Skip to Main Content

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

Allwell Medicare (HMO) H9630-002

Clark, Conway, Craighead, Faulkner, Garland, Greene, Hot Spring, Lonoke, Pope, Pulaski and Saline

Allwell Medicare Select  (HMO) H9630-003

Benton and Washington

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, 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

Allwell Medicare (HMO) H9630-002

Clark, Conway, Craighead, Faulkner, Garland, Greene, Hot Spring, Lonoke, Pope, Pulaski and Saline

Allwell Medicare Select (HMO) H9630-003

Benton and Washington

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, 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
Allwell Medicare (HMO) H9630-002 Clark, Conway, Craighead, Faulkner, Garland, Greene, Hot Spring, Lonoke, Pope, Pulaski and Saline
Allwell Medicare Select (HMO) H9630-003 Benton and Washington
Allwell Medicare (HMO) H9630-004 Baxter, Boone, Marion
Allwell Medicare Premier (HMO) H9630-005 Baxter, Boone, Marion

Please select the document for your plan and county:

For HMO Members:

Plan Name  CMS# County Low Income Subsidy
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
Allwell Medicare (HMO) H9630-002 Clark, Conway, Craighead, Faulkner, Garland, Greene, Hot Spring, Lonoke, Pope, Pulaski and Saline
Allwell Medicare Premier (HMO) H9630-003 Benton and Washington
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 is the complete list of prescription drugs covered by Allwell.

Please select the document for your plan :

Updated 10/09/19:

 

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.

Please select the document for your plan and county:

For HMO Members:

Plan Name CMS# County Extra Benefits Brochure 
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

Allwell Medicare (HMO) H9630-002

Clark, Conway, Craighead, Faulkner, Garland, Greene, Hot Spring, Lonoke, Pope, Pulaski and Saline

Allwell Medicare Select (HMO) H9630-003

Benton and Washington

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

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, 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
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
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.
  • 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!

 

 

  • 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.

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. 

Procedure Code

Procedure Description

C9050

EMAPALUMAB-LZSG

J0129

ABATACEPT INJECTION

J0178

AFLIBERCEPT INJECTION

J0584

BUROSUMAB-TWZA 1M

J0585

ONABOTULINUMTOXINA

J0604

CINACALCET, ESRD ON DIALYSIS

J0717

CERTOLIZUMAB PEGOL INJ 1MG

J0800

CORTICOTROPIN INJECTION

J0897

DENOSUMAB INJECTION

J1300

ECULIZUMAB INJECTION

J1428

ETEPLIRSEN, 10 MG

J1459

IVIG PRIVIGEN 500 MG

J1555

CUVITRU, 100 MG

J1556

IMM GLOB BIVIGAM, 500MG

J1557

GAMMAPLEX INJECTION

J1559

HIZENTRA INJECTION

J1561

GAMUNEX-C/GAMMAKED

J1566

IMMUNE GLOBULIN, POWDER

J1568

OCTAGAM INJECTION

J1569

GAMMAGARD LIQUID INJECTION

J1572

FLEBOGAMMA INJECTION

J1575

HYQVIA 100MG IMMUNEGLOBULIN

J1599

IVIG NON-LYOPHILIZED, NOS

J1602

GOLIMUMAB FOR IV USE 1MG

J1745

INFLIXIMAB (REMICADE)

J1930

LANREOTIDE INJECTION

J2323

NATALIZUMAB INJECTION

J2350

OCRELIZUMAB, 1 MG

J2353

OCTREOTIDE INJECTION, DEPOT

J2357

OMALIZUMAB INJECTION

J2503

PEGAPTANIB SODIUM INJECTION

J2778

RANIBIZUMAB INJECTION

J3262

TOCILIZUMAB, 1 MG

J3304

TRIAMCINOLONE ACE XR 1MG

J3357

USTEKINUMAB SUB CU 1 MG

J3380

VEDOLIZUMAB

J3396

VERTEPORFIN INJECTION

J7189

FACTOR VIIA

J7318

DUROLANE 1 MG

J7320

GENVISC 850, 1MG

J7321

HYALGAN SUPARTZ VISCO-3 DOSE

J7322

HYMOVIS INJECTION 1 MG

J7323

EUFLEXXA INJ PER DOSE

J7324

ORTHOVISC INJ PER DOSE

J7325

SYNVISC OR SYNVISC-ONE

J7326

GEL-ONE

J7327

MONOVISC INJ PER DOSE

J7328

GELSYN-3 INJECTION 0.1 MG

J7329

TRIVISC 1 MG

J9022

ATEZOLIZUMAB,10 MG

J9145

INJECTION DARATUMUMAB 10 MG

J9173

DURVALUMAB, 10 MG

J9176

ELOTUZUMAB, 1MG

J9308

RAMUCIRUMAB

J9311

RITUXIMAB, HYALURONIDASE

J9355

TRASTUZUMAB INJECTION

Q2043

SIPULEUCEL-T AUTO CD54+

Q5103

INFLIXIMAB (INFLECTRA)

Q5104

INFLIXIMAB (RENFLEXIS)

medicare phone number

 

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