Plan Benefit Materials |

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 parish:

For HMO Members:

Plan Name CMS# Parish Summary of Benefits
Allwell Medicare (HMO) H5117-003 Acadia, Ascension, East Baton Rouge, Iberville, Lafayette, Livingston, Pointe Coupee, St. James, St. Landry, St. Martin, St. Tammany, Tangipahoa, Washington and West Baton Rouge


For HMO D-SNP Members:

Plan Name CMS# Parish Summary of Benefits
Allwell Dual Medicare
(HMO D-SNP)
H5117-004 Ascension, East Baton Rouge, Jefferson, Livingston, Orleans, Pointe Coupee, St. Tammany, Tangipahoa, Washington and West Baton Rouge
Allwell Dual Medicare Essentials
(HMO D-SNP)
H5117-005 Ascension, East Baton Rouge, Jefferson, Livingston, Orleans, Pointe Coupee, St. Tammany, Tangipahoa, Washington and West Baton Rouge

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

Please select the document for your plan and parish:

For HMO Members:

Plan Name CMS# Parish Evidence of Coverage 

Allwell Medicare (HMO)

 

H5117-003

Acadia, Ascension, East Baton Rouge, Iberville, Lafayette, Livingston, Pointe Coupee, St. James, St. Landry, St. Martin, St. Tammany, Tangipahoa, Washington and West Baton Rouge


For HMO D-SNP Members:

Plan Name CMS# Parish Evidence of Coverage
Allwell Dual Medicare
(HMO D-SNP)
H5117-004 Ascension, East Baton Rouge, Jefferson, Livingston, Orleans, Pointe Coupee, St. Tammany, Tangipahoa, Washington and West Baton Rouge
Allwell Dual Medicare Essentials
(HMO D-SNP)
H5117 - 005 Ascension, East Baton Rouge, Jefferson, Livingston, Orleans, Pointe Coupee, St. Tammany, Tangipahoa, Washington and West Baton Rouge

If you were enrolled in Allwell from Louisiana Healthcare Connections last year, 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 parish:

For HMO Members:

Plan Name CMS# Parish Annual Notice of Changes
Allwell Medicare (HMO) H5117-003

Acadia, Ascension, East Baton Rouge, Iberville, Lafayette, Livingston, Pointe Coupee, St. James, St. Landry, St. Martin, St. Tammany, Tangipahoa, Washington and West Baton Rouge

Allwell Medicare (HMO) H5117-001-003 and H5117-002-003 Ascension, East Baton Rouge, Iberville, Livingston, Pointe Coupee, St. James, St Tammany parish, Tangipahoa, Washington Acadia, Lafayette, St. Landry, St. Martin parishes and West Baton Rouge parishes

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.

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. 

 

 

 

Material ID: Y0020_20_17590WEB_C_03192020