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. 

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, 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
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

For HMO D-SNP Members:  

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

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

For PPO Members:  

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

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
Wellcare No Premium Open (PPO) H1395-002 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
Wellcare Assist Open (PPO) H1395-003 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

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, 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

 

  • Dental Benefit Details H1215-002  - English (PDF) - coming soon
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
  • Evidence of Coverage H1215-003 - English (PDF) - coming soon

 

  • Dental Benefit Details - English H1215-003 (PDF) - coming soon

For HMO SNP Members:  

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

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

 

  • Dental Benefit Details H1215-001 - English (PDF) - coming soon

For PPO and PPO D-SNP Members:  

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

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

 

  • Dental Benefit Details H1395-001 - English (PDF) - coming soon
Wellcare No Premium Open (PPO) H1395-002 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

 

  • Dental Benefit Details - English H1395-002 (PDF) - coming soon
Wellcare Assist Open (PPO) H1395-003 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

 

  • Dental Benefit Details H1395-003 - English (PDF) - coming soon

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 Annual Notice of Changes
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
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

For HMO SNP Members:  

Plan Name CMS # County  Annual Notice of Changes
Wellcare Dual Liberty (HMO D-SNP) H1215-001

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

For PPO Members and PPO D- SNP:  

Plan Name CMS # County  Annual Notice of Changes
Wellcare Dual Access Open (PPO D-SNP) H1395-001

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
Wellcare No Premium Open (PPO) H1395-002 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
Wellcare Assist Open (PPO) H1395-003 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

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