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Plan Materials and Forms

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

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

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

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

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 ANOC
Allwell Medicare (HMO) H9811-001 George, Harrison, Hinds, Jackson, Madison, Rankin and Stone counties

This is the complete list of prescription drugs covered by Allwell.

Please select the document for your plan:

Use one of the forms below to enroll and receive prescription drugs by mail.

Please select the form for the mail order pharmacy you would like to start using. 

Print and fill out the prescription claim form for your plan.

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. 

  • 2018 - Appointing a Representative
    • Use this form to name a person to act as your representative. Must be completed by you and accepted by the person you appoint.
  • 2018 - PHI Authorization Form
    • Use this form when you want to allow Allwell to share your health information with a person or group.
  • 2018- PHI Revocation Form
    • Use this form when you want Allwell to cancel or revoke your previous permission to share health information with a person or group
  • 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.

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!

Beginner's Guide to Medicare Booklet