Plan Benefit Materials

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:

Plans	CMS#	County	Annual Notice of Changes
Wellcare Assist (HMO)	H6815-037	Benton, Clackamas, Columbia, Coos, Crook, Deschutes, Douglas, Jackson, Jefferson, Josephine, Lane, Linn, Marion, Multnomah, Polk, Washington, Yamhill	Summary of Benefits, H6815-037 - English (PDF)
Wellcare No Premium (HMO)	H6815-038	Benton, Clackamas, Columbia, Coos, Crook, Deschutes, Douglas, Jackson, Jefferson, Josephine, Lane, Linn, Marion, Multnomah, Polk, Washington, Yamhill	Summary of Benefits, H6815-038 - English (PDF)
Wellcare No Premium (HMO)	H6815-039	Benton, Clackamas, Columbia, Crook, Deschutes, Jefferson, Lane, Linn, Marion, Multnomah, Polk, Washington, Yamhill	Summary of Benefits, H6815-039 - English (PDF)

For PPO Members:

Plans	CMS#	County	Annual Notice of Changes
Wellcare Premium Ultra Open (PPO)	H5439-011	Benton, Clackamas, Douglas, Jackson, Josephine, Lane, Linn, Marion, Multnomah, Polk, Washington, Yamhill	Summary of Benefits, H5439-011 - English (PDF)
Wellcare Giveback Open (PPO)	H5439-015	Benton, Clackamas, Douglas, Jackson, Josephine, Lane, Linn, Marion, Multnomah, Polk, Washington, Yamhill	Summary of Benefits, H5439-015 - English (PDF)
Wellcare No Premium Open (PPO)	H5439-017	Benton, Clackamas, Douglas, Jackson, Josephine, Lane, Linn, Marion, Multnomah, Polk, Washington, Yamhill	Summary of Benefits, H5439-017 - English (PDF)
Wellcare Low Premium Open (PPO)	H5439-019	Benton, Clackamas, Douglas, Jackson, Josephine, Lane, Linn, Marion, Multnomah, Polk, Washington, Yamhill	Summary of Benefits, H5439-019 - English (PDF)
Wellcare Patriot No Premium Open (PPO)	H5439-010	Benton, Clackamas, Douglas, Jackson, Josephine, Lane, Linn, Marion, Multnomah, Polk, Washington, Yamhill	Summary of Benefits, H5439-010 - English (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:

Plans	CMS#	County	Evidence Of Coverage
Wellcare Assist (HMO)	H6815-037	Benton, Clackamas, Columbia, Coos, Crook, Deschutes, Douglas, Jackson, Jefferson, Josephine, Lane, Linn, Marion, Multnomah, Polk, Washington, Yamhill	Evidence of Coverage, H6815-037 - English (PDF) Dental Benefit Details -English (PDF)
Wellcare No Premium (HMO)	H6815-038	Benton, Clackamas, Columbia, Coos, Crook, Deschutes, Jackson, Jefferson, Josephine, Lane, Linn, Marion, Multnomah, Polk, Washington, Yamhill	Evidence Of Coverage, H6815-038 - English (PDF) Dental Benefit Details -English (PDF)
Wellcare No Premium (HMO)	H6815-039	Benton, Clackamas, Columbia, Crook, Deschutes, Jefferson, Lane, Linn, Marion, Multnomah, Polk, Washington, Yamhill	Evidence Of Coverage, H6815-039 - English (PDF) Dental Benefit Details -English (PDF)

Plans

CMS#

County

Evidence Of Coverage

Wellcare Assist (HMO)

H6815-037

Benton, Clackamas, Columbia, Coos, Crook, Deschutes, Douglas, Jackson, Jefferson, Josephine, Lane, Linn, Marion, Multnomah, Polk, Washington, Yamhill

Evidence of Coverage, H6815-037 - English (PDF)

Dental Benefit Details -English (PDF)

Wellcare No Premium (HMO)

H6815-038

Benton, Clackamas, Columbia, Coos, Crook, Deschutes, Jackson, Jefferson, Josephine, Lane, Linn, Marion, Multnomah, Polk, Washington, Yamhill

Evidence Of Coverage, H6815-038 - English (PDF)

Dental Benefit Details -English (PDF)

Wellcare No Premium (HMO)

H6815-039

Benton, Clackamas, Columbia, Crook, Deschutes, Jefferson, Lane, Linn, Marion, Multnomah, Polk, Washington, Yamhill

Evidence Of Coverage, H6815-039 - English (PDF)

Dental Benefit Details -English (PDF)

For PPO Members:

Plans	CMS#	County	Evidence Of Coverage
Wellcare Premium Ultra Open (PPO)	H5439-011	Benton, Clackamas, Douglas, Jackson, Josephine, Lane, Linn, Marion, Multnomah, Polk, Washington, Yamhill	Evidence Of Coverage, H5439-011 - English (PDF) Dental Benefit Details -English (PDF)
Wellcare Giveback Open (PPO)	H5439-015	Benton, Clackamas, Douglas, Jackson, Josephine, Lane, Linn, Marion, Multnomah, Polk, Washington, Yamhill	Evidence Of Coverage, H5439-015 - English (PDF) Dental Benefit Details -English (PDF)
Wellcare No Premium Open (PPO)	H5439-017	Benton, Clackamas, Douglas, Jackson, Josephine, Lane, Linn, Marion, Multnomah, Polk, Washington, Yamhill	Evidence Of Coverage, H5439-017 - English (PDF) Dental Benefit Details -English (PDF)
Wellcare Low Premium Open (PPO)	H5439-019	Benton, Clackamas, Douglas, Jackson, Josephine, Lane, Linn, Marion, Multnomah, Polk, Washington, Yamhill	Evidence Of Coverage, H5439-019 - English (PDF) Dental Benefit Details -English (PDF)
Wellcare Patriot No Premium Open (PPO)	H5439-010	Benton, Clackamas, Douglas, Jackson, Josephine, Lane, Linn, Marion, Multnomah, Polk, Washington, Yamhill	Evidence Of Coverage, H5439-010 - English (PDF) Dental Benefit Details -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:

Plans	CMS#	County	Annual Notice of Changes
Wellcare Assist (HMO)	H6815-037	Benton, Clackamas, Columbia, Coos, Crook, Deschutes, Douglas, Jackson, Jefferson, Josephine, Lane, Linn, Marion, Multnomah, Polk, Washington, Yamhill	Annual Notice of Changes, H6815-037 - English (PDF)
Wellcare No Premium (HMO)	H6815-038	Benton, Clackamas, Columbia, Coos, Crook, Deschutes, Douglas, Jackson, Jefferson, Josephine, Lane, Linn, Marion, Multnomah, Polk, Washington, Yamhill	Annual Notice of Changes, H6815-038 - English (PDF)

For PPO Members:

Plans	CMS#	County	Annual Notice of Changes
Wellcare Premium Ultra Open (PPO)	H5439-011	Benton, Clackamas, Douglas, Jackson, Josephine, Lane, Linn, Marion, Multnomah, Polk, Washington, Yamhill	Annual Notice of Changes, H5439-011 - English (PDF)
Wellcare Giveback Open (PPO)	H5439-015	Benton, Clackamas, Douglas, Jackson, Josephine, Lane, Linn, Marion, Multnomah, Polk, Washington, Yamhill	Annual Notice of Changes, H5439-015 - English (PDF)
Wellcare No Premium Open (PPO)	H5439-017	Benton, Clackamas, Douglas, Jackson, Josephine, Lane, Linn, Marion, Multnomah, Polk, Washington, Yamhill	Annual Notice of Changes, H5439-017 - English (PDF)
Wellcare Low Premium Open (PPO) to Wellcare Low Premium Open (PPO)	H5439-018 to H5439-019	Benton, Clackamas, Douglas, Jackson, Josephine, Lane, Linn, Marion, Multnomah, Polk, Washington, Yamhill	Annual Notice of Changes, H5439-018 to H5439-019 - English (PDF)
Wellcare Low Premium Open (PPO)	H5439-019	Benton, Clackamas, Douglas, Jackson, Josephine, Lane, Linn, Marion, Multnomah, Polk, Washington, Yamhill	Annual Notice of Changes, H5439-019 - English (PDF)
Wellcare Patriot No Premium Open (PPO)	H5439-010	Benton, Clackamas, Douglas, Jackson, Josephine, Lane, Linn, Marion, Multnomah, Polk, Washington, Yamhill	Annual Notice of Changes, H5439-010 - English (PDF)

Medicare Step Therapy Part B (PDF)

Covered Diabetes Testing Supplies

Over-the-Counter Catalog (PDF)

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

Plan Benefit Materials | Health Net Medicare Advantage for Oregon and Washington

Plan Materials and Forms

For HMO Members:

For PPO Members:

For HMO Members:

For PPO Members:

For HMO Members:

For PPO Members:

HMO

Wellcare Simple Value (HMO-POS) H6815-038

Wellcare Simple (HMO-POS) H6815-039

Wellcare PeaceHealth Simple (HMO-POS) H6815-040

PPO

Wellcare Patriot Giveback Open (PPO) H5439-010

Wellcare Premium Ultra Open (PPO) H5439-011

Wellcare Giveback Open (PPO) H5439-015

Wellcare Simple Open (PPO) H5439-017

Wellcare Low Premium Open (PPO) H5439-019

Additional Forms

Plan Benefit Materials | Health Net Medicare Advantage for Oregon and Washington

Plan Materials and Forms

Summary of Benefits (SB)

For HMO Members:

For PPO Members:

Evidence Of Coverage (EOC)

For HMO Members:

For PPO Members:

Annual Notice of Changes (ANOC)

For HMO Members:

For PPO Members:

Step Therapy Part B

Covered Diabetes Testing Supplies

Over-the Counter Catalog

2024 AHIP Flyer

Plan Benefit Materials

HMO

Wellcare Simple Value (HMO-POS) H6815-038

Plan Benefits

Wellcare Simple (HMO-POS) H6815-039

Plan Benefits

Wellcare PeaceHealth Simple (HMO-POS) H6815-040

Plan Benefits

PPO

Wellcare Patriot Giveback Open (PPO) H5439-010

Plan Benefits

Wellcare Premium Ultra Open (PPO) H5439-011

Plan Benefits

Wellcare Giveback Open (PPO) H5439-015

Plan Benefits

Wellcare Simple Open (PPO) H5439-017

Plan Benefits

Wellcare Low Premium Open (PPO) H5439-019

Plan Benefits

Additional Forms

Step Therapy Part B

Covered Diabetes Testing Supplies

Over-the Counter Catalog and Healthy Food

2025 AHIP Flyer