Plan Benefit Materials | Health Net Medicare Advantage for California

Plan Materials and Forms

 

Information about plan benefits, services, and drug costs can be found in your plan materials.

You can also look for plan materials based on the plan name and the county you live in.

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 CMS# County Summary of Benefits

Wellcare Premium Ultra (HMO)

(KOR)

H0562 -009
  • Amador, Placer, Sacramento, San Francisco, Stanislaus

Wellcare No Premium Focus (HMO)

(KOS)

H0562 - 012
  • Imperial, San Diego

Wellcare Premium Ultra (HMO)

(KOT)

H0562 - 039
  • Yolo

Wellcare No Premium Ruby (HMO)

(KOU)

H0562 - 079
  • Fresno, Kern, Madera, Stanislaus, Tulare

Wellcare No Premium Focus (HMO)

(KOX)

H0562 - 097
  • San Francisco

Wellcare No Premium (HMO)

(KP8)

H0562 - 128
  • Amador, San Mateo, Santa Clara, Solano, Yolo

Wellcare Low Premium (HMO)

(KP4)

H0562 - 130 - 001

 

  • Los Angeles and Orange

Wellcare Low Premium (HMO)

(KP5)

H0562 - 130 - 002
  • Imperial, Riverside, San Bernardino, San Diego

Wellcare No Premium Focus (HMO)

(KP6)

H0562-125
  • Los Angeles, Orange

Wellcare No Premium Focus (HMO)

(KP7)

H0562-126
  • Riverside, San Bernardino

For HMO DSNP, C SNP and Members:

Plans CMS# County Summary of Benefits

Wellcare Dual Liberty (HMO D-SNP)

(KPC)

H3561 - 001
  • Amador, Imperial, Kern, Placer, San Francisco, San Joaquin, Stanislaus

Wellcare CalViva Health Dual Align (HMO D-SNP)

(KPD)

H3561 - 007
  • Fresno, Kings, Madera

Wellcare Dual Align (HMO D-SNP)

(KPE)

H3561 - 008
  • Los Angeles, Sacramento, Tulare

Wellcare Dual Liberty (HMO D-SNP)

(KP3)

H3561 - 009
  • Orange, Riverside, San Bernardino, San Diego

Wellcare Specialty No Premium (HMO C-SNP)

(KOW)

H0562 - 092
  • Kern, Los Angeles, Orange, San Diego
Wellcare No Premium Open (PPO) H7360 - 001
  • Amador, Sutter

 

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 CMS# County Evidence of Coverage
Wellcare Premium Ultra (HMO) H0562 -009
  • Amador, Placer, Sacramento, San Francisco, Stanislaus
Wellcare No Premium Focus (HMO) H0562 - 012
  • Imperial, San Diego
Wellcare Premium Ultra (HMO) H0562 - 039
  • Yolo
Wellcare No Premium Ruby (HMO) H0562 - 079
  • Fresno, Kern, Madera, Stanislaus, Tulare
Wellcare No Premium Focus (HMO) H0562 - 097
  • San Francisco
Wellcare No Premium (HMO) H0562 - 128
  • Amador, San Mateo, Santa Clara, Solano, Yolo
Wellcare Low Premium (HMO) H0562 - 130 - 001
  • Los Angeles and Orange
Wellcare Low Premium (HMO) H0562 - 130 - 002
  • Imperial, Riverside, San Bernardino, San Diego
Wellcare No Premium Focus (HMO) H0562 - 125
  • Los Angeles, Orange
Wellcare No Premium Focus (HMO) H0562 - 126
  • Riverside, San Bernardino

 

For HMO DSNP, C SNP and PPO Members

Plans CMS#    County  Evidence of Coverage
Wellcare Dual Liberty (HMO D-SNP) H3561 - 001
  • Amador, Imperial, Kern, Placer, San Francisco, San Joaquin, Stanislaus
Wellcare CalViva Health Dual Align (HMO D-SNP) H3561 - 007
  • Fresno, Kings, Madera
 
Wellcare Dual Align (HMO D-SNP) H3561 - 008
  • Los Angeles, Sacramento, Tulare

 

Wellcare Dual Liberty (HMO D-SNP) H3561 - 009
  • Orange, Riverside, San Bernardino, San Diego
Wellcare Specialty No Premium (HMO C-SNP) H0562 - 092
  • Kern, Los Angeles, Orange, San Diego
Wellcare No Premium Open (PPO) H7360 - 001
  • Amador, Sutter

 

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 CMS# County Annual Notice of Changes  (ANOC)

Wellcare No Premium Ruby (HMO)
H0562 - 079
  • Fresno, Kern, Madera, Stanislaus, Tulare
Wellcare No Premium Focus (HMO) H0562 - 097
  • San Francisco
 
Wellcare No Premium (HMO) H0562 - 128
  • Amador, San Mateo, Santa Clara, Solano, Yolo
Wellcare No Premium Focus (HMO) H0562 - 125
  • Los Angeles, Orange
Wellcare Low Premium (HMO)  H0562-123 to H0562-130-001
  • Los Angeles, Orange
Wellcare Low Premium (HMO)  H0562-123 to H0562-130-002
  • Imperial, Riverside, San Bernardino, San Diego
Wellcare Premium Ultra (HMO) H0562 -009
  • Amador, Placer, Sacramento, San Francisco, Stanislaus
Wellcare Premium Ultra (HMO) H0562 -084 to H0562 -009
  • Amador, Placer, Sacramento, San Francisco, Stanislaus
Wellcare Premium Ultra (HMO) H0562 - 039
  • Yolo
Wellcare No Premium (HMO) H0562 - 103 to H0562- 128
  • Amador, San Mateo, Santa Clara, Solano, Yolo
Wellcare No Premium Focus (HMO) H0562 - 012
  • Imperial, San Diego
Wellcare No Premium Focus (HMO) H0562 - 126
  • Riverside, San Bernardino

For HMO C-SNP

Plans CMS# County Annual Notice of Changes (ANOC)
Wellcare Specialty No Premium (HMO C-SNP) H0562 - 092
  • Kern, Los Angeles, Orange, San Diego
Wellcare Specialty No Premium (HMO C-SNP) H0562-114 to H0562-092
  • Kern, Los Angeles, Orange, San Diego

 

For HMO DSNP

 
  CMS# County Annual Notice of Changes (ANOC)
Wellcare Dual Liberty (HMO D-SNP) to Wellcare Dual Liberty (HMO D-SNP) ) DSNP H0562-121 to H3561-001
  • Amador, Imperial, Kern, Placer, San Francisco, San Joaquin, Stanislaus
Wellcare Dual Liberty (HMO D-SNP) to Wellcare CalViva Health Dual Align (HMO D-SNP) H0562 - 121 to H3561 - 007
  • Fresno, Kings, Madera
Wellcare Dual Liberty Amber (HMO D-SNP) to Wellcare CalViva Health Dual Align (HMO D-SNP) H3561 - 001 to H3561 - 007
  • Fresno, Kings, Madera
Wellcare Dual Liberty (HMO D-SNP) to Wellcare Dual Align (HMO D-SNP)  H0562 - 121 to H3561 - 008
  • Los Angeles, Sacramento, Tulare

 

 

Wellcare Dual Liberty (HMO D-SNP) H3561 - 001
  • Amador, Imperial, Kern, Placer, San Francisco, San Joaquin, Stanislaus

 

 

 

Wellcare Dual Align 129 (HMO D-SNP) to Wellcare Dual Align (HMO D-SNP) H0562-129 to H3561-008
  • Los Angeles, Sacramento, Tulare
Wellcare Dual Liberty Amber (HMO D-SNP) to Wellcare Dual Align (HMO D-SNP) H3561-001 to H3561-008
  • Los Angeles, Sacramento, Tulare
Wellcare Dual Liberty (HMO D-SNP) to Wellcare Dual Liberty (HMO D-SNP) H0562-121 to H3561-009 
  • Orange, Riverside, San Bernardino, San Diego
Wellcare Dual Align 129 (HMO D-SNP) to Wellcare Dual Liberty (HMO D-SNP) H0562-129 to H3561-009
  • Orange, Riverside, San Bernardino, San Diego
 
Wellcare Dual Liberty (HMO D-SNP) to Wellcare Dual Liberty (HMO D-SNP) H5087-027 to H3561-001
  • Amador, Imperial, Kern, Placer, San Francisco, San Joaquin, Stanislaus

 

 

Wellcare Dual Align 001 (HMO D-SNP) to Wellcare Dual Align (HMO D-SNP) H5087-001 to H3561-008
  • Los Angeles, Sacramento, Tulare

For PPO

Plans CMS# County Annual Notice of Changes (ANOC)
Wellcare No Premium Open (PPO) H7360 - 001
  • Amador, Sutter