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- Shop for Plans show Shop for Plans menu
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Pharmacy Benefits
show Pharmacy Benefits menu
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- Find a Doctor or Pharmacy
- List of Drugs (Formulary)
- Medication Therapy Management (MTMP)
- Mail Order Service
- Specialty Pharmacy
- Coverage Determinations and Redeterminations
- Prior Authorization, Step Therapy & Quantity Limitations
- Out-of-Network Pharmacies
- Medication (Drug) Management and Safety
- Drug Transition Policy
- Pharmacy Forms
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Plan Benefit Materials | Health Net Medicare Advantage for California
Plan Benefit Materials
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
Additional Forms
Plan Benefit Materials
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 Premium Ultra (HMO) H0562-009 (ME0)
Counties: Amador, Placer, Sacramento, San Francisco, Stanislaus
Annual Notice of Changes
Summary of Benefits
Evidence of Coverage
Wellcare Simple Focus (HMO) H0562-012 (ME1)
Counties: Imperial, San Diego
Annual Notice of Changes
Summary of Benefits
Evidence of Coverage
Wellcare Premium Ultra (HMO) H0562-039 (ME2)
Counties: Yolo
Annual Notice of Changes
Summary of Benefits
Evidence of Coverage
Wellcare Simple Ruby (HMO) H0562-079 (ME3)
Counties: Fresno, Kern, Madera, Stanislaus, Tulare
Annual Notice of Changes
Summary of Benefits
Evidence of Coverage
Wellcare Simple Focus (HMO) H0562-097 (ME5)
Counties: San Francisco
Annual Notice of Changes
Summary of Benefits
Evidence of Coverage
Wellcare Simple Focus (HMO) H0562-125 (ME6)
Counties: Los Angeles, Orange
Annual Notice of Changes
Summary of Benefits
Evidence of Coverage
Wellcare Simple Focus (HMO) H0562-126 (ME7)
Counties: Riverside, San Bernardino
Annual Notice of Changes
Summary of Benefits
Evidence of Coverage
Wellcare Low Premium (HMO) H0562-133 (MEF)
Counties: Amador, San Mateo, Santa Clara, Solano, Yolo
Wellcare Low Premium (HMO) H0562-136 (MEG)
Counties: Los Angeles, Orange
Annual Notice of Changes
Summary of Benefits
Evidence of Coverage
Wellcare Low Premium (HMO) H0562-137 (MEH)
Counties: Imperial, Riverside, San Bernardino, San Diego
Annual Notice of Changes
Summary of Benefits
Evidence of Coverage
HMO C-SNP
Wellcare Specialty Simple (HMO C-SNP) H0562-092 (ME4)
Counties: Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego
Annual Notice of Changes
Summary of Benefits
Evidence of Coverage
HMO D-SNP
Wellcare Dual Liberty (HMO D-SNP) H3561-001 (ME8)
Counties: Amador, Calaveras, Imperial, Kern, Placer, San Francisco, San Joaquin, Stanislaus, Tuolumne
Annual Notice of Changes
Summary of Benefits
Evidence of Coverage
- Evidence of Coverage – English (PDF)
- Evidence of Coverage – Spanish (PDF)
- Dental Benefit Details – English (PDF)
- Dental Benefit Details - Armenian (PDF)
- Dental Benefit Details - Arabic (PDF)
- Dental Benefit Details - Cambodian (PDF)
- Dental Benefit Details - Chinese (PDF)
- Dental Benefit Details - Farsi (PDF)
- Dental Benefit Details - Hmong (PDF)
- Dental Benefit Details - Korean (PDF)
- Dental Benefit Details - Russian (PDF)
- Dental Benefit Details - Spanish (PDF)
- Dental Benefit Details - Tagalog (PDF)
- Dental Benefit Details - Vietnamese (PDF)
Wellcare CalViva Health Dual Align (HMO D-SNP) H3561-007 (ME9)
Counties: Fresno, Kings, Madera
Annual Notice of Changes
- ·Annual Notice of Change – English (PDF)
- Annual Notice of Change – Spanish (PDF)
- Annual Notice of Change – Hmong (PDF)
Summary of Benefits
- Summary of Benefits – English (PDF)
- Summary of Benefits – Spanish (PDF)
- Summary of Benefits – Hmong (PDF)
Evidence of Coverage
Wellcare Dual Align (HMO D-SNP) H3561-008 (MEB)
Counties: Los Angeles, Sacramento, Tulare
Annual Notice of Changes
- Annual Notice of Change – English (PDF)
- Annual Notice of Change – Spanish (PDF)
- Annual Notice of Change – Armenian (PDF)
- Annual Notice of Change – Arabic (PDF)
- Annual Notice of Change – Cambodian (PDF)
- Annual Notice of Change – Chinese (PDF)
- Annual Notice of Change – Farsi (PDF)
- Annual Notice of Change - Hmong (PDF)
- Annual Notice of Change – Korean (PDF)
- Annual Notice of Change – Russian (PDF)
- Annual Notice of Change – Tagalog (PDF)
- Annual Notice of Change – Vietnamese (PDF)
Summary of Benefits
- Summary of Benefits – English (PDF)
- Summary of Benefits – Spanish (PDF)
- Summary of Benefits – Armenian (PDF)
- Summary of Benefits – Arabic (PDF)
- Summary of Benefits – Cambodian (PDF)
- Summary of Benefits – Chinese (PDF)
- Summary of Benefits – Farsi (PDF)
- Summary of Benefits - Hmong (PDF)
- Summary of Benefits – Korean (PDF)
- Summary of Benefits – Russian (PDF)
- Summary of Benefits – Tagalog (PDF)
- Summary of Benefits – Vietnamese (PDF)
Evidence of Coverage
- Evidence of Coverage – English (PDF)
- Evidence of Coverage – Spanish (PDF)
- Evidence of Coverage – Armenian (PDF)
- Evidence of Coverage – Arabic (PDF)
- Evidence of Coverage – Cambodian (PDF)
- Evidence of Coverage – Chinese (PDF)
- Evidence of Coverage – Farsi (PDF)
- Evidence of Coverage - Hmong (PDF)
- Evidence of Coverage – Korean (PDF)
- Evidence of Coverage – Russian (PDF)
- Evidence of Coverage – Tagalog (PDF)
- Evidence of Coverage – Vietnamese (PDF)
- Dental Benefit Details – English (PDF)
- Dental Benefit Details - Armenian (PDF)
- Dental Benefit Details - Arabic (PDF)
- Dental Benefit Details - Cambodian (PDF)
- Dental Benefit Details - Chinese (PDF)
- Dental Benefit Details - Farsi (PDF)
- Dental Benefit Details - Hmong (PDF)
- Dental Benefit Details - Korean (PDF)
- Dental Benefit Details - Russian (PDF)
- Dental Benefit Details - Spanish (PDF)
- Dental Benefit Details - Tagalog (PDF)
- Dental Benefit Details - Vietnamese (PDF)
Wellcare Dual Liberty (HMO D-SNP) H3561-009 (MEC)
Counties: Orange, Riverside, San Bernardino, San Diego
Annual Notice of Changes
Summary of Benefits
Evidence of Coverage
- Dental Benefit Details – English (PDF)
- Dental Benefit Details - Armenian (PDF)
- Dental Benefit Details - Arabic (PDF)
- Dental Benefit Details - Cambodian (PDF)
- Dental Benefit Details - Chinese (PDF)
- Dental Benefit Details - Farsi (PDF)
- Dental Benefit Details - Hmong (PDF)
- Dental Benefit Details - Korean (PDF)
- Dental Benefit Details - Russian (PDF)
- Dental Benefit Details - Spanish (PDF)
- Dental Benefit Details - Tagalog (PDF)
- Dental Benefit Details - Vietnamese (PDF)
Additional Forms
- Over-the-Counter Catalog - English (PDF)
- Over-the-Counter Catalog - Spanish (PDF)
- Over-the-Counter Catalog - Chinese (PDF)
- Over-the-Counter Catalog and Healthy Food Calviva - English (PDF)
- Over-the-Counter Catalog and Healthy Food Calviva - Hmong (PDF)
- Over-the-Counter Catalog and Healthy Food Calviva - Spanish (PDF)
- Over-the-Counter Catalog and Healthy Food - English (PDF)
- Over-the-Counter Catalog and Healthy Food - Arabic (PDF)
- Over-the-Counter Catalog and Healthy Food - Armenian (PDF)
- Over-the-Counter Catalog and Healthy Food - Cambodian (PDF)
- Over-the-Counter Catalog and Healthy Food - Chinese (PDF)
- Over-the-Counter Catalog and Healthy Food - Farsi (PDF)
- Over-the-Counter Catalog and Healthy Food - Hmong (PDF)
- Over-the-Counter Catalog and Healthy Food - Korean (PDF)
- Over-the-Counter Catalog and Healthy Food - Russian (PDF)
- Over-the-Counter Catalog and Healthy Food - Tagalog (PDF)
- Over-the-Counter Catalog and Healthy Food - Vietnamese (PDF)
- Over-the-Counter Catalog and Healthy Food - Spanish (PDF)
If you have questions please, contact Member Services.
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