Plan Benefit Materials and Forms | Wellcare Nebraska

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 No Premium (HMO) H1215-002

Adams, Antelope, Boone, Buffalo, Cass, Clay, Custer, Dawson, Dodge, Douglas, Fillmore, Franklin, Gage, Hall, Hamilton, Harlan, Howard, Jefferson, Johnson, Kearney, Keith, Lancaster, Lincoln, Madison, Nemaha, Otoe, Pawnee, Perkins, Pierce, Saline, Sarpy, Saunders, Scotts Bluff, Sherman, Wayne, Webster, York
Wellcare Giveback (HMO) H1215-003

Adams, Antelope, Boone, Buffalo, Cass, Clay, Custer, Dawson, Dodge, Douglas, Fillmore, Franklin, Gage, Hall, Hamilton, Harlan, Howard, Jefferson, Johnson, Kearney, Keith, Lancaster, Lincoln, Madison, Nemaha, Otoe, Pawnee, Perkins, Pierce, Saline, Sarpy, Saunders, Scotts Bluff, Sherman, Wayne, Webster, York

For HMO D-SNP Members:  

Plan Name CMS # County  Summary of Benefits
Wellcare Dual Liberty (HMO D-SNP) H1215-001

Adams, Antelope, Boone, Buffalo, Cass, Clay, Custer, Dawson, Dodge, Douglas, Fillmore, Franklin, Gage, Hall, Hamilton, Harlan, Howard, Jefferson, Johnson, Kearney, Keith, Lancaster, Lincoln, Madison, Nemaha, Otoe, Pawnee, Perkins, Pierce, Saline, Sarpy, Saunders, Scotts Bluff, Sherman, Wayne, Webster, York

For PPO Members:  

Plan Name CMS # County  Summary of Benefits
Wellcare Dual Access Open (PPO D-SNP) H1395-001

Adams, Antelope, Boone, Buffalo, Cass, Clay, Custer, Dawson, Dodge, Douglas, Fillmore, Franklin, Gage, Hall, Hamilton, Harlan, Howard, Jefferson, Johnson, Kearney, Keith, Lancaster, Lincoln, Madison, Nemaha, Otoe, Pawnee, Perkins, Pierce, Saline, Sarpy, Saunders, Scotts Bluff, Sherman, Wayne, Webster, York
Wellcare No Premium Open (PPO) H1395-002 Adams, Antelope, Boone, Buffalo, Cass, Clay, Custer, Dawson, Dodge, Douglas, Fillmore, Franklin, Gage, Hall, Hamilton, Harlan, Howard, Jefferson, Johnson, Kearney, Keith, Lancaster, Lincoln, Madison, Nemaha, Otoe, Pawnee, Perkins, Pierce, Saline, Sarpy, Saunders, Scotts Bluff, Sherman, Wayne, Webster, York
Wellcare Assist Open (PPO) H1395-003 Adams, Antelope, Boone, Buffalo, Cass, Clay, Custer, Dawson, Dodge, Douglas, Fillmore, Franklin, Gage, Hall, Hamilton, Harlan, Howard, Jefferson, Johnson, Kearney, Keith, Lancaster, Lincoln, Madison, Nemaha, Otoe, Pawnee, Perkins, Pierce, Saline, Sarpy, Saunders, Scotts Bluff, Sherman, Wayne, Webster, York

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) H1215-002

Adams, Antelope, Boone, Buffalo, Cass, Clay, Custer, Dawson, Dodge, Douglas, Fillmore, Franklin, Gage, Hall, Hamilton, Harlan, Howard, Jefferson, Johnson, Kearney, Keith, Lancaster, Lincoln, Madison, Nemaha, Otoe, Pawnee, Perkins, Pierce, Saline, Sarpy, Saunders, Scotts Bluff, Sherman, Wayne, Webster, York
Wellcare Giveback (HMO) H1215-003

Adams, Antelope, Boone, Buffalo, Cass, Clay, Custer, Dawson, Dodge, Douglas, Fillmore, Franklin, Gage, Hall, Hamilton, Harlan, Howard, Jefferson, Johnson, Kearney, Keith, Lancaster, Lincoln, Madison, Nemaha, Otoe, Pawnee, Perkins, Pierce, Saline, Sarpy, Saunders, Scotts Bluff, Sherman, Wayne, Webster, York

For HMO SNP Members:  

Plan Name CMS # County  Evidence of Coverage
Wellcare Dual Liberty (HMO D-SNP) H1215-001

Adams, Antelope, Boone, Buffalo, Cass, Clay, Custer, Dawson, Dodge, Douglas, Fillmore, Franklin, Gage, Hall, Hamilton, Harlan, Howard, Jefferson, Johnson, Kearney, Keith, Lancaster, Lincoln, Madison, Nemaha, Otoe, Pawnee, Perkins, Pierce, Saline, Sarpy, Saunders, Scotts Bluff, Sherman, Wayne, Webster, York
 
  • Evidence of Coverage H1215-001 - Spanish (PDF)  - coming soon

For PPO Members:  

Plan Name CMS # County  Evidence of Coverage
Wellcare Dual Access Open (PPO D-SNP) H1395-001

Adams, Antelope, Boone, Buffalo, Cass, Clay, Custer, Dawson, Dodge, Douglas, Fillmore, Franklin, Gage, Hall, Hamilton, Harlan, Howard, Jefferson, Johnson, Kearney, Keith, Lancaster, Lincoln, Madison, Nemaha, Otoe, Pawnee, Perkins, Pierce, Saline, Sarpy, Saunders, Scotts Bluff, Sherman, Wayne, Webster, York
Wellcare No Premium Open (PPO) H1395-002 Adams, Antelope, Boone, Buffalo, Cass, Clay, Custer, Dawson, Dodge, Douglas, Fillmore, Franklin, Gage, Hall, Hamilton, Harlan, Howard, Jefferson, Johnson, Kearney, Keith, Lancaster, Lincoln, Madison, Nemaha, Otoe, Pawnee, Perkins, Pierce, Saline, Sarpy, Saunders, Scotts Bluff, Sherman, Wayne, Webster, York
Wellcare Assist Open (PPO) H1395-003 Adams, Antelope, Boone, Buffalo, Cass, Clay, Custer, Dawson, Dodge, Douglas, Fillmore, Franklin, Gage, Hall, Hamilton, Harlan, Howard, Jefferson, Johnson, Kearney, Keith, Lancaster, Lincoln, Madison, Nemaha, Otoe, Pawnee, Perkins, Pierce, Saline, Sarpy, Saunders, Scotts Bluff, Sherman, Wayne, Webster, York

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)