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Plan Materials and Forms

For HMO Members

Plans CMS# County Summary of Benefits
Allwell Medicare (HMO)

H0351 - 044-001

 

  • Pima
Allwell Medicare (HMO) H0351 - 044-002
  • Cochise
Allwell Medicare (HMO)

H0351 - 044-003

  • Santa Cruz
Allwell Medicare Premier (HMO) 

H0351 - 043-001

 

  • Maricopa
Allwell Medicare Premier (HMO)  H0351 - 043-004
  • Pinal
Allwell Medicare Premier (HMO) 

H9287 - 001

  • Pima
Allwell Medicare Essentials I (HMO)  H9287 - 004
  • Maricopa
Allwell Medicare Essentials II (HMO)

H0351 - 049-001

 

  • Maricopa
Allwell Medicare Essentials II (HMO)

H0351 - 049-002

  • Pinal
Allwell Medicare Select (HMO) H0351 - 041
  • Pima
Allwell Medicare Complement (HMO)  H0351 - 030
  • Cochise, Maricopa, Pinal, Santa Cruz


For HMO SNP Members

Plans  CMS# County Summary of Benefits
Allwell Dual Medicare (HMO SNP)  H5590 - 003
  • Maricopa
Allwell CHF/Diabetes Medicare (HMO SNP)  H0351 - 038
  • Maricopa, Pinal
Allwell Cardio Medicare (HMO SNP) H0351 - 042
  • Maricopa, Pinal

For HMO Members

Plans CMS# County Annual Notice of Coverage
Allwell Medicare (HMO)

H0351 - 044-001

 

  • Pima
Allwell Medicare (HMO) H0351 - 044-002
  • Cochise
Allwell Medicare (HMO)

H0351 - 044-003

  • Santa Cruz 
Allwell Medicare Premier (HMO) 

H0351 - 043-001

 

  • Maricopa
Allwell Medicare Premier (HMO)  H0351 - 043-004
  • Pinal
Allwell Medicare Premier (HMO) 

H9287 - 001

  • Pima
Allwell Medicare Essentials II (HMO)

H0351 - 049-001

 

  • Maricopa
Allwell Medicare Essentials II (HMO)

H0351 - 049-002

  • Pinal
Allwell Medicare Select (HMO) H0351 - 041
  • Pima
Allwell Medicare Complement (HMO)  H0351 - 030
  • Cochise, Maricopa, Pinal, Santa Cruz

 

For HMO SNP Members

Plans  CMS# County Annual Notice of Coverage
Allwell CHF/Diabetes Medicare (HMO SNP)  H0351 - 038
  • Maricopa, Pinal
Allwell Cardio Medicare (HMO SNP) H0351 - 042
  • Maricopa, Pinal

For HMO Members

Plans CMS# County Evidence of Coverage
Allwell Medicare (HMO) H0351 - 044-001
  • Pima
Allwell Medicare (HMO) H0351 - 044-002
  • Cochise
Allwell Medicare (HMO)

H0351 - 044-003

  • Santa Cruz
Allwell Medicare Premier (HMO)  H0351 - 043-001
  • Maricopa
Allwell Medicare Premier (HMO)  H0351 - 043-004
  • Pinal
Allwell Medicare Premier (HMO) 

H9287 - 001

  • Pima
Allwell Medicare Essentials I (HMO) H9287 - 004
  • Maricopa
Allwell Medicare Essentials II (HMO)

H0351 - 049-001

 

  • Maricopa
Allwell Medicare Essentials II (HMO)

H0351 - 049-002

  • Pinal  
Allwell Medicare Select (HMO) H0351 - 041
  • Pima
Allwell Medicare Complement (HMO)  H0351 - 030
  • Cochise, Maricopa, Pinal, Santa Cruz

 

For HMO SNP Members

Plans  CMS# County Annual Notice of Coverage
Allwell Dual Medicare (HMO SNP) H5590 - 003
  • Maricopa
Allwell CHF/Diabetes Medicare (HMO SNP)  H0351 - 038
  • Maricopa, Pinal
Allwell Cardio Medicare (HMO SNP) H0351 - 042
  • Maricopa, Pinal

For HMO Members

Plans CMS# County LIS Premium Charts
Allwell Medicare (HMO) H0351 - 044-001
  • Pima
Allwell Medicare (HMO) H0351 - 044-002
  • Cochise
Allwell Medicare (HMO)

H0351 - 044-003

  • Santa Cruz
Allwell Medicare Premier (HMO)  H0351 - 043-001
  • Maricopa
Allwell Medicare Premier (HMO)  H0351 - 043-004
  • Pinal
Allwell Medicare Premier (HMO) 

H9287 - 001

  • Pima
Allwell Medicare Essentials I (HMO)  H9287 - 004
  • Maricopa
Allwell Medicare Essentials II (HMO)

H0351 - 049-001

 

  • Maricopa
Allwell Medicare Essentials II (HMO)

H0351 - 049-002

  • Pinal
Allwell Medicare Select (HMO) H0351 - 041
  • Pima
Allwell Medicare Complement (HMO)  H0351 - 030
  • Cochise, Maricopa, Pinal, Santa Cruz

For HMO SNP Members

Plans  CMS# County Summary of Benefits
Allwell Dual Medicare (HMO SNP)  H5590 - 003
  • Maricopa
Allwell CHF/Diabetes Medicare (HMO SNP)  H0351 - 038
  • Maricopa, Pinal
Allwell Cardio Medicare (HMO SNP) H0351 - 042
  • Maricopa, Pinal

For all plans except Allwell Dual Medicare HMO SNP

Preferred Diabetes Testing Supplies (PDF)