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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 No Premium (HMO)

H6550-003

Allen, Anderson, Atchison, Bourbon, Brown, Butler, Chase, Chautauqua, Cherokee, Coffey, Cowley, Crawford, Dickinson, Doniphan, Douglas, Elk, Franklin, Geary, Greenwood, Harvey, Jackson, Jefferson, Johnson, Kingman, Labette, Leavenworth, Linn, Lyon, Marion, McPherson, Miami, Montgomery, Morris, Nemaha, Neosho, Osage, Pottawatomie, Reno, Riley, Saline, Sedgwick, Shawnee, Sumner, Wabaunsee, Wilson, Woodson, Wyandotte

Wellcare Assist (HMO)

H6550-006

Allen, Anderson, Atchison, Bourbon, Brown, Butler, Chase, Chautauqua, Cherokee, Coffey, Cowley, Crawford, Dickinson, Doniphan, Douglas, Elk, Franklin, Geary, Greenwood, Harvey, Jackson, Jefferson, Johnson, Kingman, Labette, Leavenworth, Linn, Lyon, Marion, McPherson, Miami, Montgomery, Morris, Nemaha, Neosho, Osage, Pottawatomie, Reno, Riley, Saline, Sedgwick, Shawnee, Sumner, Wabaunsee, Wilson, Woodson, Wyandotte

Wellcare Giveback (HMO)

H6550-007

Allen, Anderson, Atchison, Bourbon, Brown, Butler, Chase, Chautauqua, Cherokee, Coffey, Cowley, Crawford, Dickinson, Doniphan, Douglas, Elk, Franklin, Geary, Greenwood, Harvey, Jackson, Jefferson, Johnson, Kingman, Labette, Leavenworth, Linn, Lyon, Marion, McPherson, Miami, Montgomery, Morris, Nemaha, Neosho, Osage, Pottawatomie, Reno, Riley, Saline, Sedgwick, Shawnee, Sumner, Wabaunsee, Wilson, Woodson, Wyandotte


For HMO D-SNP Members:

Plan Name 

CMS#

County

Summary of Benefits

Wellcare Dual Access (HMO D-SNP)

H6550-004

Allen, Anderson, Atchison, Bourbon, Brown, Butler, Chase, Chautauqua, Cherokee, Coffey, Cowley, Crawford, Dickinson, Doniphan, Douglas, Elk, Franklin, Geary, Greenwood, Harvey, Jackson, Jefferson, Johnson, Kingman, Labette, Leavenworth, Linn, Lyon, Marion, McPherson, Miami, Montgomery, Morris, Nemaha, Neosho, Osage, Pottawatomie, Reno, Riley, Saline, Sedgwick, Shawnee, Sumner, Wabaunsee, Wilson, Woodson, Wyandotte

Wellcare Dual Liberty (HMO D-SNP)

H6550-009

Allen, Anderson, Atchison, Bourbon, Brown, Butler, Chase, Chautauqua, Cherokee, Coffey, Cowley, Crawford, Dickinson, Doniphan, Douglas, Elk, Franklin, Geary, Greenwood, Harvey, Jackson, Jefferson, Johnson, Kingman, Labette, Leavenworth, Linn, Lyon, Marion, McPherson, Miami, Montgomery, Morris, Nemaha, Neosho, Osage, Pottawatomie, Reno, Riley, Saline, Sedgwick, Shawnee, Sumner, Wabaunsee, Wilson, Woodson, Wyandotte

For PPO Members:

Plan Name 

CMS#

County

Summary of Benefits

Wellcare No Premium Open (PPO)

H9387-001

Allen, Anderson, Atchison, Bourbon, Brown, Butler, Chase, Chautauqua, Cherokee, Coffey, Cowley, Crawford, Dickinson, Doniphan, Douglas, Elk, Franklin, Geary, Greenwood, Harvey, Jackson, Jefferson, Johnson, Kingman, Labette, Leavenworth, Linn, Lyon, Marion, McPherson, Miami, Montgomery, Morris, Nemaha, Neosho, Osage, Pottawatomie, Reno, Riley, Saline, Sedgwick, Shawnee, Sumner, Wabaunsee, Wilson, Woodson, Wyandotte

Wellcare Patriot Giveback Open (PPO)

H9387-002

Allen, Anderson, Atchison, Bourbon, Brown, Butler, Chase, Chautauqua, Cherokee, Coffey, Cowley, Crawford, Dickinson, Doniphan, Douglas, Elk, Franklin, Geary, Greenwood, Harvey, Jackson, Jefferson, Johnson, Kingman, Labette, Leavenworth, Linn, Lyon, Marion, McPherson, Miami, Montgomery, Morris, Nemaha, Neosho, Osage, Pottawatomie, Reno, Riley, Saline, Sedgwick, Shawnee, Sumner, Wabaunsee, Wilson, Woodson, Wyandotte

For PPO D-SNP Members:

Plan Name 

CMS#

County

Summary of Benefits

Wellcare Dual Access Open (PPO D-SNP)

H9387-004

Allen, Anderson, Atchison, Bourbon, Brown, Butler, Chase, Chautauqua, Cherokee, Coffey, Cowley, Crawford, Dickinson, Doniphan, Douglas, Elk, Franklin, Geary, Greenwood, Harvey, Jackson, Jefferson, Johnson, Kingman, Labette, Leavenworth, Linn, Lyon, Marion, McPherson, Miami, Montgomery, Morris, Nemaha, Neosho, Osage, Pottawatomie, Reno, Riley, Saline, Sedgwick, Shawnee, Sumner, Wabaunsee, Wilson, Woodson, Wyandotte

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 No Premium (HMO)

H6550-003

Allen, Anderson, Atchison, Bourbon, Brown, Butler, Chase, Chautauqua, Cherokee, Coffey, Cowley, Crawford, Dickinson, Doniphan, Douglas, Elk, Franklin, Geary, Greenwood, Harvey, Jackson, Jefferson, Johnson, Kingman, Labette, Leavenworth, Linn, Lyon, Marion, McPherson, Miami, Montgomery, Morris, Nemaha, Neosho, Osage, Pottawatomie, Reno, Riley, Saline, Sedgwick, Shawnee, Sumner, Wabaunsee, Wilson, Woodson, Wyandotte

Wellcare Assist (HMO)

H6550-006

Allen, Anderson, Atchison, Bourbon, Brown, Butler, Chase, Chautauqua, Cherokee, Coffey, Cowley, Crawford, Dickinson, Doniphan, Douglas, Elk, Franklin, Geary, Greenwood, Harvey, Jackson, Jefferson, Johnson, Kingman, Labette, Leavenworth, Linn, Lyon, Marion, McPherson, Miami, Montgomery, Morris, Nemaha, Neosho, Osage, Pottawatomie, Reno, Riley, Saline, Sedgwick, Shawnee, Sumner, Wabaunsee, Wilson, Woodson, Wyandotte

Wellcare Giveback (HMO)

H6550-007

Allen, Anderson, Atchison, Bourbon, Brown, Butler, Chase, Chautauqua, Cherokee, Coffey, Cowley, Crawford, Dickinson, Doniphan, Douglas, Elk, Franklin, Geary, Greenwood, Harvey, Jackson, Jefferson, Johnson, Kingman, Labette, Leavenworth, Linn, Lyon, Marion, McPherson, Miami, Montgomery, Morris, Nemaha, Neosho, Osage, Pottawatomie, Reno, Riley, Saline, Sedgwick, Shawnee, Sumner, Wabaunsee, Wilson, Woodson, Wyandotte


For HMO D-SNP Members:

Plan Name 

CMS#

County

Evidence of Coverage

Wellcare Dual Access (HMO D-SNP)

H6550-004

Allen, Anderson, Atchison, Bourbon, Brown, Butler, Chase, Chautauqua, Cherokee, Coffey, Cowley, Crawford, Dickinson, Doniphan, Douglas, Elk, Franklin, Geary, Greenwood, Harvey, Jackson, Jefferson, Johnson, Kingman, Labette, Leavenworth, Linn, Lyon, Marion, McPherson, Miami, Montgomery, Morris, Nemaha, Neosho, Osage, Pottawatomie, Reno, Riley, Saline, Sedgwick, Shawnee, Sumner, Wabaunsee, Wilson, Woodson, Wyandotte

Wellcare Dual Liberty (HMO D-SNP)

H6550-009

Allen, Anderson, Atchison, Bourbon, Brown, Butler, Chase, Chautauqua, Cherokee, Coffey, Cowley, Crawford, Dickinson, Doniphan, Douglas, Elk, Franklin, Geary, Greenwood, Harvey, Jackson, Jefferson, Johnson, Kingman, Labette, Leavenworth, Linn, Lyon, Marion, McPherson, Miami, Montgomery, Morris, Nemaha, Neosho, Osage, Pottawatomie, Reno, Riley, Saline, Sedgwick, Shawnee, Sumner, Wabaunsee, Wilson, Woodson, Wyandotte

For PPO Members:

Plan Name 

CMS#

County

Evidence of Coverage

Wellcare No Premium Open (PPO)

H9387-001

Allen, Anderson, Atchison, Bourbon, Brown, Butler, Chase, Chautauqua, Cherokee, Coffey, Cowley, Crawford, Dickinson, Doniphan, Douglas, Elk, Franklin, Geary, Greenwood, Harvey, Jackson, Jefferson, Johnson, Kingman, Labette, Leavenworth, Linn, Lyon, Marion, McPherson, Miami, Montgomery, Morris, Nemaha, Neosho, Osage, Pottawatomie, Reno, Riley, Saline, Sedgwick, Shawnee, Sumner, Wabaunsee, Wilson, Woodson, Wyandotte

Wellcare Patriot Giveback Open (PPO)

H9387-002

Allen, Anderson, Atchison, Bourbon, Brown, Butler, Chase, Chautauqua, Cherokee, Coffey, Cowley, Crawford, Dickinson, Doniphan, Douglas, Elk, Franklin, Geary, Greenwood, Harvey, Jackson, Jefferson, Johnson, Kingman, Labette, Leavenworth, Linn, Lyon, Marion, McPherson, Miami, Montgomery, Morris, Nemaha, Neosho, Osage, Pottawatomie, Reno, Riley, Saline, Sedgwick, Shawnee, Sumner, Wabaunsee, Wilson, Woodson, Wyandotte

For PPO D-SNP Members:

Plan Name 

CMS#

County

Evidence of Coverage

Wellcare Dual Access Open (PPO D-SNP)

H9387-004

Allen, Anderson, Atchison, Bourbon, Brown, Butler, Chase, Chautauqua, Cherokee, Coffey, Cowley, Crawford, Dickinson, Doniphan, Douglas, Elk, Franklin, Geary, Greenwood, Harvey, Jackson, Jefferson, Johnson, Kingman, Labette, Leavenworth, Linn, Lyon, Marion, McPherson, Miami, Montgomery, Morris, Nemaha, Neosho, Osage, Pottawatomie, Reno, Riley, Saline, Sedgwick, Shawnee, Sumner, Wabaunsee, Wilson, Woodson, Wyandotte

 

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#CountyAnnual Notice of Change
Wellcare No Premium (HMO)H6550-003Allen, Anderson, Atchison, Bourbon, Brown, Butler, Chase, Chautauqua, Cherokee, Coffey, Cowley, Crawford, Dickinson, Doniphan, Douglas, Elk, Franklin, Geary, Greenwood, Harvey, Jackson, Jefferson, Johnson, Kingman, Labette, Leavenworth, Linn, Lyon, Marion, McPherson, Miami, Montgomery, Morris, Nemaha, Neosho, Osage, Pottawatomie, Reno, Riley, Saline, Sedgwick, Shawnee, Sumner, Wabaunsee, Wilson, Woodson, Wyandotte
Wellcare Assist (HMO)H6550-006Allen, Anderson, Atchison, Bourbon, Brown, Butler, Chase, Chautauqua, Cherokee, Coffey, Cowley, Crawford, Dickinson, Doniphan, Douglas, Elk, Franklin, Geary, Greenwood, Harvey, Jackson, Jefferson, Johnson, Kingman, Labette, Leavenworth, Linn, Lyon, Marion, McPherson, Miami, Montgomery, Morris, Nemaha, Neosho, Osage, Pottawatomie, Reno, Riley, Saline, Sedgwick, Shawnee, Sumner, Wabaunsee, Wilson, Woodson, Wyandotte
Wellcare Giveback (HMO)H6550-007AAllen, Anderson, Atchison, Bourbon, Brown, Butler, Chase, Chautauqua, Cherokee, Coffey, Cowley, Crawford, Dickinson, Doniphan, Douglas, Elk, Franklin, Geary, Greenwood, Harvey, Jackson, Jefferson, Johnson, Kingman, Labette, Leavenworth, Linn, Lyon, Marion, McPherson, Miami, Montgomery, Morris, Nemaha, Neosho, Osage, Pottawatomie, Reno, Riley, Saline, Sedgwick, Shawnee, Sumner, Wabaunsee, Wilson, Woodson, Wyandotte


For HMO D-SNP Members:

Plan Name CMS#CountyAnnual Notice of Change
Wellcare Dual Access (HMO D-SNP)H6550-004Allen, Anderson, Atchison, Bourbon, Brown, Butler, Chase, Chautauqua, Cherokee, Coffey, Cowley, Crawford, Dickinson, Doniphan, Douglas, Elk, Franklin, Geary, Greenwood, Harvey, Jackson, Jefferson, Johnson, Kingman, Labette, Leavenworth, Linn, Lyon, Marion, McPherson, Miami, Montgomery, Morris, Nemaha, Neosho, Osage, Pottawatomie, Reno, Riley, Saline, Sedgwick, Shawnee, Sumner, Wabaunsee, Wilson, Woodson, Wyandotte
Wellcare Dual Liberty (HMO D-SNP)H6550- 009Allen, Anderson, Atchison, Bourbon, Brown, Butler, Chase, Chautauqua, Cherokee, Coffey, Cowley, Crawford, Dickinson, Doniphan, Douglas, Elk, Franklin, Geary, Greenwood, Harvey, Jackson, Jefferson, Johnson, Kingman, Labette, Leavenworth, Linn, Lyon, Marion, McPherson, Miami, Montgomery, Morris, Nemaha, Neosho, Osage, Pottawatomie, Reno, Riley, Saline, Sedgwick, Shawnee, Sumner, Wabaunsee, Wilson, Woodson, Wyandotte

For PPO and PPO D-SNPMembers:

Plan Name CMS#CountyAnnual Notice of Change
Wellcare No Premium Open (PPO)H9387-001Allen, Anderson, Atchison, Bourbon, Brown, Butler, Chase, Chautauqua, Cherokee, Coffey, Cowley, Crawford, Dickinson, Doniphan, Douglas, Elk, Franklin, Geary, Greenwood, Harvey, Jackson, Jefferson, Johnson, Kingman, Labette, Leavenworth, Linn, Lyon, Marion, McPherson, Miami, Montgomery, Morris, Nemaha, Neosho, Osage, Pottawatomie, Reno, Riley, Saline, Sedgwick, Shawnee, Sumner, Wabaunsee, Wilson, Woodson, Wyandotte
Wellcare Patriot Giveback Open (PPO)H9387-002Allen, Anderson, Atchison, Bourbon, Brown, Butler, Chase, Chautauqua, Cherokee, Coffey, Cowley, Crawford, Dickinson, Doniphan, Douglas, Elk, Franklin, Geary, Greenwood, Harvey, Jackson, Jefferson, Johnson, Kingman, Labette, Leavenworth, Linn, Lyon, Marion, McPherson, Miami, Montgomery, Morris, Nemaha, Neosho, Osage, Pottawatomie, Reno, Riley, Saline, Sedgwick, Shawnee, Sumner, Wabaunsee, Wilson, Woodson, Wyandotte
Wellcare Dual Access Open (PPO D-SNP)H9387-004Allen, Anderson, Atchison, Bourbon, Brown, Butler, Chase, Chautauqua, Cherokee, Coffey, Cowley, Crawford, Dickinson, Doniphan, Douglas, Elk, Franklin, Geary, Greenwood, Harvey, Jackson, Jefferson, Johnson, Kingman, Labette, Leavenworth, Linn, Lyon, Marion, McPherson, Miami, Montgomery, Morris, Nemaha, Neosho, Osage, Pottawatomie, Reno, Riley, Saline, Sedgwick, Shawnee, Sumner, Wabaunsee, Wilson, Woodson, Wyandotte