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 Premier (HMO)	H9276 - 002	Duval	Summary of Benefits, H9276-002 - English (PDF)
Allwell Medicare (HMO)	H9276 - 004	Miami-Dade	Summary of Benefits, H9276-004 - English (PDF) Summary of Benefits, H9276-004 - Spanish (PDF)
Allwell Medicare (HMO)	H9276 - 0012	Broward	Summary of Benefits, H9276-0012- English (PDF) Summary of Benefits, H9276-0012 - Spanish (PDF)
Allwell Medicare (HMO)	H9276 - 021	Palm Beach	Summary of Benefits, H9276-021 - English (PDF) Summary of Benefits, H9276-021 - Spanish (PDF)

For HMO D-SNP Members:

Plan Name	CMS#	County	Summary of Benefits
Allwell Dual Medicare (HMO D-SNP)	H5190 - 001	Duval \| Volusia	Summary of Benefits H5150-001- English (PDF)
Allwell Dual Medicare (HMO D-SNP)	H5190 - 002	Hillsborough \| Orange \| Osceola \| Palm Beach \| Pasco \| Pinellas \| Polk \| Seminole	Summary of Benefits H5190-002 - English (PDF) Summary of Benefits H5190-002 - Spanish (PDF)
Allwell Dual Medicare (HMO D-SNP)	H5190 - 003	Broward	Summary of Benefits H5190-003 - English (PDF) Summary of Benefits H5190-003 - Spanish (PDF)
Allwell Dual Medicare (HMO D-SNP)	H5190 - 004	Miami - Dade	Summary of Benefits H5190-004 - English (PDF) Summary of Benefits H5190-004 - Spanish (PDF)

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 Premier (HMO)	H9276 - 002	Duval	Evidence of Coverage H9276-002 - English (PDF)
Allwell Medicare (HMO)	H9276 - 004	Miami-Dade	Evidence of Coverage H9276-004 - English (PDF) Evidence of Coverage H9276-004 - Spanish (PDF)
Allwell Medicare (HMO)	H9276 - 012	Broward	Evidence of Coverage H9276-012 - English (PDF) Evidence of Coverage H9276-012 - Spanish (PDF)
Allwell Medicare (HMO)	H9276 - 021	Palm Beach	Evidence of Coverage H9276-021 - English (PDF) Evidence of Coverage H9276-021 - Spanish (PDF)

For HMO D-SNP Members:

2020 Medicare Defined Cost Sharing Amounts Notice (PDF)

Plan Name	CMS#	County	Evidence of Coverage
Allwell Dual Medicare (HMO D-SNP)	H5190 - 001	Duval \| Volusia	Evidence of Coverage H5190-001 - English (PDF)
Allwell Dual Medicare (HMO D-SNP)	H5190 - 002	Hillsborough \| Orange \| Osceola \| Palm Beach \| Pasco \| Pinellas \| Polk \| Seminole	Evidence of Coverage H5190-002 - English (PDF) Evidence of Coverage H5190-002 - Spanish (PDF)
Allwell Dual Medicare (HMO D-SNP)	H5190 - 003	Broward	Evidence of Coverage H5190-003 - English (PDF) Evidence of Coverage H5190-003 - Spanish (PDF)
Allwell Dual Medicare (HMO D-SNP)	H5190 - 004	Miami - Dade	Evidence of Coverage H5190-004 - English (PDF) Evidence of Coverage H5190-004 - Spanish (PDF)

If you were enrolled in Allwell from Sunshine Health 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 county:

For HMO Members:

Plan Name	CMS#	County	Annual Notice Of Changes
Allwell Medicare (HMO)	H9276-002	Duval	Annual Notice of Changes, H9276-002 - English (PDF)
Allwell Medicare (HMO)	H9276 - 004	Miami-Dade	Annual Notice of Changes, H9276-004 - English (PDF) Annual Notice of Changes, H9276-004 - Spanish (PDF)
Allwell Medicare (HMO)	H9276 - 021	Palm Beach	Annual Notice of Changes, H9276-021 - English (PDF) Annual Notice of Changes, H9276-021 - Spanish (PDF)
Allwell Medicare (HMO)	H9276 - 0012	Broward	Annual Notice of Changes, H9276-012 - English (PDF) Annual Notice of Changes, H9276-012 - Spanish (PDF)

For HMO D-SNP Members:

Plan Name	CMS#	County	Annual Notice Of Changes
Allwell Dual Medicare (HMO D-SNP)	H5190 - 001	Baker \| Duval \| Hardee \| Hernando \| Lake \| Manatee \|Marion \| Martin \| Volusia	Annual Notice of Changes, H5190-001 - English (PDF)
Allwell Dual Medicare (HMO D-SNP)	H5190 - 002	Hillsborough \| Orange \| Osceola \| Palm Beach \| Pasco \| Pinellas \| Polk \| Seminole \| St.Lucie	Annual Notice of Changes, H5190-002 - English (PDF) Annual Notice of Changes, H5190-002 - Spanish (PDF)
Allwell Dual Medicare (HMO D-SNP)	H5190 - 003	Broward	Annual Notice of Changes, H5190-003 - English (PDF) Annual Notice of Changes, H5190-003 - Spanish (PDF)
Allwell Dual Medicare (HMO D-SNP)	H5190 - 004	Miami - Dade	Annual Notice of Changes, H5190-004 - English (PDF) Annual Notice of Changes, H5190-004 - Spanish (PDF)

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.

Over-the-Counter Catalog - English / Spanish (PDF)

Don’t want to wait? You may pick up your OTC products from a CVS or Navarro Discount Pharmacy 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

Acupuncture National Coverage (PDF)

Plan Benefit Materials | Allwell from Sunshine Health

Plan Materials and Forms

For HMO Members:

For HMO D-SNP Members:

For HMO Members:

For HMO D-SNP Members:

For HMO Members:

For HMO D-SNP Members:

Plan Benefit Materials

For HMO Members:

For HMO D-SNP Members:

For HMO Members:

For HMO D-SNP Members:

For HMO Members:

For HMO D-SNP Members:

Plan Name	CMS#	County	Summary of Benefits
Allwell Dual Medicare (HMO D-SNP)	H5190 - 001	Duval and Volusia counties	Summary of Benefits H5150-001- English (PDF)
Allwell Dual Medicare (HMO D-SNP)	H5190 - 002	Hillsborough, Orange, Osceola, Palm Beach, Pasco, Pinellas, Polk, and Seminole counties	Summary of Benefits H5190-002 - English (PDF) Summary of Benefits H5190-002 - Spanish (PDF)
Allwell Dual Medicare (HMO D-SNP)	H5190 - 003	Broward	Summary of Benefits H5190-003 - English (PDF) Summary of Benefits H5190-003 - Spanish (PDF)
Allwell Dual Medicare (HMO D-SNP)	H5190 - 004	Miami-Dade	Summary of Benefits H5190-004 - English (PDF) Summary of Benefits H5190-004 - Spanish (PDF)
Allwell Medicare Nurture (HMO D-SNP)	H5190 - 005	Broward, Duval, Hillisborough, Orange, Osceola, Palm Beach, Pasco, Pinellas, Polk, Seminole and Volusia counties	Summary of Benefits H5190-005 - English (PDF) Summary of Benefits H5190-005 - Spanish (PDF)
Allwell Medicare Nurture (HMO D-SNP)	H5190 - 006	Miami-Dade	Summary of Benefits H5190-006 - English (PDF) Summary of Benefits H5190-006 - Spanish (PDF)

Plan Benefit Materials | Allwell from Sunshine Health

Plan Materials and Forms

Summary of Benefits (SB)

For HMO Members:

For HMO D-SNP Members:

Evidence Of Coverage (EOC)

For HMO Members:

For HMO D-SNP Members:

Annual Notice of Changes (ANOC)

For HMO Members:

For HMO D-SNP Members:

Over-the-Counter Benefits

Acupuncture National Coverage

Plan Benefit Materials

Summary of Benefits (SB)

For HMO Members:

For HMO D-SNP Members:

Evidence Of Coverage (EOC)

For HMO Members:

For HMO D-SNP Members:

Annual Notice of Changes (ANOC)

For HMO Members:

For HMO D-SNP Members:

Acupuncture National Coverage

Medicare Prior Authorization List

Over-The-Counter Benefits