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	Summary of Benefits H1215-002 - English (PDF)
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	Summary of Benefits H1215-003 - English (PDF)

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	Summary of Benefits H1215-001 - English (PDF)

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	Summary of Benefits H1395-001 - English (PDF)
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	Summary of Benefits H1395-002- English (PDF)
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	Summary of Benefits H1395-003 - 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)	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	Evidence of Coverage H1215-002 - English (PDF)
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	Evidence of Coverage H1215-003 - English (PDF)

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 - English (PDF) Evidence of Coverage H1215-001 - Spanish (PDF) - coming soon

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 - English (PDF)

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	Evidence of Coverage H1395-001 - English (PDF)
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	Evidence of Coverage H1395-002 - English (PDF)
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	Evidence of Coverage H1395-003 - English (PDF)

Dental Benefits

Plan Benefit Materials and Forms | Wellcare Nebraska

Plan Materials and Forms

For HMO Members:

For HMO D-SNP Members:

For PPO Members:

For HMO Members:

For HMO SNP Members:

For PPO Members:

Plan Benefit Materials

For HMO Members:

For HMO D-SNP Members:

For PPO Members:

For HMO Members:

For HMO SNP Members:

For PPO Members:

For HMO Members:

For HMO SNP Members:

For PPO Members:

Plan Name	CMS #	County	Summary of Benefits
Wellcare No Premium (HMO)	H1215-002	Adams, Antelope, Banner, Blaine, Boone, Boyd, Buffalo, Burt, Butler, Cass, Cedar, Clay, Colfax, Cuming, Custer, Dawson, Dixon, Dodge, Douglas, Fillmore, Franklin, Frontier, Furnas, Gage, Garfield, Gosper, Greeley, Hall, Hamilton, Harlan, Hayes, Hitchcock, Holt, Howard, Jefferson, Johnson, Kearney, Keith, Knox, Lancaster, Lincoln, Logan, Madison, Merrick, Nance, Nemaha, Otoe, Pawnee, Perkins, Phelps, Pierce, Polk, Saline, Sarpy, Saunders, Scotts Bluff, Seward, Sherman, Stanton, Thayer, Valley, Washington, Wayne, Webster, Wheeler, York	Summary of Benefits H1215-002 - English (PDF)
Wellcare Giveback (HMO)	H1215-003	Adams, Antelope, Banner, Blaine, Boone, Boyd, Buffalo, Burt, Butler, Cass, Cedar, Clay, Colfax, Cuming, Custer, Dawson, Dixon, Dodge, Douglas, Fillmore, Franklin, Frontier, Furnas, Gage, Garfield, Gosper, Greeley, Hall, Hamilton, Harlan, Hayes, Hitchcock, Holt, Howard, Jefferson, Johnson, Kearney, Keith, Knox, Lancaster, Lincoln, Logan, Madison, Merrick, Nance, Nemaha, Otoe, Pawnee, Perkins, Phelps, Pierce, Polk, Saline, Sarpy, Saunders, Scotts Bluff, Seward, Sherman, Stanton, Thayer, Valley, Washington, Wayne, Webster, Wheeler, York	Summary of Benefits H1215-003 - English (PDF)

Plan Benefit Materials and Forms | Wellcare Nebraska

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 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 SNP Members:

For PPO Members:

Annual Notice of Changes

For HMO Members:

For HMO SNP Members:

For PPO Members:

Dental

Over-The-Counter Benefits