Plan Materials and Forms

Information about plan benefits, services, and drug costs can be found in your plan materials.

Look at your Wellcare member ID card for your plan number and type to view materials for your plan.

View a sample of an Wellcare 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 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 Giveback (HMO)	H9900-001	Adair, Canadian, Cleveland, Creek, Grady, Le Flore, Lincoln, Logan, Mayes, Muskogee, Oklahoma, Okmulgee, Osage, Pottawatomie, Sequoyah, Wagoner	Summary of Benefits, H9900-001 - English (PDF) Summary of Benefits, H9900-001 - Spanish (PDF) - coming soon
Wellcare No Premium (HMO)	H9900-004	Adair, Creek, Le Flore, Mayes, Muskogee, Okmulgee, Osage, Sequoyah, Wagoner	Summary of Benefits, H9900-004 - English (PDF) Summary of Benefits, H9900-004 - Spanish (PDF) - coming soon
Wellcare No Premium (HMO)	H9900-005	Canadian, Cleveland, Grady, Lincoln, Logan, Oklahoma, Pottawatomie	Summary of Benefits, H9900-005 - English (PDF) Summary of Benefits, H9900-005 - Spanish (PDF) - coming soon
Wellcare Assist (HMO)	H9900-006	Adair, Creek, Le Flore, Mayes, Muskogee, Okmulgee, Osage, Sequoyah, Wagoner	Summary of Benefits, H9900-006 - English (PDF) Summary of Benefits, H9900-006 - Spanish (PDF) - coming soon
Wellcare Assist (HMO)	H9900-007	Canadian, Cleveland, Grady, Lincoln, Logan, Oklahoma, Pottawatomie	Summary of Benefits, H9900-007 - English (PDF) Summary of Benefits, H9900-007 - Spanish (PDF) - coming soon

For HMO SNP Members:

Plan Name	CMS #	County	Summary of Benefits
Wellcare Dual Access (HMO D-SNP)	H9900-002	Adair, Canadian, Cleveland, Creek, Grady, Le Flore, Lincoln, Logan, Mayes, Muskogee, Oklahoma, Okmulgee, Osage, Pottawatomie, Sequoyah, Wagoner	Summary of Benefits, H9900-002 - English (PDF) Summary of Benefits, H9900-002 - Spanish (PDF) - coming soon
Wellcare Dual Liberty (HMO D-SNP)	H9900-003	Adair, Canadian, Cleveland, Creek, Grady, Le Flore, Lincoln, Logan, Mayes, Muskogee, Oklahoma, Okmulgee, Osage, Pottawatomie, Sequoyah, Wagoner	Summary of Benefits, H9900-003 - English (PDF) Summary of Benefits, H9900-003 - Spanish (PDF) - coming soon

For PPO Members:

Plan Name	CMS #	County	Summary of Benefits
Wellcare No Premium Open (PPO)	H4537-001	[COUNTIES_SNP_001]	Summary of Benefits, H4537-001 - English (PDF) Summary of Benefits, H4537-001 - Spanish (PDF) - coming soon
Wellcare No Premium Open (PPO)	H4537-002	[COUNTIES_SNP_002]	Summary of Benefits, H4537-002 - English (PDF) Summary of Benefits, H4537-002 - Spanish (PDF) - coming soon

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 Giveback (HMO)	H9900-001	Adair, Canadian, Cleveland, Creek, Grady, Le Flore, Lincoln, Logan, Mayes, Muskogee, Oklahoma, Okmulgee, Osage, Pottawatomie, Sequoyah, Wagoner	Evidence of Coverage, H9900-001 - English (PDF) Evidence of Coverage, H9900-001 - Spanish (PDF) - coming soon
Wellcare No Premium (HMO)	H9900-004	Adair, Creek, Le Flore, Mayes, Muskogee, Okmulgee, Osage, Sequoyah, Wagoner	Evidence of Coverage, H9900-004 - English (PDF) Evidence of Coverage, H9900-004 - Spanish (PDF) - coming soon
Wellcare No Premium (HMO)	H9900-005	Canadian, Cleveland, Grady, Lincoln, Logan, Oklahoma, Pottawatomie	Evidence of Coverage, H9900-005 - English (PDF) Evidence of Coverage, H9900-005 - Spanish (PDF) - coming soon
Wellcare Assist (HMO)	H9900-006	Adair, Creek, Le Flore, Mayes, Muskogee, Okmulgee, Osage, Sequoyah, Wagoner	Evidence of Coverage, H9900-006 - English (PDF) Evidence of Coverage, H9900-006 - Spanish (PDF) - coming soon
Wellcare Assist (HMO)	H9900-007	Canadian, Cleveland, Grady, Lincoln, Logan, Oklahoma, Pottawatomie	Evidence of Coverage, H9900-007 - English (PDF) Evidence of Coverage, H9900-007 - Spanish (PDF) - coming soon

For HMO SNP Members:

Plan Name	CMS #	County	Evidence of Coverage
Wellcare Dual Access (HMO D-SNP)	H9900-002	Adair, Canadian, Cleveland, Creek, Grady, Le Flore, Lincoln, Logan, Mayes, Muskogee, Oklahoma, Okmulgee, Osage, Pottawatomie, Sequoyah, Wagoner	Evidence of Coverage, H9900-002 - English (PDF) Evidence of Coverage, H9900-002 - Spanish (PDF) - coming soon
Wellcare Dual Liberty (HMO D-SNP)	H9900-003	Adair, Canadian, Cleveland, Creek, Grady, Le Flore, Lincoln, Logan, Mayes, Muskogee, Oklahoma, Okmulgee, Osage, Pottawatomie, Sequoyah, Wagoner	Evidence of Coverage, H9900-003 - English (PDF) Evidence of Coverage, H9900-003 - Spanish (PDF) - coming soon

Plan Name

CMS #

County

Evidence of Coverage

Wellcare Dual Access (HMO D-SNP)

H9900-002

Adair, Canadian, Cleveland, Creek, Grady, Le Flore, Lincoln, Logan, Mayes, Muskogee, Oklahoma, Okmulgee, Osage, Pottawatomie, Sequoyah, Wagoner

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

Evidence of Coverage, H9900-002 - Spanish (PDF) - coming soon

Wellcare Dual Liberty (HMO D-SNP)

H9900-003

Adair, Canadian, Cleveland, Creek, Grady, Le Flore, Lincoln, Logan, Mayes, Muskogee, Oklahoma, Okmulgee, Osage, Pottawatomie, Sequoyah, Wagoner

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

Evidence of Coverage, H9900-003 - Spanish (PDF) - coming soon

For PPO Members:

Plan Name	CMS #	County	Evidence of Coverage
Wellcare No Premium Open (PPO)	H4537-001	Adair, Creek, Le Flore, Mayes, Muskogee, Okmulgee, Osage, Sequoyah, Wagoner	Evidence of Coverage, H4537-001 - English (PDF) Evidence of Coverage, H4537-001 - Spanish (PDF) - coming soon
Wellcare No Premium Open (PPO)	H4537-002	Canadian, Cleveland, Grady, Lincoln, Logan, Oklahoma, Pottawatomie	Evidence of Coverage, H4537-002 - English (PDF) Evidence of Coverage, H4537-002 - Spanish (PDF) - coming soon

Plan Name

CMS #

County

Evidence of Coverage

Wellcare No Premium Open (PPO)

H4537-001

Adair, Creek, Le Flore, Mayes, Muskogee, Okmulgee, Osage, Sequoyah, Wagoner

Evidence of Coverage, H4537-001 - English (PDF)

Evidence of Coverage, H4537-001 - Spanish (PDF) - coming soon

Wellcare No Premium Open (PPO)

H4537-002

Canadian, Cleveland, Grady, Lincoln, Logan, Oklahoma, Pottawatomie

Evidence of Coverage, H4537-002 - English (PDF)

Evidence of Coverage, H4537-002 - Spanish (PDF) - coming soon

Dental Benefit Summary:

A complete list of services, limitations and exclusions for your dental plan coverage is available below.

For HMO Members:

Plan Name	County	Summary of Benefits
Allwell Medicare (HMO)	[COUNTIES_HMO_001]	Summary of Benefits 5000-1001 (PDF) Certificate of Benefits 5000- 1001 (PDF)
Allwell Medicare (HMO)	[COUNTIES_HMO_002]	Summary of Benefits 5000-0002 (PDF) Certificate of Benefits 5000-0002 (PDF)
Allwell Medicare Select (HMO)	[COUNTIES_HMO_003]	Summary of Benefits 5000-0003 (PDF) Certificate of Benefits 5000-0003 (PDF)
Allwell Medicare (HMO)	Baxter, Boone and Marion	Summary of Benefits 5000-0004 (PDF) Certificate of Benefits 5000-0004 (PDF)
Allwell Medicare Premier (HMO)	Baxter, Boone and Marion	Summary of Benefits 5000-0005 (PDF) Certificate of Benefits 5000-0005 (PDF)
Allwell Medicare Premier (HMO)	Benton, Carroll, Clay, Cleburne, Crawford, Cross, Franklin, Fulton, Independence, Izard, Jackson, Johnson, Lawrence, Logan, Madison, Mississippi, Newton, Perry, Poinsett, Prairie, Randolph, Scott, Searcy, Sebastian, Sharp, Stone, Van Buren, Washington, White, Woodruff, Yell.	Summary of Benefits 5000-0006 (PDF) Certificate of Benefits 5000-0006 (PDF)

Plan Benefit Materials and Forms | Wellcare Oklahoma

Plan Materials and Forms

For HMO Members:

For HMO SNP Members:

For PPO Members:

For HMO Members:

For HMO SNP Members:

For PPO Members:

Dental Benefit Summary:

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:

Dental Benefit Summary:

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)
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)
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)
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)
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)
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)

Plan Benefit Materials and Forms | Wellcare Oklahoma

Plan Materials and Forms

Summary of Benefits (SB)

For HMO Members:

For HMO SNP Members:

For PPO Members:

Evidence Of Coverage (EOC)

For HMO Members:

For HMO SNP Members:

For PPO Members:

Dental

Dental Benefit Summary:

Over-The-Counter Benefits

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:

Dental

Dental Benefit Summary:

Over-The-Counter Benefits