REQUEST FOR PRESCRIPTION DRUG COVERAGE DETERMINATION This form may be sent to us by mail or fax:
|
|
|
- Theodore Bradley
- 6 years ago
- Views:
Transcription
1 REQUEST FOR PRESCRIPTION DRUG COVERAGE DETERMINATION This form may be sent to us by mail or fax: Mailing Address: Fax Number: WellCare Advocate Complete FIDA (Medicare-Medicaid Plan) P.O. Box Tampa, FL You may also ask us for a coverage determination by phone at , or through our website at Who May Make a Request: Your prescriber may ask us for a coverage determination on your behalf. If you want another person (such as a family member or friend) to make a request for you, that person must be named as your representative. Contact us to learn how to name a representative. Participant s Information Participant s Name Date of Birth Participant s Address City State Zip Code Phone Participant s ID # Complete the following section ONLY if the person making this request is not the enrollee or prescriber: Requestor s Name Requestor s Relationship to Enrollee Address City State ZIP Code Phone If this request is being made by someone other than the participant or the participant s prescriber: Attach documentation showing the authority to represent the enrollee. Accepted documents are a completed Authorization of Representation Form CMS-1696, or a written equivalent. For more information on appointing a representative, contact us or call MEDICARE.
2 Name of prescription drug you are requesting (if known, include strength and quantity requested per month): Type of Coverage Determination Request I need a drug that is not on the plan s list of covered drugs (formulary exception).* I have been using a drug that was previously included on the plan s list of covered drugs, but is being removed or was removed from this list during the plan year (formulary exception).* I request prior authorization for the drug my prescriber has prescribed.* I request an exception to the requirement that I try another drug before I get the drug my prescriber prescribed (formulary exception).* I request an exception to the plan s limit on the number of pills (quantity limit) I can receive so that I can get the number of pills my prescriber prescribed (formulary exception).* My drug plan charges a higher co-payment for the drug my prescriber prescribed than it charges for another drug that treats my condition, and I want to pay the lower co-payment (tiering exception).* I have been using a drug that was previously included on a lower co-payment tier, but is being moved to or was moved to a higher co-payment tier (tiering exception).* My drug plan charged me a higher co-payment for a drug than it should have. I want to be reimbursed for a covered prescription drug that I paid for out of pocket. *NOTE: If you are asking for a formulary or tiering exception, your prescriber MUST provide a statement supporting your request. Requests that are subject to prior authorization (or any other utilization management requirement) may require supporting information. Your prescriber may use the attached Supporting Information for an Exception Request or Prior Authorization to support your request. Additional information we should consider (attach any supporting documents): Important Note: Expedited Decisions If you or your prescriber believes that waiting 72 hours for a standard decision could seriously harm your life, health or ability to regain maximum function, you can ask for an expedited (fast) decision. If your prescriber indicates that waiting 72 hours could seriously harm your health, we will
3 automatically give you a decision within 24 hours. If you do not obtain your prescriber's support for an expedited request, we will decide if your case requires a fast decision. You cannot request an expedited coverage determination if you are asking us to pay you back for a drug you already received. CHECK THIS BOX IF YOU BELIEVE YOU NEED A DECISION WITHIN 24 HOURS. (If you have a supporting statement from your prescriber, attach it to this request.) Signature: Date: Supporting Information for an Exception Request or Prior Authorization FORMULARY and TIERING EXCEPTION requests cannot be processed without a prescriber s supporting statement. PRIOR AUTHORIZATION requests may require supporting information. REQUEST FOR EXPEDITED REVIEW: By checking this box and signing below, I certify that applying the 72 hour standard review timeframe may seriously jeopardize the life or health of the enrollee or the enrollee s ability to regain maximum function. Prescriber s Information Name Address City State ZIP Code Office Phone Fax Prescriber s Signature Date Diagnosis and Medical Information Medication: Strength and Route of Administration: Frequency: New Prescription OR Date Therapy Initiated: Expected Length of Therapy: Quantity:
4 Height/Weight: Drug Allergies: Diagnosis: Rationale for Request Alternate drug(s) contraindicated or previously tried, but with adverse outcome, e.g., toxicity, allergy or therapeutic failure [Specify below: (1) Drug(s) contraindicated or tried; (2) adverse outcome for each; (3) if therapeutic failure, length of therapy on each drug(s)] Patient is stable on current drug(s); high risk of significant adverse clinical outcome with medication change [Specify below: Anticipated significant adverse clinical outcome] Medical need for different dosage form and/or higher dosage [Specify below: (1) Dosage form(s) and/or dosage(s) tried; (2) explain medical reason] Request for formulary tier exception [Specify below: (1) Formulary or preferred drugs contraindicated or tried and failed, or tried and not as effective as requested drug; (2) if therapeutic failure, length of therapy on each drug and adverse outcome; (3) if not as effective, length of therapy on each drug and outcome] Other (explain below) Required Explanation WellCare Advocate Complete FIDA is a managed care plan that contracts with both Medicare and the New York State Department of Health (Medicaid) to provide benefits of both programs to Participants through the Fully Integrated Duals Advantage (FIDA) Demonstration. Limitations and restrictions may apply. For more information, call WellCare Participant Services or read the WellCare Advocate Complete FIDA Participant Handbook. Benefits, List of Covered Drugs, and pharmacy and provider networks may change from time to time throughout the year and on January 1 of each year. You can get this information for free in other languages. Call and TTY/TDD 711 during 8 AM to 6 PM Eastern, Monday - Friday. The call is free. Puede obtener esta información gratis en otros idiomas. Llame al y TTY/TDD al 711 de 8 a.m. a 6 p.m., hora del este, de lunes a viernes. La llamada es gratis. 您可以免費獲得此資訊的其他語言版本 請在週一至週五, 東部時間上午 8 時至下午 6 時撥打電話 和 TTY/TDD 711 撥打此電話是免費的 Ou kapab jwenn enfòmasyon sa a gratis nan lòt lang. Rele nan nimewo ak TTY/TDD 711 depi 8 a.m. jiska 6 p.m. Lè Zòn Lès, Lendi Vandredi. Koutfil la gratis.
5 Queste informazioni possono essere ottenute gratuitamente in altre lingue. Chiamare e TTY/TDD 711 dalle ore 8 del mattino alle 6 del pomeriggio, ora della costa orientale degli USA, dal lunedì alla venerdì. La chiamata è gratuita. 이정보는다른언어로무료로제공됩니다. 월요일 - 금요일, 동부표준시, 오전 8 시 - 오후 6 시에 및 TTY/TDD 711 으로연락주십시오. 이전화통화는무료입니다. Вы можете получить эту информацию на других языках бесплатно. Звоните по номеру и TTY/TDD 711 с 8 утра до 6 вечера по восточному поясному времени, с понедельника по пятницу. Звонок бесплатный. The State of New York has created a participant ombudsman program called the Independent Consumer Advocacy Network (ICAN) to provide Participants free, confidential assistance on any services offered by WellCare Advocate Complete Medicare-Medicaid Plan. ICAN may be reached toll-free at or online at icannys.org.
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: Fax Number: CVS Caremark - Appeals Department 1-855-633-7673 MC 109 PO Box 52000 Phoenix,
Annual Notice of Change. New York. AbsoluteCare FIDA Plan (Medicare-Medicaid Plan)
Annual Notice of Change 2017 New York H5441_LGL17_02 Approved 09192016 AbsoluteCare FIDA Plan (Medicare-Medicaid Plan) Table of Contents A. Think about your Medicare and Medicaid coverage for next year...
REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION
SilverScript Insurance Company Empire Plan Medicare Rx P.O. Box 52425, Phoenix, AZ 85072-2425 REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION This form is used by SilverScript Insurance Company,
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: BlueCross BlueShield of Western New York P.O. Box 80 Buffalo, NY 14204 Attn: Pharmacy
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: Fax Number: Aetna Better Health of Virginia (HMO SNP) 1-877-270-0148 Part D Coverage Determination
Annual Notice of Changes for 2016
H9115_MEM0049 Approved 09142015 MetroPlus FIDA Plan (Medicare-Medicaid Plan) offered by MetroPlus Health Plan Annual Notice of Changes for 2016 You are currently enrolled as a Participant of MetroPlus
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
2015 Annual Notice of Changes Fidelis Dual Advantage Flex (HMO SNP)
2015 Annual Notice of Changes Fidelis Dual Advantage Flex (HMO SNP) Fidelis Dual Advantage Flex (HMO-SNP) offered by Fidelis Care Annual Notice of Changes for 2015 You are currently enrolled as a member
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: 7050 S Union Park Center Drive Suite 200 Midvale, Utah 84047 Fax Number: (866) 290-1309
Fidelis Dual Advantage Flex (HMO-SNP) offered by Fidelis Care
Fidelis Dual Advantage Flex (HMO-SNP) offered by Fidelis Care Fidelis Dual Advantage Flex (HMO-SNP) offered by Fidelis Care Annual Notice of Changes for 2016 You are currently enrolled as a member of
2013 Individual Enrollment Form
2013 Individual Enrollment Form When you are ready to enroll. Contact your local sales agent to help you choose the best plan for you and complete this individual enrollment form, or Call UnitedHealthcare
2013 Individual Enrollment Form
2013 Individual Enrollment Form When you are ready to enroll. Contact your local sales agent to help you choose the best plan for you and complete this individual enrollment form, or Call UnitedHealthcare
2016 Enrollment Request Form
2016 Enrollment Request Form Page 1 of 7 Please contact the Plan if you need information in another language or format (Braille). AARP MedicareComplete SecureHorizons Plan 2 (HMO) H0543-151 - AS2 This
MEDICARE GUIDEBOOK. You have Medicare questions? We have answers. YOU AND YOUR CHOICES. LET S DO THIS TOGETHER. usaa.com/medicare
MEDICARE MEDICARE SUPPLEMENT INSURANCE PLANS These plans are sold by private insurance companies to help cover some of the expenses Medicare Parts A and B don t. You can apply for a Medicare Supplement
Annual Notice of Changes for 2015
AlphaCare Renew (HMO) offered by AlphaCare of New York, Inc. Annual Notice of Changes for 2015 You are currently enrolled as a member of AlphaCare Renew. Next year, there will be some changes to the plan
Supporting Appropriate Payer Coverage Decisions
Supporting Appropriate Payer Coverage Decisions Providing Services for Janssen Pharmaceutical Companies of Johnson & Johnson Table of Contents Introduction 3 This document is presented for informational
ANNUAL. Notice of Changes. UnitedHealthcare Connected (Medicare-Medicaid Plan)
2017 ANNUAL Notice of Changes UnitedHealthcare Connected (Medicare-Medicaid Plan) Toll-Free 1-800-256-6533, TTY 7-1-1 8 a.m. 8 p.m. local time, Monday Friday www.uhccommunityplan.com www.myuhc.com/communityplan
Annual Notice of Change. Anthem HealthKeepers Medicare-Medicaid Plan (MMP), a Commonwealth Coordinated Care Plan
Annual Notice of Change Anthem HealthKeepers Medicare-Medicaid Plan (MMP), a Commonwealth Coordinated Care Plan Virginia Member Services: 1-855-817-5787 (TTY 711) Monday through Friday 8 a.m. to 8 p.m.
Please Provide the Following Information
MEDICARE ADVANTAGE INDIVIDUAL ENROLLMENT REQUEST FORM 445 Grant Avenue, Suite 700, San Francisco, CA 94108 Tel: (415) 955-8800 Fax: (415) 955-8819 www.cchphmo.com/medicare Please contact CCHP if you need
Enrollment packet. Your guide to getting more out of your plan. Aetna Medicare SM Plan (PPO) with Extended Service Area (ESA)
Quality health plans & benefits Healthier living Financial well-being Intelligent solutions Enrollment packet Your guide to getting more out of your plan Visit http://aetnaretireeplans.com Aetna Medicare
HP17XXXXXXX. Coventry Health Care 2017 Individual Enrollment Request Form Instructions
THIS ENROLLMENT REQUEST FORM IS IN SECTIONS. PLEASE REMOVE THIS TAB TO SEPARATE THE SECTIONS BEFORE YOU BEGIN. How to enroll You can enroll in one of the following ways: Online at http://www.coventrymedicare.com,
2018 ANNUAL NOTICE OF CHANGES
2018 ANNUAL NOTICE OF CHANGES Important changes to your plan UnitedHealthcare Dual Complete (HMO SNP) Toll-Free 1-800-514-4912, TTY 711 8 a.m. - 8 p.m. local time, 7 days a week www.uhccommunityplan.com
Annual Notice of Changes for 2015
AlphaCare Total (HMO SNP) offered by AlphaCare of New York, Inc. Annual Notice of Changes for 2015 You are currently enrolled as a member of AlphaCare Total. Next year, there will be some changes to the
AlphaCare Renew (HMO)
2014 Your Care Comes First AlphaCare Renew (HMO) Evidence of Coverage January 1 December 31, 2014 Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of AlphaCare Renew
2019 Annual Notice of Changes
2019 Annual Notice of Changes Coordinated Benefits Plan (HMO) New York City and Nassau County January 1, 2019 December 31, 2019 H3359_LGL19_04 027 1395-18_M Accepted 08302018 H3359 027 Healthfirst Coordinated
This is important information on a phone number change in your Health Net Medicare Advantage plan Evidence of Coverage.
May 2016 Dear Health Net Member, This is important information on a phone number change in your Health Net Medicare Advantage plan Evidence of Coverage. We previously sent you the 2016 Evidence of Coverage
2019 SUMMARY OF BENEFITS
2019 SUMMARY OF BENEFITS Overview of your plan AARP MedicareRx Walgreens (PDP) S5921-390 Look inside to learn more about the drug coverages the plan provides. Call Customer Servi or go online for more
2019 SUMMARY OF BENEFITS
2019 SUMMARY OF BENEFITS Overview of your plan AARP MedicareRx Preferred (PDP) S5820-024 Look inside to learn more about the drug coverages the plan provides. Call Customer Servi or go online for more
Annual Notice of Changes for 2018
Care1st Total Dual Plan (HMO SNP) offered by Care1st Health Plan Annual Notice of Changes for 2018 You are currently enrolled as a member of Care1st Total Dual Plan. Next year, there will be some changes
How the Aetna Medicare Advantage plan option compares to your current plan Below are coverage and cost examples of key benefits that are important to
151 Farmington Avenue, Hartford, CT 06156 , Key things you should know about Dow 2017
This is important information on a phone number change in your Health Net Medicare Advantage plan Evidence of Coverage.
May 2016 Dear Health Net Member, This is important information on a phone number change in your Health Net Medicare Advantage plan Evidence of Coverage. We previously sent you the 2016 Evidence of Coverage
Coverage Determinations, Appeals and Grievances
Coverage Determinations, Appeals and Grievances Filing a grievance (making a complaint) about your prescription coverage Asking for a coverage determination (coverage decision) 60-day formulary change
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
HOW TO MAKE A COMPLAINT, REQUEST A COVERAGE DECISION,
OPTIMA MEDICARE HMO HOW TO MAKE A COMPLAINT, REQUEST A COVERAGE DECISION, OR FILE AN APPEAL ABOUT COVERED MEDICARE PART C MEDICAL CARE AND SERVICES OR COVERED PART D PRESCRIPTION DRUGS Optima Medicare
2014 Summary of Benefits. Empire Plan Medicare Rx sponsored by New York State Health Insurance Program (NYSHIP)
SilverScript Insurance Company Empire Plan Medicare Rx P.O. Box 52424, Phoenix, AZ 85072-2424 Empire Plan Medicare Rx sponsored by New York State Health Insurance Program (NYSHIP) 2014 Summary of Benefits
Ambetter.BuckeyeHealthPlan.com
Ambetter.BuckeyeHealthPlan.com Welcome to Ambetter from Buckeye Health Plan! Our goal is to help you lead a healthier, better life and we can t wait to get started. Soon, you will receive your Ambetter
Medicare Part D Prescription Drug Plan
Medicare Part D Prescription Drug Plan The value you expect with exclusive Costco savings... in a plan that s easy to use and understand That s the Aetna Medicare Rx Costco Plus Plan (PDP) Enroll at www.aetnamedicare.com/costco
This is important information on a phone number change in your Health Net Medicare Advantage plan Evidence of Coverage.
May 2016 Dear Health Net Member, This is important information on a phone number change in your Health Net Medicare Advantage plan Evidence of Coverage. We previously sent you the 2016 Evidence of Coverage
Humana Medicare Advantage with Prescription Drug Plan
Humana Medicare Advantage with Prescription Drug Plan Y0040_SPRE_MAPD_HH_17 Approved GNHH31KHH_17 Let s talk about... Your eligibility The right Humana plan for you Your Medicare options Humana s Medicare
Aetna Medicare 2015 Benefits at a Glance
Aetna Medicare 2015 Benefits at a Glance Aetna Medicare Rx Saver (PDP) Aetna Medicare Rx Premier (PDP) Arizona, California, Florida, Nevada, South Carolina 58.02.396.1-NPREF Contact us for answers to your
TOWN OF WINCHESTER Aetna Medicare Rx Plan Custom RX $10/$25/$50/$50. Benefits and Premiums are effective January 01, 2019 through December 31, 2019
Benefits and Premiums are effective January 01, 2019 through December 31, 2019 PLAN DESIGN AND BENEFITS PROVIDED BY AETNA LIFE INSURANCE COMPANY PHARMACY - PRESCRIPTION DRUG BENEFITS Calendar-year deductible
Fidelis Medicare $0 Premium (HMO) offered by Fidelis Care
Fidelis Medicare $0 Premium (HMO) offered by Fidelis Care January 1 December 31, 2016 Evidence of Coverage: Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of Fidelis
GOODYEAR RETIREE Summary of Benefits. SilverScript Employer PDP sponsored by the Goodyear Retiree VEBA. Pre 1991 Retirees
P.O. Box 52424 Phoenix, AZ 85072-2424 GOODYEAR RETIREE SilverScript Employer PDP sponsored by the Goodyear Retiree VEBA 2013 Summary of Benefits Pre 1991 Retirees 2013 Summary of Benefits for SilverScript
This is important information on a phone number change in your Health Net Medicare Advantage plan Evidence of Coverage.
May 2016 Dear Health Net Member, This is important information on a phone number change in your Health Net Medicare Advantage plan Evidence of Coverage. We previously sent you the 2016 Evidence of Coverage
Summary of Benefits. Aetna Medicare Rx Costco Plus Plan (PDP) S5810. California. January 1, 2010 to December 31, 2010
January 1, 2010 to December 31, 2010 Summary of Benefits Aetna Medicare Rx S5810 California S5810_D_PE_SB_90712 (08/2009) Visit us www.aetnamedicare.com 1 Summary of Benefits: Aetna Medicare Rx Section
Summary of Benefits for Blue Shield Medicare Basic Plan (PDP) Blue Shield Medicare Enhanced Plan (PDP) Blue Shield Medicare Premium Plan (PDP)
Summary of s for Blue Shield Blue Shield Blue Shield January 1, 2012 December 31, 2012 State of California S2468 S2468_11_134 CMS Approved 09012011 blueshieldca.com Section I Introduction to Summary of
Blue Shield Medicare Basic Plan (PDP) Blue Shield Medicare Enhanced Plan (PDP)
Summary of Benefits January 1, 2014 December 31, 2014 State of California S2468_13_228 CMS Accepted 09102013 SECTION I INTRODUCTION TO SUMMARY OF BENEFITS Thank you for your interest in and. Our plans
Value Choice. Summary of Benefits. January 1 December 31, 2014 S5660 & S5983. Y0046_B00SNS4B Accepted
Value Choice Summary of Benefits January 1 December 31, 2014 S5660 & S5983 Y0046_B00SNS4B Accepted B00SNS4P Introduction to Summary of Benefits Thank you for your interest in Express Scripts Medicare (PDP).
Annual Notice of Changes for 2018
Care1st Advantage Optimum Plan (HMO) offered by Care1st Health Plan Annual Notice of Changes for 2018 You are currently enrolled as a member of Care 1st Advantage Optimum Plan. Next year, there will be
WellCare Medicare Prescription Drug Plan
WellCare Medicare Prescription Drug Plan Individual Enrollment Form How to Enroll with WellCare 1 Please contact WellCare if you need information in another language or format (Braille). 2 Please read
21 - Pharmacy Services
21 - Pharmacy Services The role of Health Plan of Nevada s (HPN) Pharmacy Services is to evaluate and determine the appropriateness of quality drug therapy while maintaining and improving therapeutic outcomes.
Chapter 17: Pharmacy and Drug Formulary
Chapter 17: Pharmacy and Drug Formulary Introduction Health Choice Insurance Co. (Health Choice) is pleased to provide the Health Choice Formulary, which is available on line at www.healthchoiceessential.com/members/rxdrugs.
Liberty Advantage (HMO SNP) Prescription Drug Transition Policy
Liberty Advantage (HMO SNP) Prescription Drug Transition Policy What to do if your current prescription drugs are not on the drug list (formulary) or are limited on the drug list (formulary). New Members
SYMPHONIX RITE AID VALUE RX (PDP)
SYMPHONIX RITE AID VALUE RX (PDP) and SYMPHONIX RITE AID PREMIER RX (PDP) (a Medicare Prescription Drug plan (PDP) offered by SYMPHONIX HEALTH INSURANCE, INC. with a Medicare contract) Summary of Benefits
Helping you stay covered. with Kaiser Permanente
Helping you stay covered with Kaiser Permanente What s inside How do I stay covered?... 2 When do I need to enroll?... 4 What are my options?... 6 Kaiser Permanente for Individuals and Families... 8 Medi-Cal...10
Enrollment Application
2016 MEDICARE ADVANTAGE Enrollment Application SmartSaver Rx PDP Value (PDP) If you have any questions, we re here to help! healthnowny.commedicare 1-888-989-9905 (TTY 711) October 1-February 14 February
Using your pharmacy benefit
Using your pharmacy benefit Your pharmacy benefit services OptumRx is your plan s pharmacy services manager and is committed to helping you find cost-effective ways to get your medication(s). Set up your
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
SecurityBlue HMO. Link to Specific Guidance Regarding Exceptions and Appeals
SecurityBlue HMO Conditions and Limitations Potential for Contract Termination Disenrollment Rights and Instructions Exceptions, Prior Authorization, Appeals and Grievances Out-of-Network Coverage Quality
Appeals and Grievances: What to Do if You Have Complaints About Your Part D Prescription Drug Benefits
Appeals and Grievances: What to Do if You Have Complaints About Your Part D Prescription Drug Benefits WHAT TO DO IF YOU HAVE COMPLAINTS We encourage you to let us know right away if you have questions,
BlueRx PDP. Link to Specific Guidance Regarding Exceptions and Appeals
BlueRx PDP Conditions and Limitations Potential for Contract Termination Disenrollment Rights and Instructions Exceptions, Prior Authorization, Appeals and Grievances Out-of-Network Coverage Quality Assurance
HEALTH MAINTENANCE ORGANIZATION
HEALTH MAINTENANCE ORGANIZATION Classic Care (HMO) offered by Brand New Day Annual Notice of Changes for 2017 You are currently enrolled as a member of Classic Care (HMO). Next year, there will be some
2019 MEDICARE ADVANTAGE
2019 MEDICARE ADVANTAGE INDIVIDUAL ENROLLMENT FORM Please contact Vitality Health Plan of California if you need information in another language or format (Braille). To Enroll in Vitality Health Plan of
The following is an explanation of why your drug is not covered or is limited under your plan.
Community Health Plan of Washington 720 Olive Way, Suite 300 Seattle, WA 98101 Dear : This letter is to inform you that Community HealthFirst
Florida Hospital Explorer Plan (HMO-POS)
Florida Hospital Explorer Plan (HMO-POS) Offered by Health First Health Plans You are currently enrolled as a member of the Explorer Plan (HMO-POS). Next year, there will be some changes to the plan s
Errata Sheet to the Imperial Health Plan of California (HMO) Traditional LA (006) & Traditional SFO (007) 2018 Evidence of Coverage
Errata Sheet to the Imperial Health Plan of California (HMO) Traditional LA (006) & Traditional SFO (007) 2018 Evidence of Coverage [Insert date] This is important information on changes in your Imperial
2018 PLAN CHANGE PACKET
2018 PLAN CHANGE PACKET These forms are NOT your application for a new plan. However, they will help us in finding you the right plan. In September, your current Part D drug plan (or Medicare Advantage
Annual Notice of Changes for 2015
Prescription Plan Basic (PDP) offered by Health Alliance Medicare Annual Notice of Changes for 2015 You are currently enrolled as a member of Health Alliance Medicare Prescription Plan Basic. Next year,
ENROLLMENT REQUEST FORM
ENROLLMENT REQUEST FORM Please contact Affinity Health Plan if you need information in another language or format (braille. To Enroll in Affinity Health Plan, Please Provide the Following Information:
Annual Notice of Change for 2019
TEAMStar Medicare Part D (PDP) TEAMStar Bronze Plan offered by The International Brotherhood of Teamsters Voluntary Employee Benefits Trust Annual Notice of Change for 2019 You are currently enrolled as
PHARMACY COVERAGE GUIDELINES ORIGINAL EFFECTIVE DATE: 1/18/18 SECTION: DRUGS LAST REVIEW DATE: 8/13/18 LAST CRITERIA REVISION DATE: ARCHIVE DATE:
STEP THERAPY Coverage for services, procedures, medical devices and drugs are dependent upon benefit eligibility as outlined in the member's specific benefit plan. This Pharmacy Coverage Guideline must
Enrollment Application
Enrollment Application Please contact Imperial Health Plan of California (HMO) and (HMO SNP) if you need information in another language or format (braille). To enroll in Imperial Health Plan, please provide
Annual Notice of Changes for 2017
Care N Care Choice Premium (PPO) offered by Care N Care Insurance Company, Inc. Annual Notice of Changes for 2017 You are currently enrolled as a member of Care N Care Health Plan I (PPO). Next year, there
SHARP HEALTH PLAN MEDICARE ADVANTAGE POLICY AND PROCEDURE Product Line (check all that apply):
SHARP HEALTH PLAN MEDICARE ADVANTAGE POLICY AND PROCEDURE Product Line (check all that apply): Title: SHP Pharmacy Management Policy and Procedure for Part D Coverage Determination All Group HMO Individual
Annual Notice of Changes for 2015
Cigna-HealthSpring Rx Secure-Xtra (PDP) offered by Cigna-HealthSpring Annual Notice of Changes for 2015 You are currently enrolled as a member of Cigna Medicare Rx Secure-Xtra (PDP). Next year, there will
Blue Cross MedicareRx (PDP) SM
(PDP) SM Summary of Benefits January 1, 2014 December 31, 2014 Y0096_BEN_IL_PDPSB14 Accepted 10012013 31980.0613 SECTION I Introduction to the Summary of Benefits for SM January 1, 2014 December 31, 2014
Employer Group POS Plan (HMO-POS)
Employer Group POS Plan (HMO-POS) Offered by Health First Health Plans You are currently enrolled as a member of the Employer Group POS Plan (HMO-POS). Next year, there will be some changes to the plan
January 1, 2017 December 31, 2017
2017 Summary of Benefits Fidelis Medicare Advantage Flex Plan (HMO-POS), Fidelis Medicare $0 Premium Plan (HMO) and Fidelis Medicare Advantage Without Rx (HMO-POS) CMS Contract # H3328 January 1, 2017
2019 SUMMARY OF BENEFITS
2019 SUMMARY OF BENEFITS Overview of your plan AARP MedicareRx Saver Plus (PDP) S5921-353 Look inside to learn more about the drug coverages the plan provides. Call Customer Servi or go online for more
2018 Enrollment Request Form
Page 1 of 8 2018 Enrollment Request Form Please contact the plan if you need this information in another language or format (Braille). UnitedHealthcare Dual Complete (HMO-POS SNP) H5322-030 - UDH This
2016 Summary of Benefits Booklet
P.O. Box 52424, Phoenix, AZ 85072-2424 2016 Summary of Benefits Booklet Employer PDP sponsored by Pfizer a Medicare Prescription Drug Plan (PDP) offered by Insurance Company with a Medicare contract January
2018 One-on-One Sales Presentation. Y0070_WCM_02476E_F001 CMS Approved
2018 One-on-One Sales Presentation Y0070_WCM_02476E_F001 CMS Approved 08312017 WellCare 2018 NA8WCMPRS02477E_1ON1 Welcome to WellCare Health Plan Thank you for considering a WellCare plan. For more than
A plan for life IN SICKNESS AND IN HEALTH
A plan for life IN SICKNESS AND IN HEALTH Keeping You Healthy As a health plan that truly puts our members first, CDPHP does more than just help you when you re sick. Many health problems can be prevented.
2015 Summary of Benefits
P.O. Box 52424, Phoenix, AZ 85072-2424 2015 Summary of Benefits sponsored by Shell (a Medicare Prescription Drug Plan (PDP) offered by SilverScript Insurance Company with a Medicare contract) January 1,
1199SEIU Home Care Employees Pension Fund
1199SEIU HOME CARE EMPLOYEES PENSION FUND 330 West 42nd Street New York, NY 10036-6977 (646) 473-9200 www.1199seiubenefits.org 1199SEIU Home Care Employees Pension Fund SUMMARY PLAN DESCRIPTION OF YOUR
WellCare/ Ohana Medicare Advantage Plans Individual Enrollment Form
WellCare/ Ohana Medicare Advantage Plans Individual Enrollment Form How to Enroll with WellCare/ Ohana 1 Please contact WellCare/ Ohana if you need an enrollment form or information in another language
2017 Summary of Benefits
P.O. Box 52424, Phoenix, AZ 85072-2424 2017 Summary of Benefits Employer PDP sponsored by The Coca-Cola Company () A Medicare Prescription Drug Plan (PDP) offered by Insurance Company with a Medicare contract
Last Name First Name Middle Initial
Page 1 of 7 2018 Enrollment Request Form Please contact the plan if you need this information in another language or format (Braille). Medica HealthCare Plans MedicareMax (HMO) H5420-001 - MMH TEAR HERE
2017 Summary of Benefits
P.O. Box 52424, Phoenix, AZ 85072-2424 2017 Summary of Benefits Employer PDP sponsored by Shell () A Medicare Prescription Drug Plan (PDP) offered by Insurance Company with a Medicare contract January
Thank you for choosing Sutter Health Plus for your health care needs.
Sutter Health Plus P.O. Box 160307 Sacramento, CA 95816 855-315-5800 sutterhealthplus.org , ,
Summary of Benefits 2011
Summary of Benefits 2011 This Summary of Benefits tells you some features of our plans. AARP Rx AARP Rx January 1, 2011-December 31, 2011 S5820 S5921 SBPDP3251059_XABE000 Y0066_PDP3238383_000 CMS Approved
Summary of Benefits. Mount Sinai Select (HMO) Manhattan January 1, 2016 December 31, 2016 H H3359_MKT16_ Accepted
Summary of Benefits Mount Sinai Select (HMO) 2016 Manhattan January 1, 2016 December 31, 2016 H3359 036 H3359_MKT16_01 036 Accepted 08312015 Proposed Effective Date Primary Care Provider Name Address Phone
Annual Notice of Changes for 2017
WellCare Rx (HMO) offered by WellCare of Connecticut, Inc. Annual Notice of Changes for 2017 You are currently enrolled as a member of WellCare Rx (HMO). Next year, there will be some changes to the plan
Medicare Made Simple
Medicare Made Simple TABLE OF CONTENTS 2 A Coverage Overview: What is Medicare? 3 Original Medicare Parts A and B 5 Medicare Part C Medicare Advantage Plans 6 Medicare Part D Prescription Drug Coverage
2018 ANNUAL NOTICE OF CHANGES
2018 ANNUAL NOTICE OF CHANGES Important changes to your plan AARP MedicareComplete Plan 2 (HMO) Toll-Free 1-800-950-9355, TTY 711 8 a.m. - 8 p.m. local time, 7 days a week www.myaarpmedicare.com Do we
2019 ANNUAL NOTICE OF CHANGES
2019 ANNUAL NOTICE OF CHANGES Important changes to your plan Toll-free 1-866-480-1086, TTY 711 8 a.m. - 8 p.m. local time, 7 days a week www.uhccommunityplan.com Do we have the right address for you? If
Annual Notice of Changes for 2018
VNSNY CHOICE Preferred (HMO SNP) offered by VNSNY CHOICE Medicare Annual Notice of Changes for 2018 You are currently enrolled as a member of VNSNY CHOICE Preferred. Next year, there will be some changes
Pharmacy Benefit Protocols
Prescription Drug Formularies The AARP MedicareComplete, Evercare, SecureHorizons MedicareComplete, SecureHorizons MedicareDirect SM and UnitedHealthcare MedicareDirect SM Prescription Drug Formularies
Annual Notice of Changes for 2018
Care N Care Choice (PPO) offered by Care N Care Insurance Company, Inc. Annual Notice of Changes for 2018 You are currently enrolled as a member of Care N Care Choice (PPO). Next year, there will be some
Using Your Medicare Drug Plan: What to Do if Your Medicine Isn t Covered SPRING 2007
Using Your Medicare Drug Plan: What to Do if Your Medicine Isn t Covered SPRING 2007 www.yourpharmacybenefit.org Table of Contents How does it work?............................................ 1 When should