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	Summary of Benefits, H0562 - 009 - English (PDF) Summary of Benefits, H0562 - 009 - Spanish (PDF)
Wellcare No Premium Focus (HMO) (KOS)	H0562 - 012	Imperial, San Diego	Summary of Benefits, H0562 - 012 - English (PDF) Summary of Benefits, H0562 - 012 - Spanish (PDF)
Wellcare Premium Ultra (HMO) (KOT)	H0562 - 039	Yolo	Summary of Benefits, H0562 - 039 - English (PDF) Summary of Benefits, H0562 - 039 - Spanish (PDF)
Wellcare No Premium Ruby (HMO) (KOU)	H0562 - 079	Fresno, Kern, Madera, Stanislaus, Tulare	Summary of Benefits, H0562 - 079 - English (PDF) Summary of Benefits, H0562 - 079 - Spanish (PDF)
Wellcare No Premium Focus (HMO) (KOX)	H0562 - 097	San Francisco	Summary of Benefits, H0562 - 097 - English (PDF) Summary of Benefits, H0562-097 - Chinese (PDF)
Wellcare No Premium (HMO) (KP8)	H0562 - 128	Amador, San Mateo, Santa Clara, Solano, Yolo	Summary of Benefits, H0562 - 128 - English (PDF) Summary of Benefits, H0562 - 128 - Spanish (PDF)
Wellcare Low Premium (HMO) (KP4)	H0562 - 130 - 001	Los Angeles and Orange	Summary of Benefits, H0562 - 130 - 001 - English (PDF) Summary of Benefits, H0562 - 130 - 001 - Spanish (PDF)
Wellcare Low Premium (HMO) (KP5)	H0562 - 130 - 002	Imperial, Riverside, San Bernardino, San Diego	Summary of Benefits, H0562 - 130 - 002 - English (PDF) Summary of Benefits, H0562 - 130- 002 - Spanish (PDF)
Wellcare No Premium Focus (HMO) (KP6)	H0562-125	Los Angeles, Orange	Summary of Benefits, H0562 - 125 - English (PDF) Summary of Benefits, H0562 - 125 - Spanish (PDF)
Wellcare No Premium Focus (HMO) (KP7)	H0562-126	Riverside, San Bernardino	Summary of Benefits, H0562 - 126 - English (PDF) Summary of Benefits, H0562 - 126 - Spanish (PDF)

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	Summary of Benefits, H3561 - 001 - English (PDF) Summary of Benefits, H3561 - 001 - Chinese (PDF) Summary of Benefits, H3561 - 001 - Russian (PDF) Summary of Benefits, H3561 - 001 - Spanish (PDF) Summary of Benefits, H3561 - 001 - Tagalog (PDF) Summary of Benefits, H3561 - 001 - Vietnamese (PDF)
Wellcare CalViva Health Dual Align (HMO D-SNP) (KPD)	H3561 - 007	Fresno, Kings, Madera	Summary of Benefits, H3561 - 007 - English (PDF) Summary of Benefits, H3561 - 007 - Spanish (PDF) Summary of Benefits, H3561 - 007 - Hmong (PDF)
Wellcare Dual Align (HMO D-SNP) (KPE)	H3561 - 008	Los Angeles, Sacramento, Tulare	Summary of Benefits, H3561 - 008 - English (PDF) Summary of Benefits, H3561 - 008 - Spanish (PDF) Summary of Benefits, H3561 - 008 - Arabic (PDF) Summary of Benefits, H3561 - 008 - Armenian (PDF) Summary of Benefits, H3561 - 008 - Cambodian (PDF) Summary of Benefits, H3561 - 008 - Chinese (PDF) Summary of Benefits, H3561 - 008 - Farsi (PDF) Summary of Benefits, H3561 - 008 - Korean (PDF) Summary of Benefits, H3561 - 008 - Russian (PDF) Summary of Benefits, H3561 - 008 - Tagalog (PDF) Summary of Benefits, H3561 - 008 - Vietnamese (PDF)
Wellcare Dual Liberty (HMO D-SNP) (KP3)	H3561 - 009	Orange, Riverside, San Bernardino, San Diego	Summary of Benefits, H3561 - 009 - English (PDF) Summary of Benefits, H3561 - 009 - Arabic (PDF) Summary of Benefits, H3561 - 009 - Chinese (PDF) Summary of Benefits, H3561 - 009 - Korean (PDF) Summary of Benefits, H3561 - 009- Armenian - (PDF) Summary of Benefits, H3561 - 009 - Spanish (PDF) Summary of Benefits, H3561 - 009 - Vietnames (PDF)
Wellcare Specialty No Premium (HMO C-SNP) (KOW)	H0562 - 092	Kern, Los Angeles, Orange, San Diego	Summary of Benefits, H0562 - 092 - English (PDF) Summary of Benefits, H0562 - 092 - Spanish (PDF)
Wellcare No Premium Open (PPO)	H7360 - 001	Amador, Sutter	Summary of Benefits, H7360 - 001 - English (PDF) Summary of Benefits, H7360 - 001 - Spanish (PDF)

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	Evidence of Coverage, H0562 - 009 - English (PDF) Evidence of Coverage, H0562 - 009 - Spanish (PDF) Dental Benefits Detail - English (PDF) Dental Benefits Detail - Spanish (PDF)
Wellcare No Premium Focus (HMO)	H0562 - 012	Imperial, San Diego	Coverage, H0562 - 012 - English (PDF) Evidence of Coverage, H0562 - 012 - Spanish (PDF) Dental Benefits Detail - English (PDF) Dental Benefits Detail - Spanish (PDF)
Wellcare Premium Ultra (HMO)	H0562 - 039	Yolo	Evidence of Coverage, H0562 - 039 - English (PDF) Evidence of Coverage, H0562 - 039 - Spanish (PDF) Dental Benefits Detail - English (PDF) Dental Benefits Detail - Spanish (PDF)
Wellcare No Premium Ruby (HMO)	H0562 - 079	Fresno, Kern, Madera, Stanislaus, Tulare	Evidence of Coverage, H0562 - 079 - English (PDF) Evidence of Coverage, H0562 - 079 - Spanish (PDF) Dental Benefits Detail - English (PDF) Dental Benefits Detail - Spanish (PDF)
Wellcare No Premium Focus (HMO)	H0562 - 097	San Francisco	Evidence of Coverage, H0562 - 097 - English (PDF) Evidence of Coverage, H0562 - 097 - Chinese (PDF) Dental Benefits Detail - English (PDF) Dental Benefits Detail - Chinese (PDF)
Wellcare No Premium (HMO)	H0562 - 128	Amador, San Mateo, Santa Clara, Solano, Yolo	Evidence of Coverage, H0562 - 128 - English (PDF) Evidence of Coverage, H0562-128 - Spanish (PDF) Dental Benefits Detail - English (PDF) Dental Benefits Detail - Spanish (PDF)
Wellcare Low Premium (HMO)	H0562 - 130 - 001	Los Angeles and Orange	Evidence of Coverage, H0562 - 130 - 001 - English (PDF) Evidence of Coverage, H0562-130- 001 - Spanish (PDF) Dental Benefits Detail - English (PDF) Dental Benefits Detail - Spanish (PDF)
Wellcare Low Premium (HMO)	H0562 - 130 - 002	Imperial, Riverside, San Bernardino, San Diego	Evidence of Coverage, H0562 - 130 - 002 - English (PDF) Evidence of Coverage, H0562-130 - 002 - Spanish (PDF) Dental Benefits Detail - English (PDF) Dental Benefits Detail - Spanish (PDF)
Wellcare No Premium Focus (HMO)	H0562 - 125	Los Angeles, Orange	Evidence of Coverage, H0562 - 125 - English (PDF) Evidence of Coverage, H0562-125 - Spanish (PDF) Dental Benefits Detail - English (PDF) Dental Benefits Detail - Spanish (PDF)
Wellcare No Premium Focus (HMO)	H0562 - 126	Riverside, San Bernardino	Evidence of Coverage, H0562 - 126 - English (PDF) Evidence of Coverage, H0562-126 - Spanish (PDF) Dental Benefits Detail - English (PDF) Dental Benefits Detail - Spanish (PDF)

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	Evidence of Coverage, H3561 - 001 - English (PDF) Evidence of Coverage, H3561 - 001 - Spanish (PDF) Evidence of Coverage, H3561 - 001 - Chinese (PDF) Evidence of Coverage, H3561 - 001 - Russian (PDF) Evidence of Coverage, H3561 - 001 - Tagalog (PDF) Evidence of Coverage, H3561 - 001 - Vietnamese (PDF) Dental Benefits Detail - English (PDF) Dental Benefits Detail - Chinese (PDF) Dental Benefits Detail - Russian (PDF) Dental Benefits Detail - Spanish (PDF) Dental Benefits Detail - Tagalog (PDF) Dental Benefits Detail - Vietnamese (PDF)
Wellcare CalViva Health Dual Align (HMO D-SNP)	H3561 - 007	Fresno, Kings, Madera	Evidence of Coverage, H3561 - 007 - English (PDF) Evidence of Coverage, H3561 - 007 - Spanish (PDF) Evidence of Coverage, H3561 - 007 - Hmong (PDF) Dental Benefits Detail - English (PDF) Dental Benefits Detail - Spanish (PDF)
Wellcare Dual Align (HMO D-SNP)	H3561 - 008	Los Angeles, Sacramento, Tulare	Evidence of Coverage, H3561 - 008 - English (PDF) Evidence of Coverage, H3561 - 008 - Arabic (PDF) Evidence of Coverage, H3561 - 008 - Spanish (PDF) Evidence of Coverage, H3561 - 008 - Chinese (PDF) Evidence of Coverage, H3561 - 008 - Korean (PDF) Evidence of Coverage, H3561 - 008 - Tagalog (PDF) Evidence of Coverage, H3561 - 008 - Vietnamese (PDF) Evidence of Coverage, H3561 - 008 - Cambodian (PDF) Evidence of Coverage, H3561 - 008 - Armenian (PDF) Evidence of Coverage, H3561 - 008 - Russian (PDF) Evidence of Coverage, H3561 - 008 - Farsi (PDF) Dental Benefits Detail - English (PDF) Dental Benefits Detail - Arabic (PDF) Dental Benefits Detail - Chinese (PDF) Dental Benefits Detail - Korean (PDF) Dental Benefits Detail - Armenian (PDF) Dental Benefits Detail - Cambodian (PDF) Dental Benefits Detail - Farsi (PDF) Dental Benefits Detail - Russian (PDF) Dental Benefits Detail - Spanish (PDF) Dental Benefits Detail - Tagalog (PDF) Dental Benefits Detail - Vietnamese (PDF)
Wellcare Dual Liberty (HMO D-SNP)	H3561 - 009	Orange, Riverside, San Bernardino, San Diego	Evidence of Coverage, H3561 - 009 - English (PDF) Evidence of Coverage, H3561 - 009 - Spanish (PDF) Evidence of Coverage, H3561 - 009 - Chinese (PDF) Evidence of Coverage, H3561 - 009 - Korean (PDF) Evidence of Coverage, H3561 - 009 - Vietnamese (PDF) Evidence of Coverage, H3561 - 009 - Farsi (PDF) Evidence of Coverage, H3561 - 009 - Arabic (PDF) Dental Benefits Detail - English (PDF) Dental Benefits Detail - Arabic (PDF) Dental Benefits Detail - Chinese (PDF) Dental Benefits Detail - Korean (PDF) Dental Benefits Detail - Farsi (PDF) Dental Benefits Detail - Spanish (PDF) Dental Benefits Detail - Vietnamese (PDF)
Wellcare Specialty No Premium (HMO C-SNP)	H0562 - 092	Kern, Los Angeles, Orange, San Diego	Evidence of Coverage, H0562 - 092 - English (PDF) Evidence of Coverage, H0562 - 092 - Spanish (PDF) Dental Benefits Detail - English (PDF) Dental Benefits Detail - Spanish (PDF)
Wellcare No Premium Open (PPO)	H7360 - 001	Amador, Sutter	Evidence of Coverage, H7360 - 001 - English (PDF) Evidence of Coverage, H7360 - 001 - Spanish (PDF) Dental Benefits Detail - English (PDF) Dental Benefits Detail - Spanish (PDF)

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	Annual Notice of Changes (ANOC), H0562 - 079 - English (PDF) Annual Notice of Changes (ANOC), H0562 - 079 - Spanish (PDF)
Wellcare No Premium Focus (HMO)	H0562 - 097	San Francisco	Annual Notice of Changes (ANOC), H0562 - 097 - English (PDF) Annual Notice of Changes (ANOC), H0562 - 097 - Chinese (PDF)
Wellcare No Premium (HMO)	H0562 - 128	Amador, San Mateo, Santa Clara, Solano, Yolo	Annual Notice of Changes (ANOC), H0562 - 128 - English (PDF) Annual Notice of Changes (ANOC), H0562 - 128 - Spanish (PDF)
Wellcare No Premium Focus (HMO)	H0562 - 125	Los Angeles, Orange	Annual Notice of Changes (ANOC), H0562 - 125 - English (PDF) Annual Notice of Changes (ANOC), H0562 - 125 - Spanish (PDF)
Wellcare Low Premium (HMO)	H0562-123 to H0562-130-001	Los Angeles, Orange	Annual Notice of Changes (ANOC), H0562-123 to H0562 - 130 - English (PDF) Annual Notice of Changes (ANOC), H0562-123 to H0562 - 130 - Spanish (PDF)
Wellcare Low Premium (HMO)	H0562-123 to H0562-130-002	Imperial, Riverside, San Bernardino, San Diego	Annual Notice of Changes (ANOC), H0562-123 to H0562 - 130 - English (PDF) Annual Notice of Changes (ANOC), H0562-123 to H0562 - 130 - Spanish (PDF)
Wellcare Premium Ultra (HMO)	H0562 -009	Amador, Placer, Sacramento, San Francisco, Stanislaus	Annual Notice of Changes (ANOC), H0562 - 009 - English (PDF) Annual Notice of Changes (ANOC), H0562 - 009 - Spanish (PDF)
Wellcare Premium Ultra (HMO)	H0562 -084 to H0562 -009	Amador, Placer, Sacramento, San Francisco, Stanislaus	Annual Notice of Changes (ANOC), H0562 -084 to H0562 -009 - English (PDF) Annual Notice of Changes (ANOC), H0562 -084 to H0562 -009 - Spanish (PDF)
Wellcare Premium Ultra (HMO)	H0562 - 039	Yolo	Annual Notice of Changes (ANOC), H0562 - 039 - English (PDF) Annual Notice of Changes (ANOC), H0562 - 039 - Spanish (PDF)
Wellcare No Premium (HMO)	H0562 - 103 to H0562- 128	Amador, San Mateo, Santa Clara, Solano, Yolo	Annual Notice of Changes (ANOC), H0562 - 103 to H0562- 128 - English (PDF) Annual Notice of Changes (ANOC), H0562 - 103 to H0562- 128 - Spanish (PDF)
Wellcare No Premium Focus (HMO)	H0562 - 012	Imperial, San Diego	Annual Notice of Changes (ANOC), H0562 - 012 - English (PDF) Annual Notice of Changes (ANOC), H0562 - 012 - Spanish (PDF)
Wellcare No Premium Focus (HMO)	H0562 - 126	Riverside, San Bernardino	Annual Notice of Changes (ANOC), H0562 - 126 - English (PDF) Annual Notice of Changes (ANOC), H0562-126 - Spanish (PDF)

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	Annual Notice of Changes (ANOC), H0562 - 092 - English (PDF) Annual Notice of Changes (ANOC), H0562 - 092 - Spanish (PDF)
Wellcare Specialty No Premium (HMO C-SNP)	H0562-114 to H0562-092	Kern, Los Angeles, Orange, San Diego	Annual Notice of Changes (ANOC), H0562-114 to H0562-092 -English (PDF) Annual Notice of Changes (ANOC), H0562-114 to H0562-092 - Spanish (PDF)

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	Annual Notice of Changes (ANOC), H0562-121 to H3561-001 - English (PDF) Annual Notice of Changes (ANOC), H0562-121 to H3561-001 - Spanish (PDF) Annual Notice of Changes (ANOC), H0562-121 to H3561-001 - Chinese (PDF) Annual Notice of Changes (ANOC), H0562-121 to H3561-001 - Russian (PDF) Annual Notice of Changes (ANOC), H0562-121 to H3561-001 - Tagalog (PDF) Annual Notice of Changes (ANOC), H0562-121 to H3561-001 - Vietnamese (PDF)
Wellcare Dual Liberty (HMO D-SNP) to Wellcare CalViva Health Dual Align (HMO D-SNP)	H0562 - 121 to H3561 - 007	Fresno, Kings, Madera	Annual Notice of Changes (ANOC), H0562 - 121 to H3561 - 007 English (PDF) Annual Notice of Changes (ANOC), H0562 - 121 to H3561 - 007 - Spanish (PDF) Annual Notice of Changes (ANOC), H0562 - 121 to H3561 - 007 - Hmong (PDF)
Wellcare Dual Liberty Amber (HMO D-SNP) to Wellcare CalViva Health Dual Align (HMO D-SNP)	H3561 - 001 to H3561 - 007	Fresno, Kings, Madera	Annual Notice of Changes (ANOC), H3561 - 001 to H3561 - 007 English (PDF) Annual Notice of Changes (ANOC), H3561 - 001 to H3561 - 007- Spanish (PDF) Annual Notice of Changes (ANOC), H3561 - 001 to H3561 - 007- Hmong (PDF)
Wellcare Dual Liberty (HMO D-SNP) to Wellcare Dual Align (HMO D-SNP)	H0562 - 121 to H3561 - 008	Los Angeles, Sacramento, Tulare	Annual Notice of Changes (ANOC), H0562 - 121 to H3561 - 008 English (PDF) Annual Notice of Changes (ANOC), H0562 - 121 to H3561 - 008- Arabic (PDF) Annual Notice of Changes (ANOC), H0562 - 121 to H3561 - 008 - Chinese (PDF) Annual Notice of Changes (ANOC), H0562 - 121 to H3561 - 008 - Korean (PDF) Annual Notice of Changes (ANOC), H0562 - 121 to H3561 - 008 - Armenian (PDF) Annual Notice of Changes (ANOC), H0562 - 121 to H3561 - 008 - Cambodian (PDF) Annual Notice of Changes (ANOC), H0562 - 121 to H3561 - 008 - Farsi (PDF) Annual Notice of Changes (ANOC), H0562 - 121 to H3561 - 008 - Russian (PDF) Annual Notice of Changes (ANOC), H0562 - 121 to H3561 - 008 - Spanish (PDF) Annual Notice of Changes (ANOC), H0562 - 121 to H3561 - 008 - Tagalog (PDF) Annual Notice of Changes (ANOC), H0562 - 121 to H3561 - 008 - Vietnamese (PDF)
Wellcare Dual Liberty (HMO D-SNP)	H3561 - 001	Amador, Imperial, Kern, Placer, San Francisco, San Joaquin, Stanislaus	Annual Notice of Changes (ANOC), H3561 - 001 - English (PDF) Annual Notice of Changes (ANOC), H3561 - 001 - Spanish (PDF) Annual Notice of Changes (ANOC), H3561 - 001 - Chinese (PDF) Annual Notice of Changes (ANOC), H3561 - 001 - Russian (PDF) Annual Notice of Changes (ANOC), H3561 - 001 - Tagalog (PDF) Annual Notice of Changes (ANOC), H3561 - 001 - Vietnamese (PDF)
Wellcare Dual Align 129 (HMO D-SNP) to Wellcare Dual Align (HMO D-SNP)	H0562-129 to H3561-008	Los Angeles, Sacramento, Tulare	Annual Notice of Changes (ANOC),H0562-129 to H3561-008- English (PDF) Annual Notice of Changes (ANOC),H0562-129 to H3561-008- Arabian (PDF) Annual Notice of Changes (ANOC),H0562-129 to H3561-008- Chinese (PDF) Annual Notice of Changes (ANOC),H0562-129 to H3561-008- Korean (PDF) Annual Notice of Changes (ANOC),H0562-129 to H3561-008- Armenian (PDF) Annual Notice of Changes (ANOC),H0562-129 to H3561-008- Cambodian (PDF) Annual Notice of Changes (ANOC),H0562-129 to H3561-008- Farsi (PDF) Annual Notice of Changes (ANOC),H0562-129 to H3561-008- Russian (PDF) Annual Notice of Changes (ANOC),H0562-129 to H3561-008- Spanish (PDF) Annual Notice of Changes (ANOC),H0562-129 to H3561-008- Tagalog (PDF) Annual Notice of Changes (ANOC),H0562-129 to H3561-008- Vietnamese (PDF)
Wellcare Dual Liberty Amber (HMO D-SNP) to Wellcare Dual Align (HMO D-SNP)	H3561-001 to H3561-008	Los Angeles, Sacramento, Tulare	Annual Notice of Changes (ANOC), H3561-001 to H3561-008- English (PDF) Annual Notice of Changes (ANOC), H3561-001 to H3561-008 - Arabian (PDF) Annual Notice of Changes (ANOC), H3561-001 to H3561-008- Chinese (PDF) Annual Notice of Changes (ANOC), H3561-001 to H3561-008 - Korean (PDF) Annual Notice of Changes (ANOC), H3561-001 to H3561-008 - Armenian (PDF) Annual Notice of Changes (ANOC), H3561-001 to H3561-008 - Cambodian (PDF) Annual Notice of Changes (ANOC), H3561-001 to H3561-008 - Russian (PDF) Annual Notice of Changes (ANOC), H3561-001 to H3561-008 - Farsi (PDF) Annual Notice of Changes (ANOC), H3561-001 to H3561-008 - Spanish (PDF) Annual Notice of Changes (ANOC), H3561-001 to H3561-008 - Tagalog (PDF) Annual Notice of Changes (ANOC), H3561-001 to H3561-008 - Vietnamese (PDF)
Wellcare Dual Liberty (HMO D-SNP) to Wellcare Dual Liberty (HMO D-SNP)	H0562-121 to H3561-009	Orange, Riverside, San Bernardino, San Diego	Annual Notice of Changes (ANOC), H0562-121 to H3561-009- English (PDF) Annual Notice of Changes (ANOC), H0562-121 to H3561-009- Arabic (PDF) Annual Notice of Changes (ANOC), H0562-121 to H3561-009- Spanish (PDF) Annual Notice of Changes (ANOC), H0562-121 to H3561-009- Chinese (PDF) Annual Notice of Changes (ANOC), H0562-121 to H3561-009- Korean (PDF) Annual Notice of Changes (ANOC), H0562-121 to H3561-009- Farsi (PDF) Annual Notice of Changes (ANOC), H0562-121 to H3561-009- Vietnamese (PDF)
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	Annual Notice of Changes (ANOC), H0562-129 to H3561-009- English (PDF) Annual Notice of Changes (ANOC), H0562-129 to H3561-009- Arabic (PDF) Annual Notice of Changes (ANOC), H0562-129 to H3561-009- Spanish (PDF) Annual Notice of Changes (ANOC), H0562-129 to H3561-009- Chinese (PDF) Annual Notice of Changes (ANOC), H0562-129 to H3561-009- Korean (PDF) Annual Notice of Changes (ANOC), H0562-129 to H3561-009- Farsi (PDF) Annual Notice of Changes (ANOC), H0562-129 to H3561-009- Vietnamese (PDF)
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	Annual Notice of Changes (ANOC), H5087-027 to H3561-001 English (PDF) Annual Notice of Changes (ANOC), H5087-027 to H3561-001- Spanish (PDF) Annual Notice of Changes (ANOC), H5087-027 to H3561-001- Chinese (PDF) Annual Notice of Changes (ANOC), H5087-027 to H3561-001- Russian (PDF) Annual Notice of Changes (ANOC), H5087-027 to H3561-001- Tagalog (PDF) Annual Notice of Changes (ANOC), H5087-027 to H3561-001- Vietnamese (PDF)
Wellcare Dual Align 001 (HMO D-SNP) to Wellcare Dual Align (HMO D-SNP)	H5087-001 to H3561-008	Los Angeles, Sacramento, Tulare	Annual Notice of Changes (ANOC), H5087-001 to H3561-008- English (PDF) Annual Notice of Changes (ANOC), H5087-001 to H3561-008- Arabic (PDF) Annual Notice of Changes (ANOC), H5087-001 to H3561-008- Chinese (PDF) Annual Notice of Changes (ANOC), H5087-001 to H3561-008- Korean (PDF) Annual Notice of Changes (ANOC), H5087-001 to H3561-008- Armenian (PDF) Annual Notice of Changes (ANOC), H5087-001 to H3561-008- Cambodian (PDF) Annual Notice of Changes (ANOC), H5087-001 to H3561-008- Farsi (PDF) Annual Notice of Changes (ANOC), H5087-001 to H3561-008- Russian (PDF) Annual Notice of Changes (ANOC), H5087-001 to H3561-008- Tagalog (PDF) Annual Notice of Changes (ANOC), H5087-001 to H3561-008- Spanish (PDF) Annual Notice of Changes (ANOC), H5087-001 to H3561-008- Vietnamese (PDF)

For PPO

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

Medicare Step Therapy Part B (PDF)

Covered Diabetes Testing Supplies

OTC Catalog

Calviva

2024 Original Medicare Defined Cost Share Amounts and Premiums (PDF)

Plan Benefit Materials | Health Net Medicare Advantage for California

Plan Materials and Forms

For HMO Members:

For HMO DSNP, C SNP and Members:

For HMO Members

For HMO DSNP, C SNP and PPO Members

For HMO C-SNP

For HMO DSNP

For PPO

Plan Benefit Materials

HMO

Wellcare Premium Ultra (HMO) H0562-009 (ME0)

Wellcare Simple Focus (HMO) H0562-012 (ME1)

Wellcare Premium Ultra (HMO) H0562-039 (ME2)

Wellcare Simple Ruby (HMO) H0562-079 (ME3)

Wellcare Simple Focus (HMO) H0562-097 (ME5)

Wellcare Simple Focus (HMO) H0562-125 (ME6)

Wellcare Simple Focus (HMO) H0562-126 (ME7)

Wellcare Low Premium (HMO) H0562-133 (MEF)

Wellcare Low Premium (HMO) H0562-136 (MEG)

Wellcare Low Premium (HMO) H0562-137 (MEH)

HMO C-SNP

Wellcare Specialty Simple (HMO C-SNP) H0562-092 (ME4)

HMO D-SNP

Wellcare Dual Liberty (HMO D-SNP) H3561-001 (ME8)

Wellcare CalViva Health Dual Align (HMO D-SNP) H3561-007 (ME9)

Wellcare Dual Align (HMO D-SNP) H3561-008 (MEB)

Wellcare Dual Liberty (HMO D-SNP) H3561-009 (MEC)

Additional Forms

Plan Benefit Materials | Health Net Medicare Advantage for California

Plan Materials and Forms

Summary of Benefits (SB)

For HMO Members:

For HMO DSNP, C SNP and Members:

Evidence Of Coverage (EOC)

For HMO Members

For HMO DSNP, C SNP and PPO Members

Annual Notice of Changes (ANOC)

For HMO C-SNP

For HMO DSNP

For PPO

Step Therapy Part B

Covered Diabetes Testing Supplies

Over-the Counter Catalog and Healthy Food

2024 AHIP Flyer

Dental Provider Form

Findhelp

Plan Benefit Materials

HMO

Wellcare Premium Ultra (HMO) H0562-009 (ME0)

Plan Benefits

Wellcare Simple Focus (HMO) H0562-012 (ME1)

Plan Benefits

Wellcare Premium Ultra (HMO) H0562-039 (ME2)

Plan Benefits

Wellcare Simple Ruby (HMO) H0562-079 (ME3)

Plan Benefits

Wellcare Simple Focus (HMO) H0562-097 (ME5)

Plan Benefits

Wellcare Simple Focus (HMO) H0562-125 (ME6)

Plan Benefits

Wellcare Simple Focus (HMO) H0562-126 (ME7)

Plan Benefits

Wellcare Low Premium (HMO) H0562-133 (MEF)

Plan Benefits

Wellcare Low Premium (HMO) H0562-136 (MEG)

Plan Benefits

Wellcare Low Premium (HMO) H0562-137 (MEH)

Plan Benefits

HMO C-SNP

Wellcare Specialty Simple (HMO C-SNP) H0562-092 (ME4)

Plan Benefits

HMO D-SNP

Wellcare Dual Liberty (HMO D-SNP) H3561-001 (ME8)

Plan Benefits

Wellcare CalViva Health Dual Align (HMO D-SNP) H3561-007 (ME9)

Plans Benefits

Wellcare Dual Align (HMO D-SNP) H3561-008 (MEB)

Plan Benefits

Wellcare Dual Liberty (HMO D-SNP) H3561-009 (MEC)

Plan Benefits

Additional Forms

Step Therapy Part B

Covered Diabetes Testing Supplies

Over-the Counter Catalog and Healthy Food

2025 AHIP Flyer