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.

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 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 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
Wellcare No Premium (HMO) H9900-004

Adair, Creek, Le Flore, Mayes, Muskogee, Okmulgee, Osage, Sequoyah, Wagoner
Wellcare No Premium (HMO) H9900-005

Canadian, Cleveland, Grady, Lincoln, Logan, Oklahoma, Pottawatomie
Wellcare Assist (HMO) H9900-006

Adair, Creek, Le Flore, Mayes, Muskogee, Okmulgee, Osage, Sequoyah, Wagoner
Wellcare Assist (HMO) H9900-007 Canadian, Cleveland, Grady, Lincoln, Logan, Oklahoma, Pottawatomie

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
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

For PPO Members:

Plan Name CMS # County Summary of Benefits
Wellcare No Premium Open (PPO) H4537-001

[COUNTIES_SNP_001]
Wellcare No Premium Open (PPO) H4537-002

[COUNTIES_SNP_002]

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 - 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 - Spanish (PDF) - coming soon
Wellcare No Premium (HMO) H9900-005

Canadian, Cleveland, Grady, Lincoln, Logan, Oklahoma, Pottawatomie
 
  • 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 - Spanish (PDF) - coming soon
Wellcare Assist (HMO)  H9900-007 Canadian, Cleveland, Grady, Lincoln, Logan, Oklahoma, Pottawatomie
  • 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 - 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 - 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 - Spanish (PDF) - coming soon
Wellcare No Premium Open (PPO) H4537-002

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