Plan Benefit Materials and Forms | Wellcare Nebraska

2026 Plan Benefit Materials

Explore your plan and its benefits by reviewing important documents like 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.”

HMO   |   HMO D-SNP   |  PPO   |  PPO D-SNP

HMO Plans

Wellcare Giveback (HMO-POS) H1215-003

Counties: Adams, Antelope, Banner, Blaine, Boone, Buffalo, Burt, Butler, Cass, Clay, Colfax, Cuming, Custer, Dawson, Dodge, Douglas, Fillmore, Franklin, Frontier, Furnas, Gage, Garfield, Gosper, Greeley, Hall, Hamilton, Harlan, Howard, Jefferson, Johnson, Kearney, Knox, Lancaster, Madison, Merrick, Nance, Nemaha, Otoe, Phelps, Pierce, Polk, Saline, Sarpy, Saunders, Scotts Bluff, Seward, Sherman, Stanton, Thayer, Valley, Washington, Wayne, Webster, Wheeler, York

Annual Notice of Change

Summary of Benefits

Evidence of Coverage

  • Evidence of Coverage - English (PDF) - Coming Soon

Dental Benefit Details

  • Dental Benefit Details - English (PDF) - Coming Soon

Wellcare Simple (HMO-POS) H1215-005

Counties: Adams, Antelope, Banner, Blaine, Boone, Buffalo, Burt, Butler, Cass, Clay, Colfax, Cuming, Custer, Dawson, Dodge, Douglas, Fillmore, Franklin, Frontier, Furnas, Gage, Garfield, Gosper, Greeley, Hall, Hamilton, Harlan, Howard, Jefferson, Johnson, Kearney, Knox, Lancaster, Madison, Merrick, Nance, Nemaha, Otoe, Phelps, Pierce, Polk, Saline, Sarpy, Saunders, Scotts Bluff, Seward, Sherman, Stanton, Thayer, Valley, Washington, Wayne, Webster, Wheeler, York

Summary of Benefits

Evidence of Coverage

  • Evidence of Coverage - English (PDF) - Coming Soon

Dental Benefit Details

  • Dental Benefit Details - English (PDF) - Coming Soon

HMO D-SNP Plans

Wellcare Dual Liberty Sync (HMO-POS D-SNP) H1215-001

Counties: 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

Annual Notice of Change

Summary of Benefits

Evidence of Coverage

  • Evidence of Coverage - English (PDF) - Coming Soon
  • Evidence of Coverage - Spanish (PDF) - Coming Soon

Dental Benefit Details

  • Dental Benefit Details - English (PDF) - Coming Soon
  • Dental Benefit Details - Spanish (PDF) - Coming Soon

PPO Plans

Wellcare Assist Open (PPO) H1395-003

Counties: Adams, Antelope, Banner, Blaine, Boone, Buffalo, Burt, Butler, Cass, Clay, Colfax, Cuming, Custer, Dawson, Dodge, Douglas, Fillmore, Franklin, Frontier, Furnas, Gage, Garfield, Gosper, Greeley, Hall, Hamilton, Harlan, Howard, Jefferson, Johnson, Kearney, Knox, Lancaster, Madison, Merrick, Nance, Nemaha, Otoe, Phelps, Pierce, Polk, Saline, Sarpy, Saunders, Scotts Bluff, Seward, Sherman, Stanton, Thayer, Valley, Washington, Wayne, Webster, Wheeler, York

Annual Notice of Change

Summary of Benefits

Evidence of Coverage

  • Evidence of Coverage - English (PDF) - Coming Soon

Dental Benefit Details

  • Dental Benefit Details - English (PDF) - Coming Soon

Wellcare Patriot Giveback Open (PPO) H1395-004

Counties: Adams, Antelope, Banner, Blaine, Boone, Buffalo, Burt, Butler, Cass, Clay, Colfax, Cuming, Custer, Dawson, Dodge, Douglas, Fillmore, Franklin, Frontier, Furnas, Gage, Garfield, Gosper, Greeley, Hall, Hamilton, Harlan, Howard, Jefferson, Johnson, Kearney, Knox, Lancaster, Madison, Merrick, Nance, Nemaha, Otoe, Phelps, Pierce, Polk, Saline, Sarpy, Saunders, Scotts Bluff, Seward, Sherman, Stanton, Thayer, Valley, Washington, Wayne, Webster, Wheeler, York

Annual Notice of Change

Summary of Benefits

Evidence of Coverage

  • Evidence of Coverage - English (PDF) - Coming Soon

Dental Benefit Details

  • Dental Benefit Details - English (PDF) - Coming Soon

Wellcare Simple Open (PPO) H1395-002

Counties: Adams, Antelope, Banner, Blaine, Boone, Burt, Butler, Cass, Clay, Colfax, Cuming, Custer, Dodge, Douglas, Fillmore, Franklin, Frontier, Furnas, Gage, Garfield, Gosper, Greeley, Hamilton, Harlan, Howard, Jefferson, Johnson, Knox, Lancaster, Madison, Merrick, Nance, Nemaha, Otoe, Pierce, Polk, Saline, Sarpy, Saunders, Scotts Bluff, Seward, Sherman, Stanton, Thayer, Valley, Washington, Wayne, Webster, Wheeler, York

Annual Notice of Change

Summary of Benefits

Evidence of Coverage

  • Evidence of Coverage - English (PDF) - Coming Soon

Dental Benefit Details

  • Dental Benefit Details - English (PDF) - Coming Soon

PPO D-SNP Plans

Wellcare Dual Access Sync Open (PPO D-SNP) H1395-001

Counties: 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

Annual Notice of Change

  • Annual Notice of Change: Wellcare Dual Access Open (PPO D-SNP) H1395-001 to Wellcare Dual Access Sync Open (PPO D-SNP) H1395-001 - English (PDF) - Coming Soon
  • Annual Notice of Change: Wellcare Dual Access Open (PPO D-SNP) H1395-001 to Wellcare Dual Access Sync Open (PPO D-SNP) H1395-001 - Spanish (PDF) - Coming Soon

Summary of Benefits

Evidence of Coverage

  • Evidence of Coverage - English (PDF) - Coming Soon
  • Evidence of Coverage - Spanish (PDF) - Coming Soon

Dental Benefit Details

  • Dental Benefit Details - English (PDF) - Coming Soon
  • Dental Benefit Details - Spanish (PDF) - Coming Soon

Additional Forms

  • Over-the-Counter Catalog (PDF) - Coming Soon
  • Over-the-Counter Catalog and Healthy Food (PDF) - Coming Soon

  • Medicare Step Therapy Part B (PDF) - Coming Soon

  • 2026 Medicare Parts A & B Premiums and Deductibles (PDF) - Coming Soon

  • Member Secure Portal Guide (PDF) - Coming Soon