Plan Materials and Forms

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

Look at your Wellcare By Health Net member ID card for your plan number and type to view materials for your plan.

View a sample of an Wellcare By Health Net Member ID Card to see where this information is located.

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

If you don’t have a Wellcare By Health Net ID card or have questions about plan materials, give us a call. We’re here to help.

For HMO Members:

Plan	CMS#	County	Summary of Benefits
Wellcare Plus Sapphire I (HMO)	H0562 - 122	Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, Santa Clara, Stanislaus	Summary of Benefits, H0562 - 122 - English (PDF) Summary of Benefits, H0562 - 122 - Spanish (PDF) Summary of Benefits, H0562 - 122 - Chinese (PDF) Summary of Benefits, H0562 - 122 - Korean (PDF) Summary of Benefits, H0562 - 122 - Vietnamese (PDF)
Wellcare Assist (HMO)	H0562 - 127	Amador, Contra Costa, Fresno, Madera, Santa Clara	Summary of Benefits, H0562 - 127 - English (PDF) Summary of Benefits, H0562 - 127 - Spanish (PDF) Summary of Benefits, H0562 - 127 - Chinese (PDF) Summary of Benefits, H0562 - 127 - Korean (PDF) Summary of Benefits, H0562 - 127 - Vietnamese (PDF)
Wellcare Plus Sapphire II (HMO)	H3561-002	Alameda, Fresno, Imperial, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Francisco, Tulare	Summary of Benefits, H3561 - 002 - English (PDF) Summary of Benefits, H3561-002 - Spanish (PDF) Summary of Benefits, H3561-002 - Chinese (PDF) Summary of Benefits, H3561-002 - Korean (PDF) Summary of Benefits, H3561-002 - Vietnamese (PDF)
Wellcare No Premium Ruby (HMO)	H0562 - 079	Fresno, Kern, Madera	Summary of Benefits, H0562 - 079 - English (PDF) Summary of Benefits, H0562 - 079 - Spanish (PDF) Summary of Benefits, H0562 - 079 - Chinese (PDF) Summary of Benefits, H0562 - 079 - Korean (PDF) Summary of Benefits, H0562 - 079 - Vietnamese (PDF)
Wellcare No Premium (HMO)	H0562 - 090	Fresno	Summary of Benefits, H0562 - 090 - English (PDF) Summary of Benefits, H0562 - 090 - Spanish (PDF) Summary of Benefits, H0562 - 090 - Chinese (PDF) Summary of Benefits, H0562 - 090 - Korean (PDF) Summary of Benefits, H0562 - 090 - Vietnamese (PDF)
Wellcare No Premium (HMO)	H0562 - 125	Los Angeles, Orange	Summary of Benefits, H0562 - 125 - English (PDF) Summary of Benefits, H0562 - 125 - Spanish (PDF) Summary of Benefits, H0562 - 125 - Chinese (PDF) Summary of Benefits, H0562 - 125 - Korean (PDF) Summary of Benefits, H0562 - 125 - Vietnamese (PDF)
Wellcare No Premium (HMO)	H0562 - 120	Santa Clara, Stanislaus	Summary of Benefits, H0562 - 120 - English (PDF) Summary of Benefits, H0562 - 120 - Spanish (PDF) Summary of Benefits, H0562 - 120 - Chinese (PDF) Summary of Benefits, H0562 - 120 - Korean (PDF) Summary of Benefits, H0562 - 120 - Vietnamese (PDF)
Wellcare Premium Ultra (HMO)	H0562 -009	Alameda, Amador, Contra Costa, San Francisco, Stanislaus	Summary of Benefits, H0562 - 009 - English (PDF) Summary of Benefits, H0562 - 009 - Spanish (PDF) Summary of Benefits, H0562 - 009 - Chinese (PDF) Summary of Benefits, H0562 - 009 - Korean (PDF) Summary of Benefits, H0562 - 009 - Vietnamese (PDF)
Wellcare Premium Ultra (HMO)	H0562 - 084	Placer, Sacramento	Summary of Benefits, H0562 - 084 - English (PDF) Summary of Benefits, H0562 - 084 - Spanish (PDF) Summary of Benefits, H0562 - 084 - Chinese (PDF) Summary of Benefits, H0562 - 084 - Korean (PDF) Summary of Benefits, H0562 - 084 - Vietnamese (PDF)
Wellcare Premium Enhanced (HMO)	H0562 - 039	Yolo	Summary of Benefits, H0562 - 039 - English (PDF) Summary of Benefits, H0562 - 039 - Spanish (PDF) Summary of Benefits, H0562 - 039 - Chinese (PDF) Summary of Benefits, H0562 - 039 - Korean (PDF) Summary of Benefits, H0562 - 039 - Vietnamese (PDF)
Wellcare No Premium (HMO)	H0562 - 097	San Francisco	Summary of Benefits, H0562 - 097 - English (PDF) Summary of Benefits, H0562 - 097 - Spanish (PDF) Summary of Benefits, H0562 - 097 - Chinese (PDF) Summary of Benefits, H0562 - 097 - Korean (PDF) Summary of Benefits, H0562 - 097 - Vietnamese (PDF)
Wellcare No Premium (HMO)	H0562 - 103	Amador, Contra Costa, Yolo	Summary of Benefits, H0562 - 103 - English (PDF) Summary of Benefits, H0562 - 103 - Spanish (PDF) Summary of Benefits, H0562 - 103 - Chinese (PDF) Summary of Benefits, H0562 - 103 - Korean (PDF) Summary of Benefits, H0562 - 103 - Vietnamese (PDF)
Wellcare No Premium (HMO)	H0562 - 124	Placer, Sacramento	Summary of Benefits, H0562 - 124 - English (PDF) Summary of Benefits, H0562 - 124 - Spanish (PDF) Summary of Benefits, H0562 - 124 - Chinese (PDF) Summary of Benefits, H0562 - 124 - Korean (PDF) Summary of Benefits, H0562 - 124 - Vietnamese (PDF)
Wellcare No Premium (HMO)	H0562 - 113	Alameda	Summary of Benefits, H0562 - 113 - English (PDF) Summary of Benefits, H0562 - 113 - Spanish (PDF) Summary of Benefits, H0562 - 113 - Chinese (PDF) Summary of Benefits, H0562 - 113 - Korean (PDF) Summary of Benefits, H0562 - 113 - Vietnamese (PDF)
Wellcare Patriot Giveback (HMO)	H0562 - 044	Alameda, Amador, Contra Costa, Los Angeles, Placer, Riverside, Sacramento, San Bernardino, Stanislaus	Summary of Benefits, H0562 - 044 - English (PDF) Summary of Benefits, H0562 - 044 - Spanish (PDF) Summary of Benefits, H0562 - 044 - Chinese (PDF) Summary of Benefits, H0562 - 044 - Korean (PDF) Summary of Benefits, H0562 - 044 - Vietnamese (PDF)
Wellcare Low Premium (HMO)	H0562 - 123	Los Angeles, Orange, Riverside, San Bernardino	Summary of Benefits, H0562 - 123 - English (PDF) Summary of Benefits, H0562 - 123 - Spanish (PDF) Summary of Benefits, H0562 - 123 - Chinese (PDF) Summary of Benefits, H0562 - 123 - Korean (PDF) Summary of Benefits, H0562 - 123 - Vietnamese (PDF)
Wellcare No Premium (HMO)	H0562 - 012	Imperial, San Diego	Summary of Benefits, H0562 - 012 - English (PDF) Summary of Benefits, H0562 - 012 - Spanish (PDF) Summary of Benefits, H0562 - 012 - Chinese (PDF) Summary of Benefits, H0562 - 012 - Korean (PDF) Summary of Benefits, H0562 - 012 - Vietnamese (PDF)
Wellcare No Premium (HMO)	H0562 - 126	Riverside, San Bernardino	Summary of Benefits, H0562 - 126 - English (PDF) Summary of Benefits, H0562 - 126 - Spanish (PDF) Summary of Benefits, H0562 - 126 - Chinese (PDF) Summary of Benefits, H0562 - 126 - Korean (PDF) Summary of Benefits, H0562 - 126 - Vietnamese (PDF)

For HMO DSNP and C SNP Members:

Plans	CMS#	County	Summary of Benefits
Wellcare Dual Liberty (HMO D-SNP)	H0562 - 121	Fresno, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Francisco & Tulare	Summary of Benefits, H0562 - 121 - English (PDF) Summary of Benefits, H0562 - 121 - Spanish (PDF) Summary of Benefits, H0562 - 121 - Chinese (PDF) Summary of Benefits, H0562 - 121 - Korean (PDF) Summary of Benefits, H0562 - 121 - Vietnamese (PDF)
Wellcare Dual Liberty Amber (HMO D-SNP)	H3561 - 001	Alameda, Amador, Fresno, Imperial, Madera, Placer, Sacramento, Stanislaus	Summary of Benefits, H3561 - 001 - English (PDF) Summary of Benefits, H3561 - 001 - Spanish (PDF) Summary of Benefits, H3561 - 001 - Chinese (PDF) Summary of Benefits, H3561 - 001 - Korean (PDF) Summary of Benefits, H3561 - 001 - Vietnamese (PDF)
Wellcare Specialty No Premium (HMO C-SNP)	H0562 - 092	Kern, Los Angeles, Orange	Summary of Benefits, H0562 - 092 - English (PDF) Summary of Benefits, H0562 - 092 - Spanish (PDF) Summary of Benefits, H0562 - 092 - Chinese (PDF) Summary of Benefits, H0562 - 092 - Korean (PDF) Summary of Benefits, H0562 - 092 - Vietnamese (PDF)
Wellcare Specialty No Premium (HMO C-SNP)	H0562 - 114	San Diego	Summary of Benefits, H0562 - 114 - English (PDF) Summary of Benefits, H0562 - 114 - Spanish (PDF) Summary of Benefits, H0562 - 114 - Chinese (PDF) Summary of Benefits, H0562 - 114 - Korean (PDF) Summary of Benefits, H0562 - 114 - Vietnamese (PDF)
Wellcare Specialty No Premium (HMO C-SNP)	H0562 - 118	Fresno, San Francisco	Summary of Benefits, H0562 - 118 - English (PDF) Summary of Benefits, H0562 - 118 - Spanish (PDF) Summary of Benefits, H0562 - 118 - Chinese (PDF) Summary of Benefits, H0562 - 118 - Korean (PDF) Summary of Benefits, H0562 - 118 - Vietnamese (PDF)

For PPO Members:

Plan	CMS#	County	Summary of Benefits
Wellcare No Premium Open (PPO)	H7360-001	Amador, Sutter	Summary of Benefits, H7360 - 001 - English (PDF) Summary of Benefits, H7360 - 001 - Spanish (PDF) Summary of Benefits, H7360 - 001 - Chinese (PDF) Summary of Benefits, H7360 - 001 - Korean (PDF) Summary of Benefits, H7360 - 001 - Vietnamese (PDF)

For HMO Members

Plan	CMS#	County	Evidence of Coverage
Wellcare Plus Sapphire I (HMO)	H0562 - 122	Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, Santa Clara, Stanislaus	Evidence of Coverage, H0562 - 122 - English (PDF) Evidence of Coverage, H0562 - 122 - Spanish (PDF) Evidence of Coverage, H0562 - 122 - Chinese (PDF) Evidence of Coverage, H0562 - 122 - Korean (PDF) Evidence of Coverage, H0562 - 122 - Vietnamese (PDF)
Wellcare Assist (HMO)	H0562 - 127	Amador, Contra Costa, Fresno, Madera, Santa Clara	Evidence of Coverage, H0562 - 127 - English (PDF) Evidence of Coverage, H0562 - 127 - Spanish (PDF) Evidence of Coverage, H0562 - 127 - Chinese (PDF) Evidence of Coverage, H0562 - 127 - Korean (PDF) Evidence of Coverage, H0562 - 127 - Vietnamese (PDF)
Wellcare Plus Sapphire II (HMO)	H3561-002	Alameda, Fresno, Imperial, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Francisco, Tulare	Evidence of Coverage, H3561 - 002 - English (PDF) Evidence of Coverage, H3561-002 - Spanish (PDF) Evidence of Coverage, H3561-002 - Korean (PDF) Evidence of Coverage, H3561-002 - Vietnamese (PDF) Evidence of Coverage, H3561-002 - Chinese (PDF
Wellcare No Premium Ruby (HMO)	H0562 - 079	Fresno, Kern, Madera	Evidence of Coverage, H0562 - 079 - English (PDF) Evidence of Coverage, H0562 - 079 - Spanish (PDF) Evidence of Coverage, H0562 - 079 - Korean (PDF) Evidence of Coverage, H0562 - 079 - Chinese (PDF) Evidence of Coverage, H0562 - 079 - Vietnamese (PDF)
Wellcare No Premium (HMO)	H0562 - 090	Fresno	Evidence of Coverage, H0562 - 090 - English (PDF) Evidence of Coverage, H0562 - 090 - Spanish (PDF) Evidence of Coverage, H0562 - 090 - Korean (PDF) Evidence of Coverage, H0562 - 090 - Vietnamese (PDF) Evidence of Coverage, H0562 - 090 - Chinese (PDF)
Wellcare No Premium (HMO)	H0562 - 125	Los Angeles, Orange	Evidence of Coverage, H0562 - 125 - English (PDF) Evidence of Coverage, H0562 - 125 - Spanish (PDF) Evidence of Coverage, H0562 - 125 - Korean (PDF) Evidence of Coverage, H0562 - 125 - Vietnamese (PDF) Evidence of Coverage, H0562 - 125 - Chinese (PDF)
Wellcare No Premium (HMO)	H0562 - 120	Santa Clara, Stanislaus	Evidence of Coverage, H0562 - 120 - English (PDF) Evidence of Coverage, H0562 - 120 - Spanish (PDF) Evidence of Coverage, H0562 - 120 - Korean (PDF) Evidence of Coverage, H0562 - 120 - Vietnamese (PDF) Evidence of Coverage, H0562 - 120 - Chinese (PDF)
Wellcare Premium Ultra (HMO)	H0562 -009	Alameda, Amador, Contra Costa, San Francisco, Stanislaus	Evidence of Coverage, H0562 - 009 - English (PDF) Evidence of Coverage, H0562 - 009 - Spanish (PDF) Evidence of Coverage, H0562 - 009 - Chinese (PDF) Evidence of Coverage, H0562 - 009 - Korean (PDF) Evidence of Coverage, H0562 - 009 - Vietnamese (PDF)
Wellcare Premium Ultra (HMO)	H0562 - 084	Placer, Sacramento	Evidence of Coverage, H0562 - 084 - English (PDF) Evidence of Coverage, H0562 - 084 - Spanish (PDF) Evidence of Coverage, H0562 - 084 - Korean (PDF) Evidence of Coverage, H0562 - 084 - Vietnamese (PDF) Evidence of Coverage, H0562 - 084 - Chinese (PDF)
Wellcare Premium Enhanced (HMO)	H0562 - 039	Yolo	Evidence of Coverage, H0562 - 039 - English (PDF) Evidence of Coverage, H0562 - 039 - Spanish (PDF) Evidence of Coverage, H0562 - 039 - Chinese (PDF) Evidence of Coverage, H0562 - 039 - Korean (PDF) Evidence of Coverage, H0562 - 039 - Vietnamese (PDF)
Wellcare No Premium (HMO)	H0562 - 097	San Francisco	Evidence of Coverage, H0562 - 097 - English (PDF) Evidence of Coverage, H0562 - 097 - Spanish (PDF) Evidence of Coverage, H0562 - 097 - Chinese (PDF) Evidence of Coverage, H0562 - 097 - Korean (PDF) Evidence of Coverage, H0562 - 097 - Vietnamese (PDF)
Wellcare No Premium (HMO)	H0562 - 103	Amador, Contra, Costa, Yolo	Evidence of Coverage, H0562 - 103 - English (PDF) Evidence of Coverage, H0562-103 - Spanish (PDF) Evidence of Coverage, H0562-103 - Korean (PDF) Evidence of Coverage, H0562-103 - Vietnamese (PDF) Evidence of Coverage, H0562-103 - Chinese (PDF)
Wellcare No Premium (HMO)	H0562 - 124	Placer, Sacramento	Evidence of Coverage, H0562 - 124 - English (PDF) Evidence of Coverage, H0562 - 124 - Spanish (PDF) Evidence of Coverage, H0562 - 124 - Korean (PDF) Evidence of Coverage, H0562 - 124 - Vietnamese (PDF) Evidence of Coverage, H0562 - 124 - Chinese (PDF)
Wellcare No Premium (HMO)	H0562 - 113	Alameda	Evidence of Coverage, H0562 - 113 - English (PDF) Evidence of Coverage, H0562 - 113 - Spanish (PDF) Evidence of Coverage, H0562 - 113 - Korean (PDF) Evidence of Coverage, H0562 - 113 - Vietnamese (PDF) Evidence of Coverage, H0562 - 113 - Chinese (PDF)
Wellcare Patriot Giveback (HMO)	H0562 - 044	Alameda, Amador, Contra Costa, Los Angeles, Placer, Riverside, Sacramento, San Bernardino, Stanislaus	Evidence of Coverage, H0562 - 044 - English (PDF) Evidence of Coverage, H0562 - 044 - Spanish (PDF) Evidence of Coverage, H0562 - 044 - Korean (PDF) Evidence of Coverage, H0562 - 044 - Chinese (PDF) Evidence of Coverage, H0562 - 044 - Vietnamese (PDF)
Wellcare Low Premium (HMO)	H0562 - 123	Los Angeles, Orange, Riverside, San Bernardino	Evidence of Coverage, H0562 - 123 - English (PDF) Evidence of Coverage, H0562 - 123 - Spanish (PDF) Evidence of Coverage, H0562 - 123 - Korean (PDF) Evidence of Coverage, H0562 - 123 - Vietnamese (PDF) Evidence of Coverage, H0562 - 123 - Chinese (PDF)
Wellcare No Premium (HMO)	H0562 - 012	Imperial, San Diego	Evidence of Coverage, H0562 - 012 - English (PDF) Evidence of Coverage, H0562 - 012 - Spanish (PDF) Evidence of Coverage, H0562 - 012 - Korean (PDF) Evidence of Coverage, H0562 - 012 - Chinese (PDF) Evidence of Coverage, H0562 - 012 - Vietnamese (PDF)
Wellcare No Premium (HMO)	H0562 - 126	Riverside, San Bernardino	Evidence of Coverage, H0562 - 126 - English (PDF) Evidence of Coverage, H0562-126 - Spanish (PDF) Evidence of Coverage, H0562-126 - Korean (PDF) Evidence of Coverage, H0562-126 - Vietnamese (PDF) Evidence of Coverage, H0562-126 - Chinese (PDF)

For HMO DSNP and C SNP Members

Plans	CMS#	County	Evidence of Coverage
Wellcare Dual Liberty (HMO D-SNP)	H0562 - 121	Fresno, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Francisco & Tulare	Evidence of Coverage, H0562 - 121 - English (PDF) Evidence of Coverage, H0562 - 121 - Spanish (PDF) Evidence of Coverage, H0562 - 121 - Chinese (PDF) Evidence of Coverage, H0562 - 121 - Korean (PDF) Evidence of Coverage, H0562 - 121 - Vietnamese (PDF)
Wellcare Dual Liberty Amber (HMO D-SNP)	H3561 - 001	Alameda, Amador, Fresno, Imperial, Madera, Placer, Sacramento, Stanislaus	Evidence of Coverage, H3561 - 001 - English (PDF) Evidence of Coverage, H3561 - 001 - Spanish (PDF) Evidence of Coverage, H3561 - 001 - Korean (PDF) Evidence of Coverage, H3561 - 001 - Vietnamese (PDF) Evidence of Coverage, H3561 - 001 - Chinese (PDF)
Wellcare Specialty No Premium (HMO C-SNP)	H0562 - 092	Kern, Los Angeles, Orange	Evidence of Coverage, H0562 - 092 - English Evidence of Coverage, H0562 - 092 - Spanish (PDF) Evidence of Coverage, H0562 - 092 - Chinese (PDF) Evidence of Coverage, H0562 - 092 - Korean (PDF) Evidence of Coverage, H0562 - 092 - Vietnamese (PDF)
Wellcare Specialty No Premium (HMO C-SNP)	H0562 - 114	San Diego	Evidence of Coverage, H0562 - 114 - English (PDF) Evidence of Coverage, H0562 - 114 - Spanish (PDF) Evidence of Coverage, H0562 - 114 - Chinese (PDF) Evidence of Coverage, H0562 - 114 - Korean (PDF) Evidence of Coverage, H0562 - 114 - Vietnamese (PDF)
Wellcare Specialty No Premium (HMO C-SNP)	H0562 - 118	Fresno, San Francisco	Evidence of Coverage, H0562 - 118 - English (PDF) Evidence of Coverage, H0562 - 118 - Spanish (PDF) Evidence of Coverage, H0562 - 118 - Chinese (PDF) Evidence of Coverage, H0562 - 118 - Korean (PDF) Evidence of Coverage, H0562 - 118 - Vietnamese (PDF)

For PPO Members:

Plans	CMS#	County	Evidence of Coverage
Wellcare No Premium Open (PPO)	H7360-001	Amador, Sutter	Evidence of Coverage, H7360 - 001 - English (PDF) Evidence of Coverage, H7360 - 001 - Spanish (PDF) Evidence of Coverage, H7360 - 001 - Korean (PDF) Evidence of Coverage, H7360 - 001 - Vietnamese (PDF) Evidence of Coverage, H7360 - 001 - Chinese (PDF)

For HMO Members

Plan	CMS#	County	Annual Notice of Changes (ANOC)
Wellcare Plus Sapphire I (HMO)	H0562 - 122	Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, Santa Clara, Stanislaus	Annual Notice of Changes (ANOC), H0562 - 122 - English (PDF) Annual Notice of Changes (ANOC), H0562 - 122 - Spanish (PDF) Annual Notice of Changes (ANOC), H0562 - 122 - Chinese (PDF) - coming soon Annual Notice of Changes (ANOC), H0562 - 122 - Korean (PDF) - coming soon Annual Notice of Changes (ANOC), H0562 - 122 - Vietnamese (PDF) - coming soon
Wellcare Plus Sapphire II (HMO)	H3561-002	Alameda, Fresno, Imperial, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Francisco, Tulare	Annual Notice of Changes (ANOC), H3561 - 002 - English (PDF) Annual Notice of Changes (ANOC), H3561-002 - Spanish (PDF) Annual Notice of Changes (ANOC), H3561-002 - Chinese (PDF) - coming soon Annual Notice of Changes (ANOC), H3561-002 - Korean (PDF) - coming soon Annual Notice of Changes (ANOC), H3561-002 - Vietnamese (PDF) - coming soon
Wellcare No Premium Ruby (HMO)	H0562 - 079	Fresno, Kern, Madera	Annual Notice of Changes (ANOC), H0562 - 079 - English (PDF) Annual Notice of Changes (ANOC), H0562 - 079 - Spanish (PDF) Annual Notice of Changes (ANOC), H0562 - 079 - Chinese (PDF) - coming soon Annual Notice of Changes (ANOC), H0562 - 079 - Korean (PDF) - coming soon Annual Notice of Changes (ANOC), H0562 - 079 - Vietnamese (PDF) - coming soon
Wellcare No Premium (HMO)	H0562 - 090	Fresno	Annual Notice of Changes (ANOC), H0562 - 090 - English (PDF) Annual Notice of Changes (ANOC), H0562 - 090 - Spanish (PDF) Annual Notice of Changes (ANOC), H0562 - 090 - Chinese (PDF) - coming soon Annual Notice of Changes (ANOC), H0562 - 090 - Korean (PDF) - coming soon Annual Notice of Changes (ANOC), H0562 - 090 - Vietnamese (PDF) - coming soon
Wellcare No Premium (HMO)	H0562 - 125	Los Angeles, Orange	Annual Notice of Changes (ANOC), H0562 - 125 - English (PDF) Annual Notice of Changes (ANOC), H0562 - 125 - Spanish (PDF) Annual Notice of Changes (ANOC), H0562 - 125 - Chinese (PDF) - coming soon Annual Notice of Changes (ANOC), H0562 - 125 - Korean (PDF) - coming soon Annual Notice of Changes (ANOC), H0562 - 125 - Vietnamese (PDF) - coming soon
Wellcare No Premium (HMO)	H0562 - 120	Santa Clara, Stanislaus	Annual Notice of Changes (ANOC), H0562 - 120 - English (PDF) Annual Notice of Changes (ANOC), H0562 - 120 - Spanish (PDF) Annual Notice of Changes (ANOC), H0562 - 120 - Chinese (PDF) - coming soon Annual Notice of Changes (ANOC), H0562 - 120 - Korean (PDF) - coming soon Annual Notice of Changes (ANOC), H0562 - 120 - Vietnamese (PDF) - coming soon
Wellcare Premium Ultra (HMO)	H0562 -009	Alameda, Amador, Contra Costa, San Francisco, Stanislaus	Annual Notice of Changes (ANOC), H0562 - 009 - English (PDF) Annual Notice of Changes (ANOC), H0562 - 009 - Spanish (PDF) Annual Notice of Changes (ANOC), H0562 - 009 - Chinese (PDF)
Wellcare Premium Ultra (HMO)	H0562 - 084	Placer, Sacramento	Annual Notice of Changes (ANOC), H0562 - 084 - English (PDF) Annual Notice of Changes (ANOC), H0562 - 084 - Spanish (PDF) Annual Notice of Changes (ANOC), H0562 - 084 - Chinese (PDF) - coming soon Annual Notice of Changes (ANOC), H0562 - 084 - Korean (PDF) - coming soon Annual Notice of Changes (ANOC), H0562 - 084 - Vietnamese (PDF) - coming soon
Wellcare Premium Enhanced (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 - 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 - 103	Amador, Contra Costa, Yolo	Annual Notice of Changes (ANOC), H0562 - 103 - English (PDF) Annual Notice of Changes (ANOC), H0562 - 103 - Spanish (PDF)
Wellcare No Premium (HMO)	H0562 - 124	Placer, Sacramento	Annual Notice of Changes (ANOC), H0562 - 124 - English (PDF) Annual Notice of Changes (ANOC), H0562 - 124 - Spanish (PDF) - coming soon
Wellcare No Premium (HMO)	H0562 - 113	Alameda	Annual Notice of Changes (ANOC), H0562 - 113 - English (PDF) Annual Notice of Changes (ANOC), H0562 - 113 - Chinese (PDF)
Wellcare Patriot Giveback (HMO)	H0562 - 044	Alameda, Amador, Contra Costa, Los Angeles, Placer, Riverside, Sacramento, San Bernardino, Stanislaus	Annual Notice of Changes (ANOC), H0562 - 044 - English (PDF) Annual Notice of Changes (ANOC), H0562 - 044 - Spanish (PDF)
Wellcare Low Premium (HMO)	H0562 - 123	Los Angeles, Orange, Riverside, San Bernardino	Annual Notice of Changes (ANOC), H0562 - 123 - English (PDF) Annual Notice of Changes (ANOC), H0562 - 123 - Spanish (PDF) Annual Notice of Changes (ANOC), H0562 - 123 - Chinese (PDF) - coming soon
Wellcare No Premium (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 (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 DSNP and C SNP Members

Plans	CMS#	County	Annual Notice of Changes (ANOC)
Wellcare Dual Liberty (HMO D-SNP)	H0562 - 121	Fresno, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Francisco & Tulare	Annual Notice of Changes (ANOC), H0562 - 121 - English (PDF) Annual Notice of Changes (ANOC), H0562 - 121 - Spanish (PDF)
Wellcare Dual Liberty Amber (HMO D-SNP)	H3561 - 001	Alameda, Amador, Fresno, Imperial, Madera, Placer, Sacramento, Stanislaus	Annual Notice of Changes (ANOC), H3561 - 001 - English (PDF) Annual Notice of Changes (ANOC), H3561 - 001 - Spanish (PDF)
Wellcare Specialty No Premium (HMO C-SNP)	H0562 - 092	Kern, Los Angeles, Orange	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	San Diego	Annual Notice of Changes (ANOC), H0562 - 114 - English (PDF) Annual Notice of Changes (ANOC), H0562 - 114 - Spanish (PDF)
Wellcare Specialty No Premium (HMO C-SNP)	H0562 - 118	Fresno, San Francisco	Annual Notice of Changes (ANOC), H0562 - 118 - English (PDF) Annual Notice of Changes (ANOC), H0562 - 118 - Spanish (PDF) Annual Notice of Changes (ANOC), H0562 - 118 - Chinese (PDF)

Plan Benefit Materials | Health Net Medicare Advantage for California

Plan Materials and Forms

Summary of Benefits (SB)

For HMO Members:

For HMO DSNP and C SNP Members:

For PPO Members:

Evidence Of Coverage (EOC)

For HMO Members

For HMO DSNP and C SNP Members

Annual Notice of Changes (ANOC)

For HMO DSNP and C SNP Members

Dental

Optional Benefit Individual Enrollment Form

Optional Supplemental Benefits Flyers

Wellcare Premium Ultra (HMO)

Riverside & San Bernardino

San Diego

Wellcare No Premium (HMO)

Yolo

Alameda & Stanislaus

Placer & Sacramento

Kern

Wellcare Premium Enhanced (HMO)

San Francisco

Wellcare Low Premium (HMO)

Alameda

Wellcare Patriot Giveback (HMO)

Fresno

Wellcare Specialty No Premium (HMO C-SNP)

Fresno, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Francisco and Tulane

Over-The-Counter Benefits

Plan Benefit Materials

Summary of Benefits (SB)

For HMO Members:

For HMO DSNP and C SNP Members:

For PPO Members:

Evidence Of Coverage (EOC)

For HMO Members

For HMO DSNP and C SNP Members

Annual Notice of Changes (ANOC)

For HMO DSNP and C SNP Members

Dental

Optional Benefit Individual Enrollment Form

Optional Supplemental Benefits Flyers

Wellcare Premium Ultra (HMO)

Riverside & San Bernardino

San Diego

Wellcare No Premium (HMO)

Yolo

Alameda & Stanislaus

Placer & Sacramento

Kern

Wellcare Premium Enhanced (HMO)

San Francisco

Wellcare Low Premium (HMO)

Alameda

Wellcare Patriot Giveback (HMO)

Fresno

Wellcare Specialty No Premium (HMO C-SNP)

Fresno, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Francisco and Tulane

Over-The-Counter Benefits

VBID