Plan Benefit Materials |
Plan Materials and Forms
Listed below are some documents that may be helpful at different times during your membership.
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 |
|---|---|---|---|
| Allwell Medicare (HMO) | H9630-001 | Benton, Carroll, Clay, Cleburne, Crawford, Crittenden, Cross, Franklin, Fulton, Independence, Izard, Jackson, Johnson, Lawrence, Logan, Madison, Mississippi, Newton, Perry, Poinsett, Prairie, Randolph, Scott, Searcy, Sebastian, Sharp, St. Francis, Stone, Van Buren, Washington, White, Woodruff, and Yell counties |
|
| Allwell Medicare (HMO) | H9630-002 | Clark, Conway, Craighead, Faulkner, Garland, Greene, Hot Spring, Lonoke, Pope, Pulaski and Saline counties |
|
| Allwell Medicare Select (HMO) | H9630-003 | Benton and Washington counties |
|
| Allwell Medicare (HMO) | H9630-004 | Baxter, Boone, Marion | |
| Allwell Medicare Premier (HMO) | H9630-005 |
Baxter, Boone, Marion |
|
| Allwell Medicare Premier (HMO) | H9630 - 006 | 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. |
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 |
|---|---|---|---|
| Allwell Medicare (HMO) | H9630-001 | Benton, Carroll, Clay, Cleburne, Crawford, Crittenden, Cross, Franklin, Fulton, Independence, Izard, Jackson, Johnson, Lawrence, Logan, Madison, Mississippi, Newton, Perry, Poinsett, Prairie, Randolph, Scott, Searcy, Sebastian, Sharp, St. Francis, Stone, Van Buren, Washington, White, Woodruff, and Yell counties |
|
| Allwell Medicare (HMO) | H9630-002 | Clark, Conway, Craighead, Faulkner, Garland, Greene, Hot Spring, Lonoke, Pope, Pulaski and Saline counties |
|
| Allwell Medicare Select (HMO) | H9630-003 | Benton and Washington counties |
|
| Allwell Medicare (HMO) |
H9630-004 | Baxter, Boone, Marion | |
| Allwell Medicare Premier (HMO) | H9630-005 | Baxter, Boone, Marion | |
| Allwell Medicare Premier (HMO) | H9630-006 | 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. |
This booklet will tell you about changes to your plan’s costs and benefits for the coming year.
Please select the document for your plan and county:
For HMO Members:
| Plan Name | CMS# | County | Annual Notice Of Changes |
|---|---|---|---|
| Allwell Medicare (HMO) | H9630-001 | Benton, Carroll, Clay, Cleburne, Crawford, Crittenden, Cross, Franklin, Fulton, Independence, Izard, Jackson, Johnson, Lawrence, Logan, Madison, Mississippi, Newton, Perry, Poinsett, Prairie, Randolph, Scott, Searcy, Sebastian, Sharp, St. Francis, Stone, Van Buren, Washington, White, Woodruff, and Yell counties | |
| Allwell Medicare (HMO) | H9630-002 | Clark, Conway, Craighead, Faulkner, Garland, Greene, Hot Spring, Lonoke, Pope, Pulaski and Saline counties | |
| Allwell Medicare Select (HMO) | H9630-003 | Benton and Washington counties | |
| Allwell Medicare (HMO) | H9630-004 | Baxter, Boone, Marion | |
| Allwell Medicare Premier (HMO) | H9630-005 | Baxter, Boone, Marion |
Members in all counties enrolled in:
|
Allwell members in all counties have an over-the-counter benefit through Walmart. Members in these counties can purchase approved OTC items in-store at Walmart, or online at the website below to have items delivered directly to their door. Ordering is easy! Click on the link below to get started. |
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) | Benton, Carroll, Clay, Cleburne, Crawford, Crittenden, Cross, Franklin, Fulton, Independence, Izard, Jackson, Johnson, Lawrence, Logan, Madison, Mississippi, Newton, Perry, Poinsett, Prairie, Randolph, Scott, Searcy, Sebastian, Sharp, St. Francis, Stone, Van Buren, Washington, White, Woodruff, and Yell counties | |
| Allwell Medicare (HMO) | Clark, Conway, Craighead, Faulkner, Garland, Greene, Hot Spring, Lonoke, Pope, Pulaski and Saline counties | |
| Allwell Medicare Select (HMO) |
Benton and Washington counties |
|
| Allwell Medicare (HMO) | Baxter, Boone and Marion | |
| Allwell Medicare Premier (HMO) | Baxter, Boone and Marion | |
| 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. |