Medicare Reference Documents

Listed below are some documents that may be helpful at different times during your membership.  

Can't find what you need?  Call Member Services.  We are 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
Allwell Medicare (HMO) H9630-001

Benton, Crawford, Sebastian, and Washington counties

Allwell Medicare (HMO) H9630-002

Garland, Pulaski, and Saline counties

Allwell Medicare Select (HMO) H9630-003

Benton and Washington counties



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, Crawford, Sebastian, and Washington counties

Allwell Medicare (HMO) H9630-002

Garland, Pulaski, and Saline counties

Allwell Medicare Select (HMO) H9630-003

Benton and Washington counties


HMO Reconsideration Form 

HMO SNP Redetermination Form 

HMO SNP Redetermination Form 

HMO Reconsideration Form 

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 ANOC
Allwell Medicare (HMO) H9630-001 Benton, Crawford, Sebastian, and Washington counties
  • Not Available
Allwell Medicare (HMO) H9630-002 Garland, Pulaski, and Saline counties
  • Not Available
Allwell Medicare Select (HMO) H9630-003 Benton and Washington counties
  • Not Available

 

  • Not Avail
H9630-
H9630-

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

Please select the document for your plan :

[2018_COUNTIES_SNP_001]

Your current plan may have an over-the-counter benefit that allows you to purchase over-the-counter (OTC) health and wellness products. This form includes a list of over-the-counter items that you can order to be directly mailed to your home.

Ordering is easy! Just follow the steps listed on your plan's form.

Please select the document for your plan and county:

For HMO Members:

Plan Name CMS# County OTC Benefits Brochure
Allwell Medicare (HMO) H9630-001

Benton, Crawford, Sebastian, and Washington counties

Allwell Medicare (HMO) H9630-002

Garland, Pulaski, and Saline counties

Allwell Medicare Select (HMO) H9630-003

Benton and Washington counties


OTC Benefits Brochure

Use one of the forms below to enroll and receive prescription drugs by mail.

Please select the form for the mail order pharmacy you would like to start using. 

Print and fill out the prescription claim form for your plan.

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. 

  • Disenrollment Form
    • We don't want you to see you go. Let us improve your experience with our plan. Please call Member Services. We are here to help. If you are still dissatisfied, please fill out and mail the disenrollment form.
  • 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.

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!

Beginner's Guide to Medicare Booklet