Plan Benefit Materials and Forms | Wellcare Oklahoma

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 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
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
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


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
Wellcare No Premium Open (PPO) H4537-002 Caddo, Canadian, Cleveland, Comanche, Garfield, Garvin, Grady, Kay, Lincoln, Logan, McClain, Oklahoma, Pottawatomie, Seminole
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
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

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
  • 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
  • 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
  • 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
  • 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
  • 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

 

  • 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

 

  • 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

 

  • 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
 
  • 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
  • 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
  • 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
  • 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
  • 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
Wellcare No Premium (HMO) H9900-004 Adair, Cherokee, Creek, Delaware, Le Flore, Mayes, McIntosh, Muskogee, Okmulgee, Osage, Ottawa, Payne, Pittsburg, Rogers, Sequoyah, Tulsa, Wagoner
Wellcare No Premium (HMO) H9900-005 Caddo, Canadian, Cleveland, Comanche, Garfield, Garvin, Grady, Kay, Lincoln, Logan, McClain, Oklahoma, Pottawatomie, Seminole
Wellcare Assist (HMO)  H9900-006 Adair, Cherokee, Creek, Delaware, Le Flore, Mayes, McIntosh, Muskogee, Okmulgee, Osage, Ottawa, Payne, Pittsburg, Rogers, Sequoyah, Tulsa, Wagoner
Wellcare Assist (HMO) H9900-007 Caddo, Canadian, Cleveland, Comanche, Garfield, Garvin, Grady, Kay, Lincoln, Logan, McClain, Oklahoma, Pottawatomie, Seminole
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

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
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

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
Wellcare No Premium Open (PPO) H4537-002 Caddo, Canadian, Cleveland, Comanche, Garfield, Garvin, Grady, Kay, Lincoln, Logan, McClain, Oklahoma, Pottawatomie, Seminole
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
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

  • Medicare Step Therapy Part B (PDF) - coming soon