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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) H7173-002

Chattahoochee, Clayton, DeKalb, Douglas, Fayette, Fulton, Greene, Gwinnett, Harris, Henry, Morgan, Muscogee, Oconee, Paulding, Rockdale, Spalding and Troup

Allwell Medicare Premier (HMO)

H7173 - 007 DeKalb, Fulton, Greene, Gwinnett and Muscogee
Allwell Medicare (HMO) H7173 - 008 Cobb
  • Summary of Benefits - English (PDF)

For HMO SNP Members:  

Plan Name CMS# County  Summary of Benefits
Allwell Dual Medicare (HMO SNP) H7173-001

Butts, Chattahoochee, Clayton, Cobb, Dawson, DeKalb, Douglas, Fayette, Forsyth, Fulton, Greene, Gwinnett, Harris, Heard, Henry, Lumpkin, Marion, Morgan, Muscogee, Oconee, Paulding, Pickens, Rabun, Rockdale, Spalding, Taliaferro, Towns, Troup, Union and White

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) H7173-002

Chattahoochee, Clayton, DeKalb, Douglas, Fayette, Fulton, Greene, Gwinnett, Harris, Henry, Morgan, Muscogee, Oconee, Paulding, Rockdale, Spalding and Troup

Allwell Medicare Premier (HMO) H7173-007 DeKalb, Fulton, Greene, Gwinnett and Muscogee
Allwell Medicare (HMO) H7173 - 008 Cobb
  • Evidence of Coverage - English (PDF)

For HMO SNP Members:  

Plan Name CMS# County  Evidence of Coverage
Allwell Dual Medicare (HMO SNP) H7173-001

Butts, Chattahoochee, Clayton, Cobb, Dawson, DeKalb, Douglas, Fayette, Forsyth, Fulton, Greene, Gwinnett, Harris, Heard, Henry, Lumpkin, Marion, Morgan, Muscogee, Oconee, Paulding, Pickens, Rabun, Rockdale, Spalding, Taliaferro, Towns, Troup, Union and White

If you were enrolled in Peach State Health Plan Medicare Advantage 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) H7173-002 Clayton, DeKalb, Fayette, Fulton, Gwinnett, Henry, and Rockdale counties
Allwell Medicare (HMO) H7173-003 Chattahoochee, Greene, Harris, Morgan, Muscogee Counties and Oconee

For HMO SNP Members:  

Plan Name CMS# County  Annual Notice Of Changes
Allwell Dual Medicare (HMO SNP) H7173-001

Butts, Chattahoochee, Clayton, Dawson, DeKalb, Fayette, Forsyth, Fulton, Greene, Gwinnett, Harris, Heard, Henry, Lumpkin, Marion, Morgan, Muscogee, Oconee, Pickens, Rabun, Rockdale, Taliaferro, Towns, Union and White counties

If you were enrolled in Peach State Health Plan Medicare Advantage 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 Low Income Subsidy
Allwell Medicare (HMO)

H7173-002 Clayton, DeKalb, Fayette, Fulton, Gwinnett, Henry, and Rockdale counties
Allwell Medicare (HMO)

H7173-003 Chattahoochee, Greene, Harris, Morgan, Muscogee Counties and Oconee
Allwell Medicare Premier (HMO)
H7173 - 007 DeKalb, Fulton, Gwinnett

For HMO SNP Members:  

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

H7173-001

Butts, Chattahoochee, Clayton, Dawson, DeKalb, Fayette, Forsyth, Fulton, Greene, Gwinnett, Harris, Heard, Henry, Lumpkin, Marion, Morgan, Muscogee, Oconee, Pickens, Rabun, Rockdale, Taliaferro, Towns, Union and White counties

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.

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 Peach State Health Plan 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
    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!

 

 

  • 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.

medicare phone number

 

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