulsa, Wagoner	Evidence of Coverage, H4537-004 - English (PDF) Dental Benefit Details - English (PDF) - coming soon

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 Giveback (HMO)	H9900-001	Adair, Caddo, Canadian, Cherokee, Cleveland, Comanche, Creek, Delaware, Garfield, Garvin, Grady, Kay, Le Flore, Lincoln, Logan, Mayes, McClain, McIntosh, Muskogee, Oklahoma, Okmulgee, Osage, Ottawa, Payne, Pittsburg, Pottawatomie, Rogers, Seminole, Sequoyah, Tulsa, Wagoner	Annual Notice of Changes, H9900-001 - English (PDF)
Wellcare No Premium (HMO)	H9900-004	Adair, Cherokee, Creek, Delaware, Le Flore, Mayes, McIntosh, Muskogee, Okmulgee, Osage, Ottawa, Payne, Pittsburg, Rogers, Sequoyah, Tulsa, Wagoner	Annual Notice of Changes, H9900-004 - English (PDF)
Wellcare No Premium (HMO)	H9900-005	Caddo, Canadian, Cleveland, Comanche, Garfield, Garvin, Grady, Kay, Lincoln, Logan, McClain, Oklahoma, Pottawatomie, Seminole	Annual Notice of Changes, H9900-005 - English (PDF)
Wellcare Assist (HMO)	H9900-006	Adair, Cherokee, Creek, Delaware, Le Flore, Mayes, McIntosh, Muskogee, Okmulgee, Osage, Ottawa, Payne, Pittsburg, Rogers, Sequoyah, Tulsa, Wagoner	Annual Notice of Changes, H9900-006 - English (PDF)
Wellcare Assist (HMO)	H9900-007	Caddo, Canadian, Cleveland, Comanche, Garfield, Garvin, Grady, Kay, Lincoln, Logan, McClain, Oklahoma, Pottawatomie, Seminole	Annual Notice of Changes, H9900-007 - English (PDF)
Wellcare Patriot No Premium (HMO)	H9909-008	Adair, Caddo, Canadian, Cherokee, Cleveland, Comanche, Creek, Delaware, Garfield, Garvin, Grady, Kay, Le Flore, Lincoln, Logan, Mayes, McClain, McIntosh, Muskogee, Oklahoma, Okmulgee, Osage, Ottawa, Payne, Pittsburg, Pottawatomie, Rogers, Seminole, Sequoyah, Tulsa, Wagoner	Annual Notice of Changes, H9900-008 - English (PDF)

For HMO D-SNP Members:

Plan Name	CMS #	County	Annual Notice of Changes
Wellcare Dual Access (HMO D-SNP)	H9900-002	Adair, Caddo, Canadian, Cherokee, Cleveland, Comanche, Creek, Delaware, Garfield, Garvin, Grady, Kay, Le Flore, Lincoln, Logan, Mayes, McClain, McIntosh, Muskogee, Oklahoma, Okmulgee, Osage, Ottawa, Payne, Pittsburg, Pottawatomie, Rogers, Seminole, Sequoyah, Tulsa, Wagoner	Annual Notice of Changes, H9900-002 - English (PDF)
Wellcare Dual Liberty (HMO D-SNP)	H9900-003	Adair, Caddo, Canadian, Cherokee, Cleveland, Comanche, Creek, Delaware, Garfield, Garvin, Grady, Kay, Le Flore, Lincoln, Logan, Mayes, McClain, McIntosh, Muskogee, Oklahoma, Okmulgee, Osage, Ottawa, Payne, Pittsburg, Pottawatomie, Rogers, Seminole, Sequoyah, Tulsa, Wagoner	Annual Notice of Changes, H9900-003 - English

For PPO and PPO D-SNP Members:

Plan Name	CMS #	County	Annual Notice of Changes
Wellcare No Premium Open (PPO)	H4537-001	Adair, Cherokee, Creek, Delaware, Le Flore, Mayes, McIntosh, Muskogee, Okmulgee, Osage, Ottawa, Payne, Pittsburg, Rogers, Sequoyah, Tulsa, Wagoner	Annual Notice of Changes, H4537-001 - English (PDF)
Wellcare No Premium Open (PPO)	H4537-002	Caddo, Canadian, Cleveland, Comanche, Garfield, Garvin, Grady, Kay, Lincoln, Logan, McClain, Oklahoma, Pottawatomie, Seminole	Annual Notice of Changes, H4537-002 - English (PDF)
Wellcare Low Premium Open (PPO)	H4537-003	Adair, Caddo, Canadian, Cherokee, Cleveland, Comanche, Creek, Delaware, Garfield, Garvin, Grady, Kay, Le Flore, Lincoln, Logan, Mayes, McClain, McIntosh, Muskogee, Oklahoma, Okmulgee, Osage, Ottawa, Payne, Pittsburg, Pottawatomie, Rogers, Seminole, Sequoyah, Tulsa, Wagoner	Annual Notice of Changes, H4537-003 - English (PDF)
Wellcare Dual Access Open (PPO D-SNP)	H4537-004	Adair, Caddo, Canadian, Cherokee, Cleveland, Comanche, Creek, Delaware, Garfield, Garvin, Grady, Kay, Le Flore, Lincoln, Logan, Mayes, McClain, McIntosh, Muskogee, Oklahoma, Okmulgee, Osage, Ottawa, Payne, Pittsburg, Pottawatomie, Rogers, Seminole, Sequoyah, Tulsa, Wagoner	Annual Notice of Changes, H4537-004 - English (PDF)

Medicare Step Therapy Part B (PDF) - coming soon

Plan Benefit Materials and Forms | Wellcare Oklahoma

Plan Materials and Forms

For HMO Members:

For HMO D-SNP Members:

For PPO and PPO D-SNP Members:

For HMO Members:

For HMO D-SNP Members:

For PPO and PPO D-SNP Members:

For HMO Members:

For HMO D-SNP Members:

For PPO and PPO D-SNP Members:

For HMO Members:

For HMO D-SNP Members:

For PPO Members:

For PPO D-SNP Members:

For HMO Members:

For HMO D-SNP Members:

For PPO Members:

For PPO D-SNP Members:

For HMO Members:

For HMO D-SNP Members:

For PPO Members:

Plan Benefit Materials and Forms | Wellcare Oklahoma

Plan Materials and Forms

Summary of Benefits (SB)

For HMO Members:

For HMO D-SNP Members:

For PPO and PPO D-SNP Members:

Evidence Of Coverage (EOC)

For HMO Members:

For HMO D-SNP Members:

For PPO and PPO D-SNP Members:

Annual Notice of Changes (ANOC)

For HMO Members:

For HMO D-SNP Members:

For PPO and PPO D-SNP Members:

Step Therapy Part B

2023 AHIP Flyer

Summary of Benefits (SB)

For HMO Members:

For HMO D-SNP Members:

For PPO Members:

For PPO D-SNP Members:

Evidence Of Coverage (EOC)

For HMO Members:

For HMO D-SNP Members:

For PPO Members:

For PPO D-SNP Members:

Annual Notice of Change (ANOC)

For HMO Members:

For HMO D-SNP Members:

For PPO Members:

Addendum To 2023 Medicare Advantage Benefits

Mid-Year Change Notification

Over-The-Counter Benefits