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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 |
|
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 |