Plan Benefit Materials |

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Plan Materials and Forms

 

Learn about your plan and all that it has to offer by reviewing helpful plan documents such as the Annual Notice of Change (ANOC), Summary of Benefits, and Evidence of Coverage.

To get started, locate your plan in the list of plans below and select “Plan Benefits.” 

HMO 

Wellcare Simple (HMO) H3499-002

Counties: Adams, Allen, Bartholomew, Benton, Blackford, Boone, Brown, Carroll, Cass, Clark, Clay, Clinton, Crawford, Daviess, DeKalb, Dearborn, Decatur, Delaware, Dubois, Elkhart, Fayette, Floyd, Fountain, Franklin, Fulton, Gibson, Grant, Greene, Hamilton, Hancock, Harrison, Hendricks, Henry, Howard, Huntington, Jackson, Jasper, Jay, Jefferson, Jennings, Johnson, Knox, Kosciusko, La Porte, Lagrange, Lake, Lawrence, Madison, Marion, Marshall, Martin, Miami, Monroe, Montgomery, Morgan, Newton, Noble, Ohio, Orange, Owen, Parke, Perry, Pike, Porter, Posey, Pulaski, Putnam, Randolph, Ripley, Rush, Scott, Shelby, Spencer, St. Joseph, Starke, Steuben, Sullivan, Switzerland, Tippecanoe, Tipton, Union, Vanderburgh, Wabash, Warren, Warrick, Washington, Wayne, Wells, White, Whitley

Annual Notice of Changes

  • Annual Notice of Change – English (PDF) - coming soon

Summary of Benefits

  • Summary of Benefits – English (PDF) - coming soon

Evidence of Coverage

  • Evidence of Coverage – English (PDF) - coming soon
  • Dental Benefit Details – English (PDF) - coming soon

Wellcare Assist (HMO) H3499-008

Counties: Adams, Allen, Bartholomew, Benton, Blackford, Boone, Brown, Carroll, Cass, Clark, Clay, Clinton, Crawford, Daviess, DeKalb, Dearborn, Decatur, Delaware, Dubois, Elkhart, Fayette, Floyd, Fountain, Franklin, Fulton, Gibson, Grant, Greene, Hamilton, Hancock, Harrison, Hendricks, Henry, Howard, Huntington, Jackson, Jasper, Jay, Jefferson, Jennings, Johnson, Knox, Kosciusko, La Porte, Lagrange, Lake, Lawrence, Madison, Marion, Marshall, Martin, Miami, Monroe, Montgomery, Morgan, Newton, Noble, Ohio, Orange, Owen, Parke, Perry, Pike, Porter, Posey, Pulaski, Putnam, Randolph, Ripley, Rush, Scott, Shelby, Spencer, St. Joseph, Starke, Steuben, Sullivan, Switzerland, Tippecanoe, Tipton, Union, Vanderburgh, Wabash, Warren, Warrick, Washington, Wayne, Wells, White, Whitley

Annual Notice of Changes

  • Annual Notice of Change – English (PDF) - coming soon

Summary of Benefits

  • Summary of Benefits – English (PDF) - coming soon

Evidence of Coverage

  • Evidence of Coverage – English (PDF) - coming soon
  • Dental Benefit Details – English (PDF) - coming soon

PPO 

Wellcare Simple Open (PPO) H6348-002

Counties: Adams, Allen, Bartholomew, Benton, Blackford, Boone, Brown, Carroll, Cass, Clark, Clay, Clinton, Crawford, Daviess, DeKalb, Dearborn, Decatur, Delaware, Dubois, Elkhart, Fayette, Floyd, Fountain, Franklin, Fulton, Gibson, Grant, Greene, Hamilton, Hancock, Harrison, Hendricks, Henry, Howard, Huntington, Jackson, Jasper, Jay, Jefferson, Jennings, Johnson, Knox, Kosciusko, La Porte, Lagrange, Lake, Lawrence, Madison, Marion, Marshall, Martin, Miami, Monroe, Montgomery, Morgan, Newton, Noble, Ohio, Orange, Owen, Parke, Perry, Pike, Porter, Posey, Pulaski, Putnam, Randolph, Ripley, Rush, Scott, Shelby, Spencer, St. Joseph, Starke, Steuben, Sullivan, Switzerland, Tippecanoe, Tipton, Union, Vanderburgh, Wabash, Warren, Warrick, Washington, Wayne, Wells, White, Whitley

Annual Notice of Changes

  • Annual Notice of Change – English (PDF) - coming soon
  • Annual Notice of Change: Wellcare Low Premium Open (PPO) to Wellcare Simple Open (PPO) - English (PDF) - coming soon

Summary of Benefits

  • Summary of Benefits – English (PDF) - coming soon

Evidence of Coverage

  • Evidence of Coverage – English (PDF) - coming soon
  • Dental Benefit Details – English (PDF) - coming soon

Wellcare Patriot Giveback Open (PPO) H6348-005

Counties: Adams, Allen, Bartholomew, Benton, Blackford, Boone, Brown, Carroll, Cass, Clark, Clay, Clinton, Crawford, Daviess, DeKalb, Dearborn, Decatur, Delaware, Dubois, Elkhart, Fayette, Floyd, Fountain, Franklin, Fulton, Gibson, Grant, Greene, Hamilton, Hancock, Harrison, Hendricks, Henry, Howard, Huntington, Jackson, Jasper, Jay, Jefferson, Jennings, Johnson, Knox, Kosciusko, La Porte, Lagrange, Lake, Lawrence, Madison, Marion, Marshall, Martin, Miami, Monroe, Montgomery, Morgan, Newton, Noble, Ohio, Orange, Owen, Parke, Perry, Pike, Porter, Posey, Pulaski, Putnam, Randolph, Ripley, Rush, Scott, Shelby, Spencer, St. Joseph, Starke, Steuben, Sullivan, Switzerland, Tippecanoe, Tipton, Union, Vanderburgh, Wabash, Warren, Warrick, Washington, Wayne, Wells, White, Whitley

Annual Notice of Changes

  • Annual Notice of Change – English (PDF) - coming soon

Summary of Benefits

  • Summary of Benefits – English (PDF) - coming soon

Evidence of Coverage

  • Evidence of Coverage – English (PDF) - coming soon
  • Dental Benefit Details – English (PDF) - coming soon

Wellcare Giveback Open (PPO) H6348-008

Counties: Adams, Allen, Bartholomew, Benton, Blackford, Boone, Brown, Carroll, Cass, Clark, Clay, Clinton, Crawford, Daviess, DeKalb, Dearborn, Decatur, Delaware, Dubois, Elkhart, Fayette, Floyd, Fountain, Franklin, Fulton, Gibson, Grant, Greene, Hamilton, Hancock, Harrison, Hendricks, Henry, Howard, Huntington, Jackson, Jasper, Jay, Jefferson, Jennings, Johnson, Knox, Kosciusko, La Porte, Lagrange, Lake, Lawrence, Madison, Marion, Marshall, Martin, Miami, Monroe, Montgomery, Morgan, Newton, Noble, Ohio, Orange, Owen, Parke, Perry, Pike, Porter, Posey, Pulaski, Putnam, Randolph, Ripley, Rush, Scott, Shelby, Spencer, St. Joseph, Starke, Steuben, Sullivan, Switzerland, Tippecanoe, Tipton, Union, Vanderburgh, Wabash, Warren, Warrick, Washington, Wayne, Wells, White, Whitley

Summary of Benefits

  • Summary of Benefits – English (PDF) - coming soon

Evidence of Coverage

  • Evidence of Coverage – English (PDF) - coming soon
  • Dental Benefit Details – English (PDF) - coming soon

Wellcare Assist Open (PPO) H6348-009

Counties: Adams, Allen, Bartholomew, Benton, Blackford, Boone, Brown, Carroll, Cass, Clark, Clay, Clinton, Crawford, Daviess, DeKalb, Dearborn, Decatur, Delaware, Dubois, Elkhart, Fayette, Floyd, Fountain, Franklin, Fulton, Gibson, Grant, Greene, Hamilton, Hancock, Harrison, Hendricks, Henry, Howard, Huntington, Jackson, Jasper, Jay, Jefferson, Jennings, Johnson, Knox, Kosciusko, La Porte, Lagrange, Lake, Lawrence, Madison, Marion, Marshall, Martin, Miami, Monroe, Montgomery, Morgan, Newton, Noble, Ohio, Orange, Owen, Parke, Perry, Pike, Porter, Posey, Pulaski, Putnam, Randolph, Ripley, Rush, Scott, Shelby, Spencer, St. Joseph, Starke, Steuben, Sullivan, Switzerland, Tippecanoe, Tipton, Union, Vanderburgh, Wabash, Warren, Warrick, Washington, Wayne, Wells, White, Whitley

Summary of Benefits

  • Summary of Benefits – English (PDF) - coming soon

Evidence of Coverage

  • Evidence of Coverage – English (PDF) - coming soon
  • Dental Benefit Details – English (PDF) - coming soon

Wellcare Premium Enhanced Open (PPO) H6348-010

Counties: Adams, Allen, Bartholomew, Benton, Blackford, Boone, Brown, Carroll, Cass, Clark, Clay, Clinton, Crawford, Daviess, DeKalb, Dearborn, Decatur, Delaware, Dubois, Elkhart, Fayette, Floyd, Fountain, Franklin, Fulton, Gibson, Grant, Greene, Hamilton, Hancock, Harrison, Hendricks, Henry, Howard, Huntington, Jackson, Jasper, Jay, Jefferson, Jennings, Johnson, Knox, Kosciusko, La Porte, Lagrange, Lake, Lawrence, Madison, Marion, Marshall, Martin, Miami, Monroe, Montgomery, Morgan, Newton, Noble, Ohio, Orange, Owen, Parke, Perry, Pike, Porter, Posey, Pulaski, Putnam, Randolph, Ripley, Rush, Scott, Shelby, Spencer, St. Joseph, Starke, Steuben, Sullivan, Switzerland, Tippecanoe, Tipton, Union, Vanderburgh, Wabash, Warren, Warrick, Washington, Wayne, Wells, White, Whitley

Summary of Benefits

  • Summary of Benefits – English (PDF) - coming soon

Evidence of Coverage

  • Evidence of Coverage – English (PDF) - coming soon
  • Dental Benefit Details – English (PDF) - coming soon

Additional Forms

  • Medicare Step Therapy Part B (PDF) - coming soon

  • Covered Diabetes Testing Supplies - coming soon

  • Over-the-Counter Catalog (PDF) - coming soon

  • 2025 Original Medicare Defined Cost Share Amounts and Premiums (PDF) - coming soon