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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, 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 and Yell counties

Allwell Medicare (HMO) H9630-002

Clark, Conway, Craighead, Faulkner, Garland, Greene, Hot Springs, 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 Mississippi, Newton, Perry, Poinsett, Prairie, Randolph, Scott, Searcy, Sebastian, Sharp, Stone, Van Buren, Washington, White, Woodruff, Yell
  • Summary of Benefits, H9630-006  - English (PDF)

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, 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 and Yell counties

Allwell Medicare (HMO) H9630-002

Clark, Conway, Craighead, Faulkner, Garland, Greene, Hot Springs, 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

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, 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 and Yell counties
Allwell Medicare (HMO) H9630-002 Clark, Conway, Craighead, Faulkner, Garland, Greene, Hot Springs, Lonoke, Pope, Pulaski and Saline counties
Allwell Medicare Select (HMO) H9630-003 Benton and Washington counties

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 Low Income Subsidy
[2020_PRODUCT_NAME_HMO_001] H9630-001 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 and Yell counties
[2020_PRODUCT_NAME_HMO_002] H9630-002 Clark, Conway, Craighead, Faulkner, Garland, Greene, Hot Springs, Lonoke, Pope, Pulaski and Saline counties
[2020_PRODUCT_NAME_HMO_003] H9630-003 Benton and Washington counties
Allwell Medicare (HMO) H9630-004

Baxter, Boone, Marion
Allwell Medicare Premier H9630-005

Baxter, Boone, Marion

This is the complete list of prescription drugs covered by Allwell.

Please select the document for your plan :

HMO Formulary

 

All members enrolled in the following plans:

  • Allwell Medicare (HMO) -
    Plan # H9630-001, 

  • Allwell Medicare (HMO) -
    Plan # H9630-002, or 

  • Allwell Medicare Select (HMO) -
    Plan # H9630-003.

Allwell members in Benton, Carroll, Clark, Conway, Craighead, Crawford, Faulkner, Franklin, Garland, Greene, Hot Spring, Logan, Lonoke, Madison, Pope, Pulaski, Saline, Scott, Sebastian and Washington counties have an over-the-counter (OTC) benefit through OTC Health Solutions.

You can buy OTC health and wellness products to be mailed to your home. Check the catalog for item limits.

Ordering is easy. Just follow the steps in your plan's catalog.

Members in Baxter, Boone and Marion Counties enrolled in:

  • Allwell Medicare (HMO) -
    Plan # H9630-004, or 

  • Allwell Medicare Premier (HMO) -
    Plan # H9630-005.

Allwell members in Baxter, Boone and Marion 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 Enhanced (HMO) Benton, Carroll, Crawford, Franklin, Logan, Madison, Scott, Sebastian and Washington 
Allwell Medicare Preventive  (HMO) Benton, Carroll, Crawford, Franklin, Logan, Madison, Scott, Sebastian and Washington 
Allwell Medicare (HMO) Clark, Conway, Craighead, Faulkner, Garland, Greene, Hot Spring, Lonoke, Pope, Pulaski and Saline 
Allwell Medicare Select (HMO) Benton and Washington
Allwell Medicare (HMO) Baxter, Boone and Marion
Allwell Medicare Premier (HMO) Baxter, Boone and Marion
  • PHI Authorization Form (PDF)
    • Use this form when you want to allow Allwell to share your health information with a person or group.
       
  • PHI Revocation Form (PDF)
    • Use this form when you want Allwell to cancel or revoke your previous permission to share health information with a person or group.

Important choices can be simple choices. So let us help!

Take a look at the below Beginner's Guide to Medicare booklet.  Our Medicare guide will give you a solid foundation for understanding the basics of Medicare and available options you have as a new Medicare beneficiary.

If you have any questions or need assistance, call us.  We are here to help!

 

 

This is an introduction to the provider and pharmacy directory, including an explanation of the provider symbols found in the directory.

Visit our Find a Doctor or Pharmacy page to learn more. 

  • Best Available Evidence (BAE)
    • This is a CMS policy that allows for changes to cost-sharing for low-income beneficiaries when there is evidence that information from a beneficiary is not up-to-date or accurate.

medicare phone number

 

Can't find what you need? Contact Member Services. We are here to help!