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 Medicare (HMO)- Plan #H9630-001
  • Allwell Medicare (HMO)- Plan #H9630-002
  • Allwell Medicare (HMO)- Plan #H9630-003
  • Allwell Medicare (HMO)- Plan #H9630-004
  • Allwell Medicare Premier (HMO) -
    Plan # H9630-005
  • Allwell Medicare Premier (HMO) -
    Plan # H9630-006

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.