These are the Optional Supplemental Benefits you can buy.
|
|
|
- Cassandra Stafford
- 5 years ago
- Views:
Transcription
1 These are the Optional Supplemental Benefits you can buy. If you are enrolled in Allwell Medicare, you have the choice to customize and enhance your coverage with optional supplemental benefits. For an additional monthly premium of $26, you can take advantage of these great benefits. Comprehensive Dental Buy-up Package Comprehensive Dental Services Annual benefit maximum $1,000 Includes: Diagnostic services, restorative services, endodontics, periodontics, extractions, prosthodontics, oral/maxillofacial surgery and non-routine services. You must use a network provider for this plan Y0020_19_7963TEMP_FINAL_9130_M Accepted
2 This information is not a complete description of benefits. Call (TTY: 711) for more information. The actual complete terms and conditions of the health plan are set forth in the applicable Evidence of Coverage document. From October 1 to March 31, you can call us 7 days a week from 8 a.m. to 8 p.m. From April 1 to September 30, you can call us Monday through Friday from 8 a.m. to 8 p.m. A messaging system is used after hours, weekends, and on federal holidays. Allwell is contracted with Medicare for HMO, HMO SNP and PPO plans, and with some state Medicaid programs. Enrollment in Allwell depends on contract renewal. FLY023903EK00 (8/18)
3 Section 1557 Non-Discrimination Language Notice of Non-Discrimination Allwell complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Allwell does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Allwell: Provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print, accessible electronic formats, other formats). Provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, contact Allwell s Member Services telephone number listed for your state on the Member Services Telephone Numbers by State Chart. From October 1 to March 31, you can call us 7 days a week from 8 a.m. to 8 p.m. From April 1 to September 30, you can call us Monday through Friday from 8 a.m. to 8 p.m. A messaging system is used after hours, weekends, and on federal holidays. If you believe that Allwell has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance by calling the number in the chart below and telling them you need help filing a grievance; Allwell s Member Services is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Offce for Civil Rights, electronically through the Offce for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services, 200 Independence Avenue SW, Room 509F, HHH Building, Washington, DC 20201, (TTY: ). Complaint forms are available at Member Services Telephone Numbers by State Chart State Telephone Number and Plan Type Arizona / (HMO and HMO SNP) (TTY: 711) Arkansas (HMO) (TTY: 711) Florida (HMO); (HMO SNP) (TTY: 711) Georgia (HMO); (HMO SNP) (TTY: 711) Illinois (HMO) (TTY: 711) Indiana (HMO and PPO); (HMO SNP) (TTY: 711) Kansas (HMO); (HMO SNP) (TTY: 711) Louisiana (HMO) (TTY: 711) Mississippi (HMO); (HMO SNP) (TTY: 711) Missouri (HMO); (HMO SNP) (TTY: 711) New Mexico (HMO SNP) (TTY: 711) Ohio (HMO); (HMO SNP) (TTY: 711) Pennsylvania (HMO); (HMO SNP) (TTY: 711) South Carolina (HMO and HMO SNP) (TTY: 711) Texas (HMO); (HMO SNP) (TTY: 711) Wisconsin (HMO SNP) (TTY: 711) ALL_19_8450FLY_C_ACCEPTED_
4 Section 1557 Non-Discrimination Language Multi-Language Interpreter Services
5
6 Allwell is contracted with Medicare for HMO, HMO SNP and PPO plans, and with some state Medicaid programs. Enrollment in Allwell depends on contract renewal. FLY020520ZK00 (8/18)
Request for Redetermination of Medicare Prescription Drug Denial
Request for Redetermination of Medicare Prescription Drug Denial Because we, Allwell, denied your request for coverage of (or payment for) a prescription drug, you have the right to ask us for a redetermination
Any missing information may cause a delay in processing your request.
Member Reimbursement Claim Form *3000* This form may be used for Allwell Medicare products. Important: Complete a separate Member Reimbursement Claim Form for each member asking for reimbursement for covered
REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION This form may be sent to us by mail or fax:
REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION This form may be sent to us by mail or fax: Address: Medicare Part D Prior Authorization Department P.O. Box 419069 Rancho Cordova, CA 95741
<Logo> 2019 Allwell Medicare (HMO) H1664: 004 Crawford, Franklin, Jefferson, Lincoln, St. Charles, Warren, and Washington Counties, MO
2019 Allwell Medicare (HMO) H1664: 004 Crawford, Franklin, Jefferson, Lincoln, St. Charles, Warren, and Washington Counties, MO H1664_19_7896SB_004_M_Accepted 09082018 This booklet provides you
2019 Allwell Medicare (HMO) H7173: 002 Clayton, DeKalb, Fayette, Fulton, Gwinnett, Henry, and Rockdale Counties, GA
2019 Allwell Medicare (HMO) H7173: 002 Clayton, DeKalb, Fayette, Fulton, Gwinnett, Henry, and Rockdale Counties, GA H7173_19_8074SB_002_M Accepted 09072018 This booklet provides you with a summary of what
2019 Allwell Medicare (HMO) H Kane County, IL
2019 Allwell Medicare (HMO) H1475 -- 002 Kane County, IL H1475_19_7967SB_002_M Accepted 09282018 This booklet provides you with a summary of what we cover and your cost-sharing responsibilities. It does
2019 Allwell Medicare (HMO) H2915: 005 Clarion, Clearfield, Crawford, Elk, Erie, Forest, Jefferson, McKean, Mercer, Venango, and Warren Counties, PA
2019 Allwell Medicare (HMO) H2915: 005 Clarion, Clearfield, Crawford, Elk, Erie, Forest, Jefferson, McKean, Mercer, Venango, and Warren Counties, PA H2915_19_8121SB_005_M Accepted 09072018 This booklet
2019 Allwell Medicare (HMO) H0062: 002 Collin, Dallas, Denton, Rockwall, Smith and Tarrant counties, TX
2019 Allwell Medicare (HMO) H0062: 002 Collin, Dallas, Denton, Rockwall, Smith and Tarrant counties, TX H0062_19_7952SB_002_M_Accepted 09072018 This booklet provides you with a summary of what we cover
2019 Allwell Medicare (HMO) H2915: 003 Allegheny, Armstrong, Beaver, Bedford, Blair, Butler, Cambria, Fayette, Greene, Indiana, Lawrence, Somerset,
2019 Allwell Medicare (HMO) H2915: 003 Allegheny, Armstrong, Beaver, Bedford, Blair, Butler, Cambria, Fayette, Greene, Indiana, Lawrence, Somerset, Washington, and Westmoreland Counties, PA H2915_19_8120SB_003_M
Allwell 2019 Individual Enrollment Form
Allwell 2019 Individual Enrollment Form Please contact Allwell if you need information in another language or format (Braille). To enroll in Allwell, please provide the following information: Please check
Allwell 2019 Individual Enrollment Form
Allwell 2019 Individual Enrollment Form Please contact Allwell if you need information in another language or format (Braille). To enroll in Allwell, please provide the following information: Please check
2019 Allwell Dual Medicare (HMO SNP) H1436: 005 Abbeville, Allendale, Anderson, Bamberg, Barnwell, Beaufort, Berkeley, Calhoun, Charleston, Chester,
2019 Allwell Dual Medicare (HMO SNP) H1436: 005 Abbeville, Allendale, Anderson, Bamberg, Barnwell, Beaufort, Berkeley, Calhoun, Charleston, Chester, Chesterfield, Clarendon, Colleton, Dillon, Edgefield,
Allwell 2019 Individual Enrollment Form
Allwell 2019 Individual Enrollment Form Please contact Allwell if you need information in another language or format (Braille). To enroll in Allwell, please provide the following information: Please check
2019 Allwell Dual Medicare Essentials (HMO SNP) H1436: 006 Abbeville, Allendale, Anderson, Bamberg, Barnwell, Beaufort, Berkeley, Calhoun,
2019 Allwell Dual Medicare Essentials (HMO SNP) H1436: 006 Abbeville, Allendale, Anderson, Bamberg, Barnwell, Beaufort, Berkeley, Calhoun, Charleston, Chester, Chesterfield, Clarendon, Colleton, Dillon,
2019 Health Net Seniority Plus Green (HMO) H0562:045 Alameda, Placer, Sacramento and Stanislaus Counties, CA
2019 Health Net Seniority Plus Green (HMO) H0562:045 Alameda, Placer, Sacramento and Stanislaus Counties, CA H0562_19_7815SB_045_M_Accepted 09072018 1 This booklet provides you with a summary of what we
Summary of Benefits. Allwell Medicare Premier (HMO) Duval, Pinellas, Polk, Hernando, Pasco and Volusia Counties, Florida H
2018 Summary of Benefits Duval, Pinellas, Polk, Hernando, Pasco and Volusia Counties, Florida H9276-002 Benefits effective January 1, 2018 H9276_18_2859SB_B_Accepted 10032017 This booklet provides you
Summary of Benefits. Allwell Medicare (HMO) Duval, Lake, Pinellas, Polk and Volusia Counties, Florida H H9276_18_2858SB _A Accepted
2018 Summary of Benefits Duval, Lake, Pinellas, Polk and Volusia Counties, Florida H9276-001 Benefits effective January 1, 2018 H9276_18_2858SB _A Accepted 09172017 This booklet provides you with a summary
2018 Summary of Benefits
2018 Summary of Benefits Ascension, East Baton Rouge, Livingston, West Baton Rouge, and Tangipahoa Parishes, LA H5117--001 Benefits effective January 1, 2018 H5117_18_2922SB Accepted 09302017 This booklet
Summary of Benefits. Allwell Medicare (HMO) Cameron and Hidalgo counties, TX H
2018 Summary of Benefits Allwell Medicare (HMO) Cameron and Hidalgo counties, TX H0062 -- 003 Benefits effective January 1, 2018 H0062_18_2965SB_Accepted 09102017 This booklet provides you with a summary
Health Net Medicare Advantage Plans 2019 Optional Benefit Individual Enrollment Form
Health Net Medicare Advantage Plans 2019 Optional Benefit Individual Enrollment Form Health Net offers optional benefits for an additional monthly plan premium. This form may be used only by our current
2019 Health Net Ruby (HMO) H Lane County, OR
2019 Health Net Ruby (HMO) H6815-003-003 Lane County, OR H6815_19_8067SB_003_003_M Accepted 09072018 This booklet provides you with a summary of what we cover and your cost-sharing responsibilities. It
2019 Allwell Medicare (HMO) H1664: 002 Cass, Clay, Jackson, and Platte Counties, MO. H1664_19_7894SB_002_M_Accepted
2019 Allwell Medicare (HMO) H1664: 002 Cass, Clay, Jackson, and Platte Counties, MO H1664_19_7894SB_002_M_Accepted 09082018 This booklet provides you with a summary of what we cover and the cost-sharing
2018 Summary of Benefits
2018 Summary of Benefits Allwell Medicare Select (HMO) Benton, Washington counties, AR H9630--003 Benefits effective January 1, 2018 H9630_18_2915SB Accepted 09302017 This booklet provides you with a summary
2019 Health Net Violet 2 (PPO) H Marion and Polk Counties, OR
2019 Health Net Violet 2 (PPO) H5439-014-003 Marion and Polk Counties, OR H5439_19_8049SB_014_003_M Accepted 09072018 This booklet provides you with a summary of what we cover and your cost-sharing responsibilities.
Summary of Benefits. Allwell Medicare (HMO) Palm Beach, Manatee, Marion and Seminole Counties, Florida H
2018 Summary of Benefits Palm Beach, Manatee, Marion and Seminole Counties, Florida H9276-003 Benefits effective January 1, 2018 H9276_18_2860SB_A Accepted 09172017 This booklet provides you with a summary
2019 Health Net Aqua (PPO) H5439: 010 Benton, Clackamas, Lane, Linn, Marion, Multnomah, Polk, Washington, and Yamhill Counties, OR; Clark County, WA
2019 Health Net Aqua (PPO) H5439: 010 Benton, Clackamas, Lane, Linn, Marion, Multnomah, Polk, Washington, and Yamhill Counties, OR; Clark County, WA H5439_19_8025SB_010_M Accepted 09072018 This booklet
2018 Summary of Benefits
2018 Summary of Benefits Abbeville, Allendale, Bamberg, Barnwell, Chester, Chesterfield, Clarendon, Dillon, Edgefield, Florence, Georgetown, Laurens, Lee, Marion, Marlboro, McCormick, Newberry, Orangeburg,
Summary of Benefits. Allwell Medicare Essentials II (HMO) Maricopa County, Arizona H
2018 Summary of Benefits Allwell Medicare Essentials II (HMO) Maricopa County, Arizona H0351 -- 049-001 Benefits effective January 1, 2018 H0351_18_3205SB_B_ Accepted 10142017 This booklet provides you
2018 Summary of Benefits
2018 Summary of Benefits Hamilton, Howard, and Marion counties, Indiana H3499--001 Benefits effective January 1, 2018 H3499_18_3257SB_A Accepted 09172017 This booklet provides you with a summary of what
Summary of Benefits. Allwell Medicare Premier (HMO) Pinal County, Arizona H
2018 Summary of Benefits Allwell Medicare Premier (HMO) Pinal County, Arizona H0351 -- 043-004 Benefits effective January 1, 2018 H0351_18_3060SB_A_ Accepted 10142017 This booklet provides you with a summary
Mail all medical claims to: or Mail all behavioral health claims to: Any missing information may cause a delay in processing your request.
Member Reimbursement Claim Form This form may be used for Health Net Medicare products. Important: Complete a separate Member Reimbursement Claim Form for each member asking for reimbursement for covered
2019 Health Net Ruby Select (HMO) H0562:112 Fresno County, CA
2019 Health Net Ruby Select (HMO) H0562:112 Fresno County, CA H0562_19_7914SB_112_M_Accepted 09072018 1 This booklet provides you with a summary of what we cover and your cost-sharing responsibilities.
Summary of Benefits. Allwell Medicare (HMO) Bexar County, TX H Benefits effective January 1, 2018 H0062_18_2962SB_Accepted
2018 Summary of Benefits Bexar County, TX H0062 -- 001 Benefits effective January 1, 2018 H0062_18_2962SB_Accepted 09102017 This booklet provides you with a summary of what we cover and your cost-sharing.
2019 Health Net Violet 1 (PPO) H5439: 011 Benton, Clackamas, Lane, Linn, Marion, Multnomah, Polk, Washington, and Yamhill Counties, OR; Clark County,
2019 Health Net Violet 1 (PPO) H5439: 011 Benton, Clackamas, Lane, Linn, Marion, Multnomah, Polk, Washington, and Yamhill Counties, OR; Clark County, WA H5439_19_8026SB_011_M Accepted 09072018 This booklet
2018 Summary of Benefits
2018 Summary of Benefits Benton, Crawford, Sebastian, Washington Counties, AR H9630--001 Benefits effective January 1, 2018 H9630_18_2913SB Accepted 09302017 This booklet provides you with a summary of
2019 Health Net Gold Select (HMO) H0562: Riverside and San Bernardino Counties, CA
2019 Health Net Gold Select (HMO) H0562:101-002 Riverside and San Bernardino Counties, CA H0562_19_7860SB_101_002_M_Accepted 09072018 1 This booklet provides you with a summary of what we cover and your
Summary of Benefits. Tufts Medicare Preferred PDP PLANS Employer Group Tufts Medicare Preferred PDP3
Tufts Medicare Preferred PDP PLANS 2018 Summary of Benefits Employer Group Tufts Medicare Preferred PDP3 The benefit information provided is a summary of what we cover and that you pay. It does not list
2018 Summary of Benefits
2018 Summary of Benefits Barry, Christian, Greene, Jasper, Lawrence, and Newton Counties, MO H1664--001 Benefits effective January 1, 2018 H1664_18_2916SB Accepted 09302017 This booklet provides you with
Individual Enrollment Form
Please contact Peach State Health Plan if you need information in another language or format (Braille). To enroll in Peach State Health Plan, please provide the following information: Please check which
Summary of Benefits. Allwell Dual Medicare (HMO SNP)
2018 Summary of Benefits Allwell Dual Medicare (HMO SNP) Abbeville, Allendale, Bamberg, Barnwell, Beaufort, Calhoun, Charleston, Chester, Chesterfield, Clarendon, Colleton, Dillon, Edgefield, Fairfield,
Your Vision Website from Health Net
Your Vision Website from Health Net See it to believe it! Kim Aung Health Net Your Health Net of California, Inc. and Health Net Life Insurance Company (Health Net) vision member website offers detailed
2018 Plan Year Monthly Plan Premium for People Who Get Extra Help From Medicare to Help Pay for Their Prescription Drug Costs
2018 Plan Year Monthly Plan for People Who Get Extra Help From Medicare to Help Pay for Their Prescription Drug Costs If you get extra help from Medicare to help pay for your Medicare prescription drug
Summary of Benefits. Allwell Dual Medicare (HMO SNP) Bexar and Nueces counties, TX H H5294_18_2765SB_002_004_A_Accepted
2018 Summary of Benefits Allwell Dual Medicare (HMO SNP) Bexar and Nueces counties, TX H5294-002-004 Benefits effective January 1, 2018 H5294_18_2765SB_002_004_A_Accepted 09172017 This booklet provides
Plan Comparison Chart. Includes medical and prescription drug (Rx) benefit information
Medicare Advantage (HMO) Plans 2019 Plan Comparison Chart Includes medical and prescription drug () benefit information Plan Comparison Chart HMO Saver or Basic plans may be a good fit if you: Are relatively
Health Net 2019 Individual Enrollment Form
Health Net 2019 Individual Enrollment Form Please contact Health Net if you need information in another language or format (Braille). To enroll in Health Net, please provide the following information:
Coverage Through Employer/Union name Grp# Last Name: First Name: Middle Initial: 9 F
PO Box 9178 Watertown, MA 02472 2019 Employer Group HMO Election Form Please contact Tufts Health Plan Medicare Preferred if you need information in another language or format (Braille). DATE STAMP Please
Summary of Benefits January 1, 2017 December 31, 2017
Pennsylvania Northeastern and West Virginia Pennsylvania BLUE RX PDP Summary of Benefits January 1, 2017 December 31, 2017 This booklet gives you a summary of what we cover and what you pay. It doesn t
Tufts Medicare Preferred Supplement. IMportant information. PO Box 9178 Watertown, MA 02472
Tufts Medicare Preferred Supplement 2018 Enrollment Application PO Box 9178 Watertown, MA 02472 IMportant information Please read the Important Information section, fill out the application on page 1,
Health Options Program
Pennsylvania Public School Employees Retirement System (PSERS) Health Options Program 2017 Annual Notice of Changes You are currently enrolled as a member of the Enhanced, Basic or Value Medicare Rx Option.
INTRODUCTION TO SUMMARY OF BENEFITS
INTRODUCTION TO This booklet gives you a summary of what we cover and what you pay. It doesn't list every service that we cover or list every limitation or exclusion. To get a complete list of services
Alternate Phone Number: ( ) Address: Sex: 9 M ( ) 9 F. Permanent Residence Address (P.O. Box is not allowed): City: State: Zip Code:
PO Box 9178 Watertown, MA 02472 2018 TUFTS MEDICARE PREFERRED HMO INDIVIDUAL ENROLLMENT FORM Please contact Tufts Health Plan Medicare Preferred if you need information in another language or format (Braille).
Individual Enrollment Form
Please contact Sunshine Health Medicare Advantage if you need information in another language or format (Braille). To enroll in Sunshine Health Medicare Advantage, please provide the following information:
9 HMO Basic Rx $23.00 per month 9 HMO Value Rx $54.00 per month 9 HMO Prime Rx $79.00 per month 9 HMO Prime Rx Plus $99.
PO Box 9178 Watertown, MA 02472 2019 TUFTS MEDICARE PREFERRED HMO INDIVIDUAL ENROLLMENT FORM Please contact Tufts Health Plan Medicare Preferred if you need information in another language or format (Braille).
2019 Short Enrollment Request
Page 1 of 7 Medicare Advantage HMO South Region 2019 Short Enrollment Request FOR OFFICE USE ONLY Member ID no. Effective date of coverage Election period individual is enrolling in: AEP SEP ICEP IEP OEPI
2018 CareOregon Advantage Star (HMO) Summary of Benefits
2018 Summary of Benefits For Oregon counties: Clackamas, Columbia, Multnomah and Washington H5859_1099_CO_3018v3 CMS ACCEPTED CAREOREGON ADVANTAGE STAR (HMO) (A Medicare Advantage Health Maintenance Organization
2019 Allwell Medicare (HMO) H6550: 003 Cherokee, Crawford and Sedgwick Counties, KS
2019 Allwell Medicare (HMO) H6550: 003 Cherokee, Crawford and Sedgwick Counties, KS H6550_19_7950SB_003_M_Accepted 09072018 This booklet provides you with a summary of what we cover and the cost-sharing
Check Plan Type: Check Enrollment Type: Fill Out Sections: q KP/HSA Small Group Employee Enrollment Form q Multi-Choice
Kaiser Foundation Health Plan of Georgia, Inc. Kaiser Permanente Insurance Company (KPIC) Check Plan Type: Check Enrollment Type: Fill Out Sections: q KP/HSA q New Hire A, B, C, D q Added Choice/HSA Added
CarePartners of Connecticut HMO Plans Buyer s Guide. Includes a chart comparing all HMO plan options
CarePartners of Connecticut HMO Plans 2019 Buyer s Guide Includes a chart comparing all HMO plan options Service Area: to join a CarePartners of Connecticut plan, you must live in our service area: Hartford,
Humana Medicare Employer Plan
GHHHWTDEN_18_NMRHCA Humana Medicare Employer Plan Plans that go the extra mile MILE Humana Medicare Advantage At Humana, we help you understand the many aspects of Medicare and try to make your options
Pediatric Dental and Vision
Individual & Family Plans (IFP) and Small Business Group (SBG) Health Net Life Insurance Company (Health Net) Pediatric Dental and Vision When you choose a Health Net PPO insurance plan, your medical plan
2018 Summary of Benefits
January 1 December 31, 2018 2018 Summary of Benefits Kaiser Permanente Medicare Advantage (HMO) for Federal Members High, Standard, and High Deductible Health Plan Options MA0001579-51-17 About this Summary
Please check which plan you want to enroll in: If you live in Litchfield, Hartford, New Haven, New London, Tolland, or Windham Counties: Sex: 9 M ( )
PO Box 9178 Watertown, MA 02472 2019 CarePartners of Connecticut (HMo) INDIVIDUAL ENROLLMENT FORM Please contact CarePartners of Connecticut if you need information in another language or format (Braille).
PLAN CHOICES. What You Need to Know. Pennsylvania Service Areas. This is a summary of drug and health services for January 1, 2017 December 31, 2017
PLAN CHOICES What You Need to Know This is a summary of drug and health services for January 1, 2017 December 31, 2017 The benefit information provided is a summary of what we cover and what you pay. It
Annual Notice of Changes for 2019
BlueAdvantage Diamond (PPO) SM offered by BlueCross BlueShield of Tennessee Annual Notice of Changes for 2019 You are currently enrolled as a member of BlueAdvantage Diamond. Next year, there will be some
Summary of Benefits. Community Blue Medicare HMO. Western Pennsylvania. January 1, 2018 December 31, Service Area
Western Pennsylvania Community Blue Medicare HMO Summary of Benefits January 1, 2018 December 31, 2018 Service Area Our service area includes the following counties in Pennsylvania: Allegheny, Armstrong,
Medicare Made Simple. A guide to your health plan options
Medicare Made Simple A guide to your health plan options Introduction When you re eligible for Medicare, understanding and comparing all of your health plan options can be confusing. This guide describes
2018 Community Blue Medicare PPO Summary of Benefits
2018 Community Blue Medicare PPO Summary of Benefits Residents of the following counties: Allegheny, Beaver, Butler, Erie, Greene, Fayette, Washington, Westmoreland, please click here. Residents of the
Medicare Made Simple. A guide to your health plan options
Medicare Made Simple A guide to your health plan options Introduction When you re eligible for Medicare, comparing all of your health plan options can be confusing. The truth is, it doesn t have to be.
Medicare Advantage HMO plans
2018 Medicare Advantage HMO plans Essence (HMO-POS) Essence Rx (HMO-POS) Esteem Rx (HMO-POS) Spirit (HMO-POS) Spirit Rx (HMO-POS) Medicare coverage that works with and for you Y0117_MC-778-2820-C-10-17
Please contact Sharp Health Plan if you need information in another language or format (Braille).
2019 Sharp Direct Advantage SM Basic (HMO) & Sharp Direct Advantage SM Premium (HMO) Enrollment Form Completing your enrollment is your first step to becoming a Sharp Direct Advantage Medicare member.
Annual Notice of Changes for 2019
Allwell Dual Medicare (HMO SNP) offered by Superior Health Plan, Inc. Annual Notice of Changes for 2019 You are currently enrolled as a member of Allwell Dual Medicare (HMO SNP). Next year, there will
Medicare Advantage HMO plans
2018 Medicare Advantage HMO plans Promise Rx (HMO-POS) Surety Rx (HMO-POS) Medicare coverage that works with and for you Y0117_MC-778-2822-C-10-17 approved Why choose a plan from Security Health Plan?
Summary of Benefits. Express Scripts Medicare. Value Choice S5660 & S5983. January 1, 2016 December 31, 2016
Express Scripts Medicare Value Choice (a Medicare prescription drug plan (PDP) offered by Medco Containment Life Insurance Company and Medco Containment Insurance Company of New York (for members located
MA BENEFIT COMPARISON PLAN OPTIONS FOR MA-SMGP-COMP-1216
MA BENEFIT COMPARISON PLAN OPTIONS FOR -MA-SMGP-COMP-1216 Massachusetts Small Group Plan Design Comparison uctible Medical// / HMO Copay Plans HMO Value Platinum - $0/$0 0/ $7000 5 5 CIF 0 $200 $40 $70
Prescription Drug Claim Form
Prescription Drug Claim Form This claim form is to be used for reimbursement on covered medications provided by pharmacies. The filing of this form does not guarantee reimbursement. Please consult your
Health Options Program Option Selection Period FAQs
Health Options Program Option Selection Period FAQs The Health Options Program Q What is a Qualifying Event? A A Qualifying Event is what makes you eligible for enrollment in the Health Options Program.
Federal Regulation Required Employer Notices
November 1, 2016 Federal Regulation Required Employer Notices Tell Us When You re Medicare Eligible Please notify Human Resources when you or your dependents become eligible for Medicare. You will need
HealthSpring Prescription Drug Plan (PDP) 2013 Summary of Benefits S5932
HealthSpring Prescription Drug Plan (PDP) 2013 Summary of Benefits S5932 Alabama, Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Delaware, District of Columbia, Florida, Georgia, Hawaii,
2018 Outline of Coverage McLaren Medicare Supplement Plans A, C, F, High Deductible-F, G & N
2018 Outline of Coverage McLaren Medicare Supplement Plans A, C, F, High Deductible-F, G & N McLarenHealthPlan.com/MedicareSupplement Call us toll-free (888) 327-0671, Monday - Friday from 8 a.m. 6 p.m.
2013 Summary of Benefits
2013 Summary of Benefits SilverScript Basic (PDP) SilverScript Choice (PDP) SilverScript Plus (PDP) January 1, 2013 December 31, 2013 S5601 SilverScript Basic (PDP), SilverScript Choice (PDP) and SilverScript
Annual Notice of Changes for 2018
Brand New Day Classic Care Drug Savings (HMO) offered by Brand New Day Annual Notice of Changes for 2018 You are currently enrolled as a member of Classic Care. Next year, there will be some changes to
2019 SUMMARY OF BENEFITS
2019 SUMMARY OF BENEFITS Vitality Health Plan of California (HMO) County and County H1426 001/002/003 H1426_19_078_MK_ENG_M H1426 001/002/003 Vitality Health Plan of California January 1, 2019 December
Medicare Advantage Plans
2016 BlueShield of Northeastern New York Medicare Advantage Plans Gloria and Anai, Members Y0086_MRK1529 Accepted The benefits of Blue Understanding Medicare and choosing a health plan are not always easy.
Plan documents are the final arbiter of coverage. Dental Accident Critical Illness Pets Best
Benefit Disclosures Accident, Critical Illness or Dental individual coverage may not be available in all states. These individual policies have exclusions and limitations and provisions regarding termination
Annual Notice of Changes for 2018
Brand New Day Harmony Choice for Medi-Medi (HMO SNP) offered by Brand New Day Annual Notice of Changes for 2018 You are currently enrolled as a member of Harmony - Dual Access. Next year, there will be
Enhanced Rx $10/30/50 - $20/60/100 with $0 Pharmacy Deductible. Blue Shield of California
An independent member of the Blue Shield Association Enhanced Rx $10/30/50 - $20/60/100 with $0 Pharmacy Deductible Outpatient Prescription Drug Coverage (For groups of 101 and above) THIS DRUG COVERAGE
MEDICAID BUY-IN PROGRAMS
MEDICAID BUY-IN PROGRAMS Under federal law, states have the option of creating Medicaid buy-in programs that enable employed individuals with disabilities who make more than what is allowed under Section
Enrollment Request Form
Employer name: Coverage effective date: Employer group number (Medical): Important Please print all sections in black ink. For the application to be valid, you must submit all applicable pages. 1. Select
Pharmacy Benefits Member Guide
Commercial Pharmacy Benefits Member Guide Optimizing your pharmacy benefits for a healthier you Carol Kim, Health Net We focus on getting you the health information you need, when you need it. Understanding
Medical Benefits Claim Instructions
Medical Benefits Claim Instructions Any person who knowingly and with intent to injure, defraud or deceive any insurance company or other person files an application for insurance or statement of claim
NOTIFICATION FROM EMPLOYEE BENEFITS
NOTIFICATION FROM EMPLOYEE BENEFITS The Open Enrollment period will commence on November 1, 2017 and end on November 21, 2017. All changes made during this period will be effective January 1, 2018. If
ANNUAL NOTICE OF CHANGES FOR 2016
Cigna-HealthSpring Preferred (HMO) offered by Cigna-HealthSpring ANNUAL NOTICE OF CHANGES FOR 2016 You are currently enrolled as a member of Cigna-HealthSpring Preferred (HMO). Next year, there will be
ANNUAL NOTICE OF CHANGES FOR 2016
Cigna-HealthSpring Advantage (HMO) offered by Cigna-HealthSpring ANNUAL NOTICE OF CHANGES FOR 2016 You are currently enrolled as a member of Cigna-HealthSpring Advantage (HMO). Next year, there will be
Annual Notice of Changes for 2018
Allwell Dual Medicare (HMO SNP) offered by Sunshine State Health Plan, Inc. Annual Notice of Changes for 2018 You are currently enrolled as a member of Sunshine Health Medicare Advantage. Next year, there
Aetna Individual Direct Pay Commissions Schedule
Aetna Individual Direct Pay Commissions Schedule Cards Issued Broker Rate Broker Tier Per Year 1st Yr 2nd Yr 3+ Yrs Levels 11-Jan 4.00% 4.00% 3.00% Bronze 24-Dec 6.00% 4.00% 3.00% Silver 25-49 8.00% 4.00%
Participating Pharmacy 9 Non-Participating Pharmacy 7,8
Rx Spectrum $10/25/40 - $20/50/80 with $0 Pharmacy Deductible Outpatient Prescription Drug Coverage (For groups of 101 and above) Highlight: $0 Calendar Year Pharmacy Deductible $10 Tier 1 / $25 Tier 2
d e n t a l p l a n f o r g r o u p s o f 2 t h r o u g h 9 e m p l o y e e s Dental Cents REV. 12/18
a lifetime of commitment a commonsense d e n t a l p l a n f o r g r o u p s o f 2 t h r o u g h 9 e m p l o y e e s RATE INFORMATION Dental Cents 95076 REV. 12/18 Standard Industry Code (SIC) Factors
Sharp Advantage Employer Group Enrollment Form
2017-2018 Sharp Advantage Employer Group Enrollment Form To enroll in Sharp Advantage please provide the following information: Effective Date of Coverage: MM/DD/YY ( / 01 / ) Employer or Union Name: City
ANNUAL NOTICE OF CHANGES FOR 2019
Cigna HealthSpring Advantage (HMO) offered by Cigna HealthSpring ANNUAL NOTICE OF CHANGES FOR 2019 You are currently enrolled as a member of Cigna HealthSpring Advantage (HMO). Next year, there will be
2012 Summary of Benefits
Community CCRx Basic (PDP) Community CCRx Choice (PDP) 2012 Summary of Benefits January 1, 2012 December 31, 2012 S5803 S5825 Y0080_PRE_SumBen CMS Approved 08/25/2011 Community CCRx PDP is offered by SilverScript