Plan Materials and Forms

Listed below are some documents that may be helpful at different times during your membership.

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 Name	CMS #	County	Summary of Benefits
Allwell Medicare (HMO)	H2915-003	Allegheny, Armstrong, Beaver, Bedford, Blair, Butler, Cambria, Cameron, Clarion, Clearfield, Crawford, Elk, Erie, Fayette, Forest, Greene, Indiana, Jefferson, Lawrence, McKean, Mercer, Potter, Somerset, Venango, Warren, Washington and Westmoreland	Summary of Benefits, H2915-003 - English (PDF)
Allwell Medicare (HMO)	H2915-006	Berks, Bradford, Bucks, Centre, Chester, Cumberland, Dauphin, Delaware, Fulton, Huntingdon, Juniata, Lackawanna, Lancaster, Lebanon, Lycoming, Mifflin, Montgomery, Perry, Philadelphia, Synder, Sullivan, Susquehanna, Tioga, Union, Wayne and Wyoming	Summary of Benefits, H2915-006 - English (PDF)

For HMO D-SNP Members:

Plan Name	CMS #	County	Summary of Benefits
Allwell Dual Medicare (HMO D-SNP)	H2915-001	Allegheny, Armstrong, Beaver, Bedford, Blair, Butler, Cambria, Cameron, Clarion, Clearfield, Crawford, Elk, Erie, Fayette, Forest, Greene, Indiana, Jefferson, Lawrence, McKean, Mercer, Potter, Somerset, Venango, Warren, Washington and Westmoreland	Summary of Benefits, H2915-001 - English (PDF)
Allwell Dual Medicare (HMO D-SNP)	H2915-002	Bucks, Chester, Delaware, Montgomery, and Philadelphia	Summary of Benefits, H2915-002 - English (PDF)
Allwell Dual Medicare (HMO D-SNP)	H2915-007	Adam, Berks, Bradford, Carbon, Centre, Clinton, Cumberland, Dauphin, Franklin, Fulton, Huntingdon, Juniata, Lackawanna, Lancaster, Lebanon, Lehigh, Luzerne, Lycoming, Mifflin, Monroe, Northampton, Perry, Pike, Schuylkill, Snyder, Sullivan, Susquehanna, Tioga, Union, Wayne, Wyoming and York	Summary of Benefits, H2915-007 - English (PDF)

Plan Name

CMS #

County

Summary of Benefits

Allwell Dual Medicare
(HMO D-SNP)

H2915-001

Allegheny, Armstrong, Beaver, Bedford, Blair, Butler, Cambria, Cameron, Clarion, Clearfield, Crawford, Elk, Erie, Fayette, Forest, Greene, Indiana, Jefferson, Lawrence, McKean, Mercer, Potter, Somerset, Venango, Warren, Washington and Westmoreland

Summary of Benefits, H2915-001 - English (PDF)

Allwell Dual Medicare
(HMO D-SNP)

H2915-002

Bucks, Chester, Delaware, Montgomery, and Philadelphia

Summary of Benefits, H2915-002 - English (PDF)

Allwell Dual Medicare
(HMO D-SNP)

H2915-007

Adam, Berks, Bradford, Carbon, Centre, Clinton, Cumberland, Dauphin, Franklin, Fulton, Huntingdon, Juniata, Lackawanna, Lancaster, Lebanon, Lehigh, Luzerne, Lycoming, Mifflin, Monroe, Northampton, Perry, Pike, Schuylkill, Snyder, Sullivan, Susquehanna, Tioga, Union, Wayne, Wyoming and York

Summary of Benefits, H2915-007 - English (PDF)

This booklet gives you a complete list of services, limitations and exclusions for your plan coverage.

Please select the document for your plan and county:

For HMO Members:

Plan Name	CMS #	County	Evidence of Coverage (EOC)
Allwell Medicare (HMO)	H2915-003	Allegheny, Armstrong, Beaver, Bedford, Blair, Butler, Cambria, Cameron, Clarion, Clearfield, Crawford, Elk, Erie, Fayette, Forest, Greene, Indiana, Jefferson, Lawrence, McKean, Mercer, Potter, Somerset, Venango, Warren, Washington and Westmoreland	Evidence of Coverage, H2915-003 - English (PDF)
Allwell Medicare (HMO)	H2915-006	Berks, Bradford, Bucks, Centre, Chester, Cumberland, Dauphin, Delaware, Fulton, Huntingdon, Juniata, Lackawanna, Lancaster, Lebanon, Lycoming, Mifflin, Montgomery, Perry, Philadelphia, Synder, Sullivan, Susquehanna, Tioga, Union, Wayne and Wyoming	Evidence of Coverage, H2915-006 - English (PDF)

For HMO D-SNP Members:

2020 Medicare Defined Cost Sharing Amounts Notice (PDF)

Plan Name	CMS #	County	Evidence of Coverage (EOC)
Allwell Dual Medicare (HMO D-SNP)	H2915-001	Allegheny, Armstrong, Beaver, Bedford, Blair, Butler, Cambria, Cameron, Clarion, Clearfield, Crawford, Elk, Erie, Fayette, Forest, Greene, Indiana, Jefferson, Lawrence, McKean, Mercer, Potter, Somerset, Venango, Warren, Washington and Westmoreland	Evidence of Coverage, H2915-001 - English (PDF)
Allwell Dual Medicare (HMO D-SNP)	H2915-002	Bucks, Chester, Delaware, Montgomery, and Philadelphia	Evidence of Coverage, H2915-002 - English (PDF)
Allwell Dual Medicare (HMO D-SNP)	H2915-007	Adam, Berks, Bradford, Carbon, Centre, Clinton, Cumberland, Dauphin, Franklin, Fulton, Huntingdon, Juniata, Lackawanna, Lancaster, Lebanon, Lehigh, Luzerne, Lycoming, Mifflin, Monroe, Northampton, Perry, Pike, Schuylkill, Snyder, Sullivan, Susquehanna, Tioga, Union, Wayne, Wyoming and York	Evidence of Coverage, H2915-007 - English (PDF)

This booklet will tell you about changes to your plan’s costs and benefits for the coming year.

Please select the document for your plan and county:

For HMO Members:

Plan Name	CMS #	County	Annual Notice Of Changes (ANOC)
Allwell Medicare (HMO)	H2915-003 H2915-005 - 003	Allegheny, Armstrong, Beaver, Bedford, Blair, Butler, Cambria, Cameron, Clarion, Clearfield, Crawford, Elk, Erie, Fayette, Forest, Greene, Indiana, Jefferson, Lawrence, McKean, Mercer, Potter, Somerset, Venango, Warren, Washington and Westmoreland	Annual Notice of Changes, H2915-003 - English (PDF) Annual Notice of Changes H2915 - 005 - 003 English (PDF)
Allwell Medicare (HMO)	H2915-006	Berks, Bradford, Bucks, Centre, Chester, Cumberland, Dauphin, Delaware, Fulton, Huntingdon, Juniata, Lackawanna, Lancaster, Lebanon, Lycoming, Mifflin, Montgomery, Perry, Philadelphia, Synder, Sullivan, Susquehanna, Tioga, Union, Wayne and Wyoming	Annual Notice of Changes H2915 - 006 - English (PDF)

Plan Name

CMS #

County

Annual Notice Of Changes (ANOC)

Allwell Medicare (HMO)

H2915-003

H2915-005 - 003

Annual Notice of Changes, H2915-003 - English (PDF)

Annual Notice of Changes H2915 - 005 - 003 English (PDF)

Allwell Medicare (HMO)

H2915-006

Berks, Bradford, Bucks, Centre, Chester, Cumberland, Dauphin, Delaware, Fulton, Huntingdon, Juniata, Lackawanna, Lancaster, Lebanon, Lycoming, Mifflin, Montgomery, Perry, Philadelphia, Synder, Sullivan, Susquehanna, Tioga, Union, Wayne and Wyoming

Annual Notice of Changes H2915 - 006 - English (PDF)

For HMO D-SNP Members:

Plan Name	CMS #	County	Annual Notice Of Changes (ANOC)
Allwell Dual Medicare (HMO D-SNP)	H2915-001 H2915-009 - 001	Allegheny, Armstrong, Beaver, Bedford, Blair, Butler, Cambria, Cameron, Clarion, Clearfield, Crawford, Elk, Erie, Fayette, Forest, Greene, Indiana, Jefferson, Lawrence, McKean, Mercer, Potter, Somerset, Venango, Warren, Washington and Westmoreland	Annual Notice of Changes, H2915-001 - English (PDF) Annual Notice of Changes H2915 - 009 - 001- English (PDF)
Allwell Dual Medicare (HMO D- SNP)	H2915-002	Bucks, Chester, Delaware, Montgomery, and Philadelphia	Annual Notice of Changes, H2915-002 - English (PDF)
Allwell Dual Medicare (HMO D- SNP)	H2915 - 007	Adam, Berks, Bradford, Carbon, Centre, Clinton, Cumberland, Dauphin, Franklin, Fulton, Huntingdon, Juniata, Lackawanna, Lancaster, Lebanon, Lehigh, Luzerne, Lycoming, Mifflin, Monroe, Northampton, Perry, Pike, Schuylkill, Snyder, Sullivan, Susquehanna, Tioga, Union, Wayne, Wyoming and York	Annual Notice of Changes H2915 - 007 - English (PDF)

Plan Name

CMS #

County

Annual Notice Of Changes (ANOC)

Allwell Dual Medicare (HMO D-SNP)

H2915-001

H2915-009 - 001

Annual Notice of Changes, H2915-001 - English (PDF)

Annual Notice of Changes H2915 - 009 - 001- English (PDF)

Allwell Dual Medicare (HMO D- SNP)

H2915-002

Bucks, Chester, Delaware, Montgomery, and Philadelphia

Annual Notice of Changes, H2915-002 - English (PDF)

Allwell Dual Medicare (HMO D- SNP)

H2915 - 007

Annual Notice of Changes H2915 - 007 - English (PDF)

Your current plan may have an over-the-counter (OTC) benefit that lets you buy OTC health and wellness products. This catalog includes a list of OTC items that you can order to be mailed to your home. Check the catalog for item limits.

Ordering is easy. Just follow the steps in your plan's catalog.

Over-the-Counter Catalog - English / Spanish (PDF)

Don’t want to wait? You may be able to pick up your OTC products from a CVS store near you. Please note: this does not include CVS locations inside of Target stores.

Connect to the CVS OTC website to view available products and store information.

Acupuncture National Coverage (PDF)

Plan Name	CMS #	County	Summary of Benefits
Allwell Medicare (HMO)	H2915-003	Allegheny, Armstrong, Beaver, Bedford, Blair, Butler, Cambria, Cameron, Clarion, Clearfield, Crawford, Elk, Erie, Fayette, Forest, Greene, Indiana, Jefferson, Lawrence, McKean, Mercer, Potter, Somerset, Venango, Warren, Washington and Westmoreland counties	Summary of Benefits, H2915-003 - English (PDF)
Allwell Medicare Simple (HMO)	H2915-010	Allegheny, Armstrong, Beaver, Bedford, Berks, Blair, Bradford, Butler, Cambria, Cameron, Centre, Clarion, Clearfield, Crawford, Cumberland, Dauphin, Elk, Erie, Fayette, Forest, Fulton, Greene, Huntingdon, Indiana, Jefferson, Juniata, Lackawanna, Lancaster, Lawrence, Lebanon, Lycoming, McKean, Mercer, Mifflin, Perry, Potter, Snyder, Somerset, Sullivan, Susquehanna, Tioga, Union, Venango, Warren, Washington, Wayne, Westmoreland and Wyoming counties	Summary of Benefits, H2915-010 - English (PDF)
Allwell Medicare Complement (HMO)	H2915-011	Allegheny, Armstrong, Beaver, Bedford, Berks, Blair, Bradford, Bucks, Butler, Cambria, Cameron, Centre, Chester, Clarion, Clearfield, Crawford, Cumberland, Dauphin, Delaware, Elk, Erie, Fayette, Forest, Fulton, Greene, Huntingdon, Indiana, Jefferson, Juniata, Lackawanna, Lancaster, Lawrence, Lebanon, Lycoming, McKean, Mercer, Mifflin, Montgomery, Perry, Philadelphia, Potter, Snyder, Somerset, Sullivan, Susquehanna, Tioga, Union, Venango, Warren, Washington, Wayne, Westmoreland and Wyoming counties	Summary of Benefits, H2915-011 - English (PDF)
Allwell Medicare Boost (HMO)	H2915-012	Allegheny, Armstrong, Beaver, Bedford, Berks, Blair, Bradford, Butler, Cambria, Cameron, Centre, Clarion, Clearfield, Crawford, Cumberland, Dauphin, Elk, Erie, Fayette, Forest, Fulton, Greene, Huntingdon, Indiana, Jefferson, Juniata, Lackawanna, Lancaster, Lawrence, Lebanon, Lycoming, McKean, Mercer, Mifflin, Perry, Potter, Snyder, Somerset, Sullivan, Susquehanna, Tioga, Union, Venango, Warren, Washington, Wayne, Westmoreland and Wyoming counties	Summary of Benefits, H2915-012 - English (PDF)
Allwell Medicare Simple (HMO)	H2915-013	Bucks, Chester, Delaware, Montgomery and Philadelphia counties	Summary of Benefits, H2915-013 - English (PDF)
Allwell Medicare Boost (HMO)	H2915-014	Bucks, Chester, Delaware, Montgomery and Philadelphia counties	Summary of Benefits, H2915-014 - English (PDF)
Allwell Medicare (HMO)	H2915-015-002	Berks, Bradford, Centre, Cumberland, Dauphin, Fulton, Huntingdon, Juniata, Lackawanna, Lancaster, Lebanon, Lycoming, Mifflin, Perry, Snyder, Sullivan, Susquehanna, Tioga, Union, Wayne and Wyoming counties	Summary of Benefits, H2915-015-002 - English (PDF)
Allwell Medicare (HMO)	H2915-015-003	Bucks, Chester, Delaware, Montgomery and Philadelphia counties	Summary of Benefits, H2915-015-003 - English (PDF)

Plan Name	CMS #	County	Evidence of Coverage (EOC)
Allwell Medicare (HMO)	H2915-003	Allegheny, Armstrong, Beaver, Bedford, Blair, Butler, Cambria, Cameron, Clarion, Clearfield, Crawford, Elk, Erie, Fayette, Forest, Greene, Indiana, Jefferson, Lawrence, McKean, Mercer, Potter, Somerset, Venango, Warren, Washington and Westmoreland counties	Evidence of Coverage, H2915-003 - English (PDF)
Allwell Medicare Simple (HMO)	H2915-010	Allegheny, Armstrong, Beaver, Bedford, Berks, Blair, Bradford, Butler, Cambria, Cameron, Centre, Clarion, Clearfield, Crawford, Cumberland, Dauphin, Elk, Erie, Fayette, Forest, Fulton, Greene, Huntingdon, Indiana, Jefferson, Juniata, Lackawanna, Lancaster, Lawrence, Lebanon, Lycoming, McKean, Mercer, Mifflin, Perry, Potter, Snyder, Somerset, Sullivan, Susquehanna, Tioga, Union, Venango, Warren, Washington, Wayne, Westmoreland and Wyoming counties	Evidence of Coverage, H2915-010 - English (PDF)
Allwell Medicare Complement (HMO)	H2915-011	Allegheny, Armstrong, Beaver, Bedford, Berks, Blair, Bradford, Bucks, Butler, Cambria, Cameron, Centre, Chester, Clarion, Clearfield, Crawford, Cumberland, Dauphin, Delaware, Elk, Erie, Fayette, Forest, Fulton, Greene, Huntingdon, Indiana, Jefferson, Juniata, Lackawanna, Lancaster, Lawrence, Lebanon, Lycoming, McKean, Mercer, Mifflin, Montgomery, Perry, Philadelphia, Potter, Snyder, Somerset, Sullivan, Susquehanna, Tioga, Union, Venango, Warren, Washington, Wayne, Westmoreland and Wyoming counties	Evidence of Coverage, H2915-011 - English (PDF)
Allwell Medicare Boost (HMO)	H2915-012	Allegheny, Armstrong, Beaver, Bedford, Berks, Blair, Bradford, Butler, Cambria, Cameron, Centre, Clarion, Clearfield, Crawford, Cumberland, Dauphin, Elk, Erie, Fayette, Forest, Fulton, Greene, Huntingdon, Indiana, Jefferson, Juniata, Lackawanna, Lancaster, Lawrence, Lebanon, Lycoming, McKean, Mercer, Mifflin, Perry, Potter, Snyder, Somerset, Sullivan, Susquehanna, Tioga, Union, Venango, Warren, Washington, Wayne, Westmoreland and Wyoming counties	Evidence of Coverage, H2915-012 - English (PDF)
Allwell Medicare Simple (HMO)	H2915-013	Bucks, Chester, Delaware, Montgomery and Philadelphia counties	Evidence of Coverage, H2915-013 - English (PDF)
Allwell Medicare Boost (HMO)	H2915-014	Bucks, Chester, Delaware, Montgomery and Philadelphia counties	Evidence of Coverage, H2915-014 - English (PDF)
Allwell Medicare (HMO)	H2915-015-002	Berks, Bradford, Centre, Cumberland, Dauphin, Fulton, Huntingdon, Juniata, Lackawanna, Lancaster, Lebanon, Lycoming, Mifflin, Perry, Snyder, Sullivan, Susquehanna, Tioga, Union, Wayne and Wyoming counties	Evidence of Coverage, H2915-015-002 - English (PDF)
Allwell Medicare (HMO)	H2915-015-003	Bucks, Chester, Delaware, Montgomery and Philadelphia counties	Evidence of Coverage, H2915-015-003 - English (PDF)

Plan Benefit Materials | Allwell from PA Health and Wellness

Plan Materials and Forms

For HMO Members:

For HMO D-SNP Members:

For HMO Members:

For HMO D-SNP Members:

For HMO Members:

For HMO D-SNP Members:

Plan Benefit Materials

For HMO Members:

For HMO SNP Members:

For HMO Members:

For HMO SNP Members:

For HMO Members:

For HMO SNP Members:

Plan Benefit Materials | Allwell from PA Health and Wellness

Plan Materials and Forms

Summary of Benefits

For HMO Members:

For HMO D-SNP Members:

Evidence Of Coverage (EOC)

For HMO Members:

For HMO D-SNP Members:

Annual Notice of Changes (ANOC)

For HMO Members:

For HMO D-SNP Members:

Over-the-Counter Benefits

Acupuncture National Coverage

Plan Benefit Materials

Summary of Benefits

For HMO Members:

For HMO SNP Members:

Evidence Of Coverage (EOC)

For HMO Members:

For HMO SNP Members:

Annual Notice of Changes (ANOC)

For HMO Members:

For HMO SNP Members:

Optional Supplemental Benefits Brochure

Optional Individual Benefit Enrollment Form

Acupuncture National Coverage

Over-The-Counter Benefits