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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)

H9811-001 George, Hancock, Harrison, Hinds, Jackson, Madison, Rankin and Stone counties
Allwell Medicare (HMO) H9811-005 DeSoto, Lafayette, Panola, and Tate counties


For HMO D-SNP Members:

Plan Name  CMS# County Summary of Benefits
Allwell Dual  Medicare (HMO D-SNP)
H9811-006 George, Hancock, Harrison, Hinds, Jackson, Madison, Rankin and Stone
Allwell Dual  Medicare (HMO D-SNP) H9811-007 George, Hancock, Harrison, Hinds, Jackson, Madison, Rankin and Stone

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 

Allwell Medicare (HMO)

 

H9811-001

 

 

George, Hancock, Harrison, Hinds, Jackson, Madison, Rankin and Stone counties

 

Allwell Medicare (HMO) H9811-005 DeSoto, Lafayette, Panola, and Tate counties


For HMO D-SNP Members:

  • 2019 Medicare Defined Cost Sharing Amounts Notice (PDF) - coming soon
Plan Name  CMS# County Evidence of Coverage
Allwell Dual  Medicare
(HMO D-SNP)
H9811-006 George, Hancock, Harrison, Hinds, Jackson, Madison, Rankin and Stone
Allwell Dual  Medicare
(HMO D-SNP)
H9811 - 007 George, Hancock, Harrison, Hinds, Jackson, Madison, Rankin and Stone

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
Allwell Medicare (HMO) H9811-001 George, Harrison, Hinds, Jackson, Madison, Rankin and Stone counties
Allwell Medicare (HMO) H9811-005 DeSoto, Lafayette, Panola, and Tate counties
Allwell Dual Medicare (HMO D-SNP) H9811-006 George, Hancock, Harrison, Hinds, Jackson, Madison, Rankin and Stone

Please select the document for your plan and county:

For HMO Members:

Plan Name  CMS# County Low Income Subsidy
Allwell Medicare (HMO)

H9811-001 George, Harrison, Hinds, Jackson, Madison, Rankin and Stone counties
Allwell Medicare (HMO) H9811-005 DeSoto, Lafayette, Panola, and Tate counties

 

For HMO D-SNP Members:

Plan Name  CMS# County Low Income Subsidy
Allwell Dual  Medicare (HMO D-SNP)
H9811-006 George, Harrison, Hinds, Jackson, Madison, Rankin and Stone counties
Allwell Dual Medicare (HMO D-SNP) H9811-007 George, Hancock, Harrison, Hinds, Jackson, Madison, Rankin and Stone

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.

Please select the document for your plan and county:

For HMO Members:

Plan Name  CMS# County Extra Benefits Brochure
Allwell Medicare (HMO)

H9811-001 George, Hancock, Harrison, Hinds, Jackson, Madison, Rankin and Stone counties
Allwell Medicare (HMO) H9811-005 DeSoto, Lafayette, Panola, and Tate counties


For HMO SNP Members:

Plan Name  CMS# County Extra Benefits Brochure
Allwell Dual  Medicare (HMO SNP)
H9811-006 George, Hancock, Harrison, Hinds, Jackson, Madison, Rankin and Stone
Allwell Dual  Medicare (HMO SNP) H9811-007 George, Hancock, Harrison, Hinds, Jackson, Madison, Rankin and Stone
  • Dental Benefits Flyer (PDF)- coming soon

Need help at the doctor's office?

Visiting the doctor’s office can be difficult when you are trying to remember the details of your medical needs and health concerns over a period of time. With the amount of paperwork to fill out and questions to answer, it can be hard to make sure you are able to tell your doctor exactly what the problems are.   

Don’t wait until you get to the doctor’s office to start thinking of the reasons for your appointment. Try these helpful doctor visit guides from Magnolia Health to learn what to expect and prepare to ask your own questions about your medications, treatment options, warning signs, health tips and diet needs.

These helpful guides include details about common medical issues, so you’ll be ready to talk to your doctor about your issue, find out the information you need, and better understand what to expect from your visit.

  1. Click on any of the forms listed below
  2. Print out the form you need
  3. Fill in the answers before your appointment
  4. Take it with you to the doctor

These helpful doctor visit guides can be useful when you're being seen for any of the following conditions:

  • Beginner's Guide to Medicare Booklet (PDF)
    Important choices can be simple choices. So let us help! Take a look at the below Beginner's Guide to Medicare booklet. Our Medicare guide will give you a solid foundation for understanding the basics of Medicare and available options you have as a new Medicare beneficiary. If you have any questions or need assistance, call us. We are here to help!

 

This is an introduction to the provider and pharmacy directory, including an explanation of the provider symbols found in the directory.

Visit our Find a Doctor or Pharmacy page to learn more. 

  • Best Available Evidence (BAE)
    • This is a CMS policy that allows for changes to cost-sharing for low-income beneficiaries when there is evidence that information from a beneficiary is not up-to-date or accurate.

Procedure Code

Procedure Description

C9050

EMAPALUMAB-LZSG

J0129

ABATACEPT INJECTION

J0178

AFLIBERCEPT INJECTION

J0584

BUROSUMAB-TWZA 1M

J0585

ONABOTULINUMTOXINA

J0604

CINACALCET, ESRD ON DIALYSIS

J0717

CERTOLIZUMAB PEGOL INJ 1MG

J0800

CORTICOTROPIN INJECTION

J0897

DENOSUMAB INJECTION

J1300

ECULIZUMAB INJECTION

J1428

ETEPLIRSEN, 10 MG

J1459

IVIG PRIVIGEN 500 MG

J1555

CUVITRU, 100 MG

J1556

IMM GLOB BIVIGAM, 500MG

J1557

GAMMAPLEX INJECTION

J1559

HIZENTRA INJECTION

J1561

GAMUNEX-C/GAMMAKED

J1566

IMMUNE GLOBULIN, POWDER

J1568

OCTAGAM INJECTION

J1569

GAMMAGARD LIQUID INJECTION

J1572

FLEBOGAMMA INJECTION

J1575

HYQVIA 100MG IMMUNEGLOBULIN

J1599

IVIG NON-LYOPHILIZED, NOS

J1602

GOLIMUMAB FOR IV USE 1MG

J1745

INFLIXIMAB (REMICADE)

J1930

LANREOTIDE INJECTION

J2323

NATALIZUMAB INJECTION

J2350

OCRELIZUMAB, 1 MG

J2353

OCTREOTIDE INJECTION, DEPOT

J2357

OMALIZUMAB INJECTION

J2503

PEGAPTANIB SODIUM INJECTION

J2778

RANIBIZUMAB INJECTION

J3262

TOCILIZUMAB, 1 MG

J3304

TRIAMCINOLONE ACE XR 1MG

J3357

USTEKINUMAB SUB CU 1 MG

J3380

VEDOLIZUMAB

J3396

VERTEPORFIN INJECTION

J7189

FACTOR VIIA

J7318

DUROLANE 1 MG

J7320

GENVISC 850, 1MG

J7321

HYALGAN SUPARTZ VISCO-3 DOSE

J7322

HYMOVIS INJECTION 1 MG

J7323

EUFLEXXA INJ PER DOSE

J7324

ORTHOVISC INJ PER DOSE

J7325

SYNVISC OR SYNVISC-ONE

J7326

GEL-ONE

J7327

MONOVISC INJ PER DOSE

J7328

GELSYN-3 INJECTION 0.1 MG

J7329

TRIVISC 1 MG

J9022

ATEZOLIZUMAB,10 MG

J9145

INJECTION DARATUMUMAB 10 MG

J9173

DURVALUMAB, 10 MG

J9176

ELOTUZUMAB, 1MG

J9308

RAMUCIRUMAB

J9311

RITUXIMAB, HYALURONIDASE

J9355

TRASTUZUMAB INJECTION

Q2043

SIPULEUCEL-T AUTO CD54+

Q5103

INFLIXIMAB (INFLECTRA)

Q5104

INFLIXIMAB (RENFLEXIS)

medicare phone number

 

Can't find what you need? Contact Member Services. We are here to help!