Plan Materials and Forms

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

Look at your Wellcare By Allwell from Sunflower Health Plan 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 By Allwell from Sunflower Health Plan 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)	H6550-003	Allen, Bourbon, Butler, Cherokee, Cowley, Crawford, Douglas, Harvey, Jackson, Jefferson, Johnson, Kingman, Labette, Leavenworth, Linn, McPherson, Miami, Sedgwick, Shawnee, Sumner, Woodson, Wyandotte	Summary of Benefits, H6550-003 - English (PDF)
Wellcare Assist (HMO)	H6550-006	Allen, Bourbon, Butler, Cherokee, Cowley, Crawford, Douglas, Harvey, Jackson, Jefferson, Johnson, Kingman, Labette, Leavenworth, Linn, McPherson, Miami, Sedgwick, Shawnee, Sumner, Woodson, Wyandotte	Summary of Benefits, H6550-006 - English (PDF)
Wellcare Giveback (HMO)	H6550-007	Allen, Bourbon, Butler, Cherokee, Cowley, Crawford, Douglas, Harvey, Jackson, Jefferson, Johnson, Kingman, Labette, Leavenworth, Linn, McPherson, Miami, Sedgwick, Shawnee, Sumner, Woodson, Wyandotte	Summary of Benefits, H6550-007 - English (PDF)

For HMO D-SNP Members:

Plan Name	CMS#	County	Summary of Benefits
Wellcare Dual Access (HMO D-SNP)	H6550-004	Allen, Bourbon, Butler, Cherokee, Cowley, Crawford, Douglas, Harvey, Jackson, Jefferson, Johnson, Kingman, Labette, Leavenworth, Linn, McPherson, Miami, Sedgwick, Shawnee, Sumner, Woodson, Wyandotte	Summary of Benefits, H6550-004 - English (PDF)
Wellcare Dual Liberty (HMO D-SNP)	H6550-009	Allen, Bourbon, Butler, Cherokee, Cowley, Crawford, Douglas, Harvey, Jackson, Jefferson, Johnson, Kingman, Labette, Leavenworth, Linn, McPherson, Miami, Sedgwick, Shawnee, Sumner, Woodson, Wyandotte	Summary of Benefits, H6550-009 - English (PDF)

For PPO Members:

Plan Name	CMS#	County	Summary of Benefits
Wellcare No Premium Open (PPO)	H9387-001	Allen, Bourbon, Butler, Cherokee, Cowley, Crawford, Douglas, Harvey, Jackson, Jefferson, Johnson, Kingman, Labette, Leavenworth, Linn, McPherson, Miami, Sedgwick, Shawnee, Sumner, Woodson, Wyandotte	Summary of Benefits, H9387-001 - English (PDF)
Wellcare Patriot Giveback Open (PPO)	H9387-002	Allen, Bourbon, Butler, Cherokee, Cowley, Crawford, Douglas, Harvey, Jackson, Jefferson, Johnson, Kingman, Labette, Leavenworth, Linn, McPherson, Miami, Sedgwick, Shawnee, Sumner, Woodson, Wyandotte	Summary of Benefits, H9387-002 - English (PDF)
Wellcare Premium Hybrid Open (PPO)	H9387-003	Allen, Bourbon, Butler, Cherokee, Cowley, Crawford, Douglas, Harvey, Jackson, Jefferson, Johnson, Kingman, Labette, Leavenworth, Linn, McPherson, Miami, Sedgwick, Shawnee, Sumner, Woodson, Wyandotte	Summary of Benefits, H9387-003 - English (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:

For HMO Members:

Plan Name	CMS#	County	Evidence of Coverage
Wellcare No Premium (HMO)	H6550-003	Allen, Bourbon, Butler, Cherokee, Cowley, Crawford, Douglas, Harvey, Jackson, Jefferson, Johnson, Kingman, Labette, Leavenworth, Linn, McPherson, Miami, Sedgwick, Shawnee, Sumner, Woodson, Wyandotte	Evidence of Coverage - English, H6550-003 - English (PDF)
Wellcare Assist (HMO)	H6550-006	Allen, Bourbon, Butler, Cherokee, Cowley, Crawford, Douglas, Harvey, Jackson, Jefferson, Johnson, Kingman, Labette, Leavenworth, Linn, McPherson, Miami, Sedgwick, Shawnee, Sumner, Woodson, Wyandotte	Evidence of Coverage - English, H6550-006 - English (PDF)
Wellcare Giveback (HMO)	H6550-007	Allen, Bourbon, Butler, Cherokee, Cowley, Crawford, Douglas, Harvey, Jackson, Jefferson, Johnson, Kingman, Labette, Leavenworth, Linn, McPherson, Miami, Sedgwick, Shawnee, Sumner, Woodson, Wyandotte	Evidence of Coverage - English, H6550-007 - English (PDF)

For HMO D-SNP Members:

Plan Name	CMS#	County	Evidence of Coverage
Wellcare Dual Access (HMO D-SNP)	H6550-004	Allen, Bourbon, Butler, Cherokee, Cowley, Crawford, Douglas, Harvey, Jackson, Jefferson, Johnson, Kingman, Labette, Leavenworth, Linn, McPherson, Miami, Sedgwick, Shawnee, Sumner, Woodson, Wyandotte	Evidence of Coverage, H6550-004 - English (PDF)
Wellcare Dual Liberty (HMO D-SNP)	H6550-009	Allen, Bourbon, Butler, Cherokee, Cowley, Crawford, Douglas, Harvey, Jackson, Jefferson, Johnson, Kingman, Labette, Leavenworth, Linn, McPherson, Miami, Sedgwick, Shawnee, Sumner, Woodson, Wyandotte	Evidence of Coverage, H6550-009 - English (PDF)

For PPO Members:

Plan Name	CMS#	County	Evidence of Coverage
Wellcare No Premium Open (PPO)	H9387-001	Allen, Bourbon, Butler, Cherokee, Cowley, Crawford, Douglas, Harvey, Jackson, Jefferson, Johnson, Kingman, Labette, Leavenworth, Linn, McPherson, Miami, Sedgwick, Shawnee, Sumner, Woodson, Wyandotte	Evidence of Coverage, H9387-001 - English (PDF)
Wellcare Patriot Giveback Open (PPO)	H9387-002	Allen, Bourbon, Butler, Cherokee, Cowley, Crawford, Douglas, Harvey, Jackson, Jefferson, Johnson, Kingman, Labette, Leavenworth, Linn, McPherson, Miami, Sedgwick, Shawnee, Sumner, Woodson, Wyandotte	Evidence of Coverage, H9387-002 - English (PDF)
Wellcare Premium Hybrid Open (PPO)	H9387-003	Allen, Bourbon, Butler, Cherokee, Cowley, Crawford, Douglas, Harvey, Jackson, Jefferson, Johnson, Kingman, Labette, Leavenworth, Linn, McPherson, Miami, Sedgwick, Shawnee, Sumner, Woodson, Wyandotte	Evidence of Coverage, H9387-003 - English (PDF)

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 Change
Wellcare No Premium (HMO)	H6550-003	Allen, Bourbon, Butler, Cherokee, Cowley, Crawford, Douglas, Harvey, Jackson, Jefferson, Johnson, Kingman, Labette, Leavenworth, Linn, McPherson, Miami, Sedgwick, Shawnee, Sumner, Woodson, Wyandotte	Annual Notice of Change, H6550-003 - English (PDF)
Wellcare Assist (HMO)	H6550-006	Allen, Bourbon, Butler, Cherokee, Cowley, Crawford, Douglas, Harvey, Jackson, Jefferson, Johnson, Kingman, Labette, Leavenworth, Linn, McPherson, Miami, Sedgwick, Shawnee, Sumner, Woodson, Wyandotte	Annual Notice of Change, H6550-006 - English (PDF)
Wellcare Giveback (HMO)	H6550-007	Allen, Bourbon, Butler, Cherokee, Cowley, Crawford, Douglas, Harvey, Jackson, Jefferson, Johnson, Kingman, Labette, Leavenworth, Linn, McPherson, Miami, Sedgwick, Shawnee, Sumner, Woodson, Wyandotte	Annual Notice of Change, H6550-007 - English (PDF)

For HMO D-SNP Members:

Plan Name	CMS#	County	Annual Notice of Change
Wellcare Dual Access (HMO D-SNP)	H6550-004	Allen, Bourbon, Butler, Cherokee, Cowley, Crawford, Douglas, Harvey, Jackson, Jefferson, Johnson, Kingman, Labette, Leavenworth, Linn, McPherson, Miami, Sedgwick, Shawnee, Sumner, Woodson, Wyandotte	Annual Notice of Change, H6550-004 - English (PDF)

For PPO Members:

Plan Name	CMS#	County	Annual Notice of Change
Wellcare No Premium Open (PPO)	H9387-001	Allen, Bourbon, Butler, Cherokee, Cowley, Crawford, Douglas, Harvey, Jackson, Jefferson, Johnson, Kingman, Labette, Leavenworth, Linn, McPherson, Miami, Sedgwick, Shawnee, Sumner, Woodson, Wyandotte	Annual Notice of Change, H9387-001 - English (PDF)
Wellcare Patriot Giveback Open (PPO)	H9387-002	Allen, Bourbon, Butler, Cherokee, Cowley, Crawford, Douglas, Harvey, Jackson, Jefferson, Johnson, Kingman, Labette, Leavenworth, Linn, McPherson, Miami, Sedgwick, Shawnee, Sumner, Woodson, Wyandotte	Annual Notice of Change, H9387-002 - English (PDF)

Dental Provider Selection Form (PDF)

Over-The-Counter Catalog - English (PDF)

Plan Name	CMS #	County	Summary of Benefits
Allwell Medicare (HMO)	H6550-003	Allen, Bourbon, Cherokee, Crawford, Douglas, Johnson, Leavenworth, Linn, Miami, Sumner, Woodson, and Wyandotte counties	Summary of Benefits, H6550-003 - English (PDF)
Allwell Medicare Complement (HMO)	H6550-006	Allen, Bourbon, Cherokee, Crawford, Douglas, Johnson, Leavenworth, Linn, Miami, Sumner, Woodson and Wyandotte counties	Summary of Benefits, H6550-006 - English (PDF)
Allwell Medicare Boost (HMO)	H6550-007	Allen, Bourbon, Cherokee, Crawford, Douglas, Johnson, Leavenworth, Linn, Miami, Sumner, Woodson and Wyandotte counties	Summary of Benefits, H6550-007 - English (PDF)
Allwell Medicare Simple (HMO)	H6550-008	Allen, Bourbon, Cherokee, Crawford, Douglas, Johnson, Leavenworth, Linn, Miami, Sumner, Woodson and Wyandotte counties	Summary of Benefits, H6550-008 - English (PDF)

Plan Name	CMS #	County	Summary of Benefits
Allwell Dual Medicare (HMO D-SNP)	H6550-004	Allen, Bourbon, Butler, Cherokee, Crawford, Douglas, Harvey, Johnson, Leavenworth, Linn, Miami, Sedgwick, Shawnee, Sumner, Woodson and Wyandotte counties	Summary of Benefits, H6550-004 - English (PDF)
Allwell Medicare Harmony (HMO D-SNP)	H6550-005	Allen, Bourbon, Butler, Cherokee, Crawford, Douglas, Harvey, Johnson, Leavenworth, Linn, Miami, Sedgwick, Shawnee, Sumner, Woodson and Wyandotte counties	Summary of Benefits, H6550-005 - English (PDF)

Plan Name	CMS#	County	Evidence of Coverage
Allwell Medicare (HMO)	H6550-003	Allen, Bourbon, Cherokee, Crawford, Douglas, Johnson, Leavenworth, Linn, Miami, Sumner, Woodson, and Wyandotte counties	Evidence of Coverage, H6550-003 - English (PDF)
Allwell Medicare Complement (HMO)	H6550-006	Allen, Bourbon, Cherokee, Crawford, Douglas, Johnson, Leavenworth, Linn, Miami, Sumner, Woodson and Wyandotte counties	Evidence of Coverage, H6550-006 - English (PDF)
Allwell Medicare Boost (HMO)	H6550-007	Allen, Bourbon, Cherokee, Crawford, Douglas, Johnson, Leavenworth, Linn, Miami, Sumner, Woodson and Wyandotte counties	Evidence of Coverage, H6550-007 - English (PDF)
Allwell Medicare Simple (HMO)	H6550-008	Allen, Bourbon, Cherokee, Crawford, Douglas, Johnson, Leavenworth, Linn, Miami, Sumner, Woodson and Wyandotte counties	Evidence of Coverage, H6550-008 - English (PDF)

Plan Name	CMS#	County	Annual Notice of Changes
Allwell Medicare (HMO)	H6550-001-003	Allen, Bourbon, Cherokee, Crawford, Douglas, Johnson, Leavenworth, Linn, Miami, Sumner, Woodson, and Wyandotte counties	Annual Notice of Change, H6550-001-003 - English (PDF)
Allwell Medicare (HMO)	H6550-003	Allen, Bourbon, Cherokee, Crawford, Douglas, Johnson, Leavenworth, Linn, Miami, Sumner, Woodson, and Wyandotte counties	Annual Notice of Change, H6550-003 - English (PDF)

Plan Benefit Materials |

Plan Materials and Forms

For HMO Members:

For HMO D-SNP Members:

For PPO Members:

For HMO Members:

For HMO D-SNP Members:

For PPO Members:

For HMO Members:

For HMO D-SNP Members:

For PPO Members:

Plan Benefit Materials

For HMO Members:

For HMO D-SNP Members:

For PPO Members:

For HMO Members:

For HMO D-SNP Members:

For PPO Members:

For HMO Members:

For HMO D-SNP Members:

Plan Name	CMS #	County	Summary of Benefits
Allwell Medicare (PPO)	H9387-001	Douglas, Johnson, Leavenworth, Miami and Wyandotte counties	Summary of Benefits, H9387-001 - English (PDF)
Allwell Medicare Simple (PPO)	H9387-002	Douglas, Johnson, Leavenworth, Miami and Wyandotte counties	Summary of Benefits, H9387-002 - English (PDF)

Plan Benefit Materials |

Plan Materials and Forms

Summary of Benefits (SB)

For HMO Members:

For HMO D-SNP Members:

For PPO Members:

Evidence Of Coverage (EOC)

For HMO Members:

For HMO D-SNP Members:

For PPO Members:

Annual Notice of Changes (ANOC)

For HMO Members:

For HMO D-SNP Members:

For PPO Members:

Dental

Over-The-Counter Benefits

Plan Benefit Materials

Summary of Benefits (SB)

For HMO Members:

For HMO D-SNP Members:

For PPO Members:

Evidence Of Coverage (EOC)

For HMO Members:

For HMO D-SNP Members:

For PPO Members:

Annual Notice of Changes (ANOC)

For HMO Members:

For HMO D-SNP Members:

Dental

Over-The-Counter Benefits