Plan Benefit Materials and Forms | Wellcare Oklahoma
Plan Materials and Forms
Learn about your plan and all that it has to offer by reviewing helpful plan documents such as the Annual Notice of Change (ANOC), Summary of Benefits, and Evidence of Coverage.
To get started, locate your plan in the list of plans below and select “Plan Benefits.”
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 | |
| 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) | 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 |
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 | |
| 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) | 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 |
|
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 |
|
| 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) | 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
|
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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 | |
| 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 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 |