Plan Benefit Materials | Allwell from Western Sky Community Care

Plan Materials and Forms

 

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

Look at your Allwell from Western Sky Community Care member ID card for your plan number and type to view materials for your plan. 

  • View a sample of an 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 Allwell from Western Sky Community Care 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 No Premium (HMO) H2134-005-000 Bernalillo, Chaves, Cibola, Curry, Dona Ana, Luna, McKinley, Quay, Roosevelt, San Juan, Sandoval, Santa Fe, Taos, Torrance, and Valencia counties
Wellcare Patriot No Premium (HMO) H2134-006-000 Bernalillo, Chaves, Cibola, Curry, Dona Ana, Luna, McKinley, Quay, Roosevelt, San Juan, Sandoval, Santa Fe, Taos, Torrance, and Valencia counties
Wellcare Giveback (HMO) H2134-002-000 Bernalillo, Chaves, Cibola, Curry, Dona Ana, Luna, McKinley, Quay, Roosevelt, San Juan, Sandoval, Santa Fe, Taos, Torrance, and Valencia counties
Wellcare Assist (HMO) H2134-004-000 Bernalillo, Chaves, Cibola, Curry, Dona Ana, Luna, McKinley, Quay, Roosevelt, San Juan, Sandoval, Santa Fe, Taos, Torrance, and Valencia counties

For HMO D-SNP Members:

Plan Name  CMS # County Summary of Benefits
Wellcare Dual Liberty (HMO D-SNP) H2134-001-000 Bernalillo, Chaves, Cibola, Curry, Dona Ana, Luna, McKinley, Quay, Roosevelt, San Juan, Sandoval, Santa Fe, Taos, Torrance, and Valencia counties
Wellcare Dual Access (HMO D-SNP) H2134-003-000 Bernalillo, Chaves, Cibola, Curry, Dona Ana, Luna, McKinley, Quay, Roosevelt, San Juan, Sandoval, Santa Fe, Taos, Torrance, and Valencia counties

For PPO Members:

Plan Name CMS # County Summary of Benefits
Wellcare No Premium Open (PPO) H9976-002-000 Bernalillo, Chaves, Cibola, Curry, Dona Ana, Luna, McKinley, Quay, Roosevelt, San Juan, Sandoval, Santa Fe, Taos, Torrance, and Valencia counties
Wellcare Low Premium Open (PPO) H9976-003-000 Bernalillo, Chaves, Cibola, Curry, Dona Ana, Luna, McKinley, Quay, Roosevelt, San Juan, Sandoval, Santa Fe, Taos, Torrance, and Valencia counties
Wellcare Assist Open (PPO) H9976-001-000 Bernalillo, Chaves, Cibola, Curry, Dona Ana, Luna, McKinley, Quay, Roosevelt, San Juan, Sandoval, Santa Fe, Taos, Torrance, and Valencia counties
Wellcare Giveback Open (PPO) H9976-004-000 Bernalillo, Chaves, Cibola, Curry, Dona Ana, Luna, McKinley, Quay, Roosevelt, San Juan, Sandoval, Santa Fe, Taos, Torrance, and Valencia counties

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 Patriot No Premium (HMO) MA Only H2134006000 Bernalillo, Dona Ana, Rio Arriba, Sandoval, Santa Fe, Torrance, Valencia
  • Evidence of Coverage, H2134006000 - English (PDF)

  • Evidence of Coverage, H2134006000 - Spanish (PDF)
Wellcare Giveback (HMO) MAPD H2134002000 Bernalillo, Dona Ana, Rio Arriba, Sandoval, Santa Fe, Torrance, Valencia
  • Evidence of Coverage, H2134002000 - English (PDF)

  • Evidence of Coverage, H2134002000 - Spanish (PDF)
Wellcare Assist (HMO) MAPD H2134004000 Bernalillo, Dona Ana, Rio Arriba, Sandoval, Santa Fe, Torrance, Valencia
  • Evidence of Coverage, H2134004000 - English (PDF)

  • Evidence of Coverage, H2134004000 - Spanish (PDF)
Wellcare No Premium (HMO) MAPD H2134005000 Bernalillo, Dona Ana, Rio Arriba, Sandoval, Santa Fe, Torrance, Valencia
  • Evidence of Coverage, H2134005000 - English (PDF)

  • Evidence of Coverage, H2134005000 - Spanish (PDF)

For HMO D-SNP Members:

Plan Name  CMS # County Summary of Benefits
Wellcare Dual Liberty (HMO D-SNP) H2134001000 Bernalillo, Chaves, Cibola, Curry, Dona Ana, Luna, McKinley, Quay, Rio Arriba, Roosevelt, San Juan, Sandoval, Santa Fe, Taos, Torrance, Valencia
  • Evidence of Coverage, H2134001000 - English (PDF)

  • Evidence of Coverage, H2134001000 - Spanish (PDF)
Wellcare Dual Access (HMO D-SNP) H2134003000 Bernalillo, Chaves, Cibola, Curry, Dona Ana, Luna, McKinley, Quay, Rio Arriba, Roosevelt, San Juan, Sandoval, Santa Fe, Taos, Torrance, Valencia
  • Evidence of Coverage, H2134003000 - English (PDF)

  • Evidence of Coverage, H2134003000 - Spanish (PDF)

For PPO Members:

Plan Name  CMS # County Evidence of Coverage
Wellcare Assist Open (PPO) H9976001000 Bernalillo, Chaves, Cibola, Curry, Dona Ana, Luna, McKinley, Quay, Rio Arriba, Roosevelt, Sandoval, Santa Fe, Taos, Torrance, Valencia
  • Evidence of Coverage, H9976001000 - English (PDF)

  • Evidence of Coverage, H9976001000 - Spanish (PDF)
Wellcare No Premium Open (PPO) H9976002000 Bernalillo, Chaves, Cibola, Curry, Dona Ana, Luna, McKinley, Quay, Rio Arriba, Roosevelt, Sandoval, Santa Fe, Taos, Torrance, Valencia
  • Evidence of Coverage, H9976002000 - English (PDF)

  • Evidence of Coverage, H9976002000 - Spanish (PDF)
Wellcare Low Premium Open (PPO) H9976003000 Bernalillo, Chaves, Cibola, Curry, Dona Ana, Luna, McKinley, Quay, Rio Arriba, Roosevelt, Sandoval, Santa Fe, Taos, Torrance, Valencia
  • Evidence of Coverage, H9976003000 - English (PDF)

  • Evidence of Coverage, H9976003000 - Spanish (PDF)
Wellcare Giveback Open (PPO) H9976004000 Bernalillo, Chaves, Cibola, Curry, Dona Ana, Luna, McKinley, Quay, Rio Arriba, Roosevelt, Sandoval, Santa Fe, Taos, Torrance, Valencia
  • Evidence of Coverage, H9976004000 - English (PDF)

  • Evidence of Coverage, H9976004000 - Spanish (PDF)

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:

Plan Name  CMS # County Annual Notice of Change (ANOC)
Allwell Dual Medicare (HMO D-SNP) to Wellcare Dual Liberty (HMO D-SNP) H2134001000 Bernalillo, Chaves, Cibola, Curry, Dona Ana, Luna, McKinley, Quay, Rio Arriba, Roosevelt, San Juan, Sandoval, Santa Fe, Taos, Torrance, Valencia
  • Annual Notice of Change (ANOC), H2134001000 - English (PDF)

  • Annual Notice of Change (ANOC), H2134001000 - Spanish (PDF)
Allwell Dual Medicare (HMO D-SNP) to Wellcare Dual Access (HMO D-SNP) H2134003000 Bernalillo, Chaves, Cibola, Curry, Dona Ana, Luna, McKinley, Quay, Rio Arriba, Roosevelt, San Juan, Sandoval, Santa Fe, Taos, Torrance, Valencia
  • Annual Notice of Change (ANOC), H2134003000 - English (PDF)

  • Annual Notice of Change (ANOC), H2134003000 - Spanish (PDF)
Allwell Dual Medicare Harmony (HMO D-SNP) to Wellcare Dual Access (HMO D-SNP) H2134003000 Bernalillo, Chaves, Cibola, Curry, Dona Ana, Luna, McKinley, Quay, Rio Arriba, Roosevelt, San Juan, Sandoval, Santa Fe, Taos, Torrance, Valencia
  • Annual Notice of Change (ANOC), H2134003000 - English (PDF)

  • Annual Notice of Change (ANOC), H2134003000 - Spanish (PDF)
Allwell Medicare Simple (HMO) to Wellcare Patriot No Premium (HMO) H2134006000 Bernalillo, Dona Ana, Rio Arriba, Sandoval, Santa Fe, Torrance, Valencia
  • Annual Notice of Change (ANOC), H2134006000 - English (PDF)

  • Annual Notice of Change (ANOC), H2134006000 - Spanish (PDF)