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 PPO Members
Plans	CMS#	County	Summary of Benefits
Wellcare Patriot No Premium Open (PPO)	H5439-010	Benton, Clackamas, Clark, Douglas, Jackson, Josephine, Lane, Linn, Marion, Multnomah, Polk, Washington, Yamhill	Summary of Benefits, H5439-010 - English (PDF) Summary of Benefits, H5439-010 - Korean (PDF)
Wellcare Premium Ultra Open (PPO)	H5439-011	Benton, Clackamas, Clark, Douglas, Jackson, Josephine, Lane, Linn, Marion, Multnomah, Polk, Washington, Yamhill	Summary of Benefits, H5439-011 - English (PDF) Summary of Benefits, H5439-011 - Korean (PDF)
Wellcare Low Premium Open (PPO)	H5439-018	Benton, Clackamas, Clark, Lane, Linn, Marion, Multnomah, Polk, Washington, Yamhill	Summary of Benefits, H5439-018 - English (PDF) Summary of Benefits, H5439-018 - Korean (PDF)
Wellcare Low Premium Open (PPO)	H5439-019	Douglas, Jackson, Josephine	Summary of Benefits, H5439-019 - English (PDF)
Wellcare Giveback Open (PPO)	H5439-015	Benton, Clackamas, Clark, Douglas, Jackson, Josephine, Lane, Linn, Marion, Multnomah, Polk, Washington, Yamhill	Summary of Benefits, H5439-015 – English (PDF) Summary of Benefits, H5439-015 – Korean (PDF)
Wellcare No Premium Open (PPO)	H5439-017	Lane	Summary of Benefits, H5439-017 - English (PDF)

For HMO Members
Plans	CMS#	County	Summary of Benefits
Wellcare No Premium (HMO)	H6815-038	Benton, Clackamas, Columbia, Coos, Crook, Deschutes, Jackson, Jefferson, Josephine, Lane, Linn, Marion, Multnomah, Polk, Washington, YamhillClackamas, Multnomah & Washington	Summary of Benefits, H6815-038 - English (PDF)
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)

For PPO Members

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

For HMO Members

Plans	CMS#	County	Evidence of Coverage
Wellcare No Premium (HMO)	H6815-038	Benton, Clackamas, Columbia, Coos, Crook, Deschutes, Jackson, Jefferson, Josephine, Lane, Linn, Marion, Multnomah, Polk, Washington, YamhillClackamas, Multnomah & Washington	Evidence of Coverage, H6815-038 - English (PDF)
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)

For PPO Members

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

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, Jackson, Jefferson, Josephine, Lane, Linn, Marion, Multnomah, Polk, Washington, YamhillClackamas, Multnomah & Washington	Annual Notice of Changes, H6815-038 - English (PDF)
Health Net Ruby (HMO) to Wellcare No Premium (HMO)	H6815-005 - H6815-038	Benton, Clackamas, Columbia, Coos, Crook, Deschutes, Jackson, Jefferson, Josephine, Lane, Linn, Marion, Multnomah, Polk, Washington, Yamhill, Clackamas, Multnomah & Washington	Annual Notice of Changes, H6815-005 - H6815-038 - English (PDF)
Health Net Ruby (HMO) to Wellcare No Premium (HMO)	H6815-006 - H6815-038	Benton, Clackamas, Columbia, Coos, Crook, Deschutes, Jackson, Jefferson, Josephine, Lane, Linn, Marion, Multnomah, Polk, Washington, YamhillClackamas, Multnomah & Washington	Annual Notice of Changes, H6815-006 - H6815-038 - English (PDF)

Medicare Part B Drug List (PDF)

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

Plan Materials and Forms

For PPO Members

For HMO Members

For PPO Members

For HMO Members

Plan Benefit Materials

For HMO Members:

For PPO Members:

For HMO Members:

For PPO Members:

For HMO Members:

For PPO Members:

Plans	CMS#	County	Summary of Benefits
Wellcare Premium Ultra Open (PPO)	H5439-011	Benton, Clackamas, Douglas, Jackson, Josephine, Lane, Linn, Marion, Multnomah, Polk, Washington, Yamhill counties in Oregon & Clark county in Washington	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 counties in Oregon & Clark county in Washington	Summary of Benefits, H5439-015 - English (PDF)
Wellcare No Premium Open (PPO)	H5439-017	Lane	Summary of Benefits, H5439-017 - English (PDF)
Wellcare Low Premium Open (PPO)	H5439-018	Benton, Clackamas, Lane, Linn, Marion, Multnomah, Polk, Washington, Yamhill counties in Oregon & Clark county in Washington	Summary of Benefits, H5439-018 - English (PDF)
Wellcare Low Premium Open (PPO)	H5439-019	Douglas, Jackson, Josephine	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 counties in Oregon & Clark county in Washington	Summary of Benefits, H5439-010 - English (PDF)

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

Plan Materials and Forms

Summary of Benefits (SB)

For PPO Members

For HMO Members

Evidence Of Coverage (EOC)

For PPO Members

For HMO Members

Annual Notice of Changes (ANOC)

Medicare Part B Drug List

Over-The-Counter Benefits

Plan Benefit Materials

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:

Medicare Part B Drug List

2023 AHIP Flyer

Over-The-Counter Catalog