REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION This form may be sent to us by mail or fax:
|
|
|
- Randolph Hoover
- 6 years ago
- Views:
Transcription
1 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 MC 109 PO Box Phoenix, AZ You may also ask us for a coverage determination by phone at , TTY/TDD 711, 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 individual (such as a family member or friend) to make a request for you, that individual must be your representative. Contact us to learn how to name a representative. Enrollee s Information Enrollee s Name Date of Birth Enrollee s Address Phone Enrollee s Member 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 Phone Representation documentation for requests made by someone other than enrollee or the enrollee s prescriber: Attach documentation showing the authority to represent the enrollee (a completed Authorization of Representation Form CMS-1696 or a written equivalent). For more information on appointing a representative, contact your plan or Medicare ( ). H5441_RXM17_01 Accepted
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 copayment for the drug my prescriber prescribed than it charges for another drug that treats my condition, and I want to pay the lower copayment (tiering exception).* I have been using a drug that was previously included on a lower copayment tier, but is being moved to or was moved to a higher copayment tier (tiering exception).* My drug plan charged me a higher copayment 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 believe 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 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.
3 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 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: Height/Weight: Drug Allergies: Diagnosis: Rationale for Request
4 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 Healthfirst AbsoluteCare FIDA Plan (Medicare-Medicaid Plan) 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. Participants generally must use network pharmacies to access their prescription drug benefit. The List of Covered Drugs and/or pharmacy and provider networks may change throughout the year. We will send you a notice before we make a change that affects you. You can get this information for free in other languages. Call and TTY/TDD 711, 7 days a week from 8 am to 8 pm. The call is free. Usted puede obtener esta información de forma gratuita en otros idiomas. Llame al y al TTY/TDD 711, los 7 días de la semana de 8:00 a.m. a 8:00 p.m. La llamada es gratuita. Вы можете получить эту информацию бесплатно на других языках. Звоните по телефону или 711 (для пользующихся TTY/TDD) 7 дней в неделю с 8 утра до 8 вечера. Звонок бесплатный. 本資訊有其他語言版本供免費索取 請致電 , 聽力語言殘障服務專線 TTY/TDD 711, 服務時間每週七天, 每天上午 8 時至晚上 8 時 以上均為免費電話 이와동일한정보를무상으로다른언어버전으로도얻으실수있습니다. 문의는 (TTY/TDD 711) 으로연중무휴오전 8 시에서오후 8 시사이에연락주십시오. 통화는무료입니다. Ou kapab jwenn enfòmasyon sa yo gratis nan lòt lang yo. Rele nimewo ak TTY/TDD 711 pandan 7 jou pa semèn depi 8 am jiska to 8 pm. Koutfil la gratis. È possibile ottenere queste informazioni gratuitamente in altre lingue chiamando il numero (utenti TTY/TDD: 711), 7 giorni alla settimana dalle 8 alle 20. La telefonata è gratuita.
5 You can ask for this notice in other formats, such as Braille or large print. Call or TTY: 711, 7 days a week from 8 am to 8 pm. Healthfirst Medicare Plan complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. 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 Healthfirst AbsoluteCare FIDA Plan (Medicare-Medicaid Plan). The Participant Ombudsman may be reached toll-free at , TTY 711 or online at icannys.org.
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 PRESCRIPTION DRUG COVERAGE DETERMINATION This form may be sent to us by mail or fax:
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) 1-866-388-1767 P.O.
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
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
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
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
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
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
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
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
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
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
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
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 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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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,
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
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
2019 Enrollment Request Form
Page 1 of 9 2019 Enrollment Request Form Please contact the plan if you need this information in another language or an accessible format (Braille). UnitedHealthcare Dual Complete (HMO SNP) H0169-002 -
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
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
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). Erickson Advantage Champion (HMO-POS SNP) H5652-004 - EC This plan
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,
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
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
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
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
2019 Benefit Highlights
Los Angeles and Orange Counties 2019 Benefit Highlights VillageHealth (HMO-POS SNP) Medicare Advantage Plan Plan Details Monthly Plan Premium $0 $34.80 $34.80 Annual Plan Deductible $0 deductible deductible
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
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.
SUMMARY OF BENEFITS E0654_19SBSBP
2019 SUMMARY OF BENEFITS JANUARY 1, 2019 DECEMBER 31, 2019 E0654_19SBSBP FI755 TEAMStar MEDICARE PART D PRESCRIPTION DRUG PROGRAM (PDP) (a Medicare Prescription Drug plan (PDP) offered by the International
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).
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
2017 SilverScript Insurance Company Medicare Prescription Drug Plan brought to you by Health Net Enrollment Form
2017 SilverScript Insurance Company Medicare Prescription Drug Plan brought to you by Health Net Enrollment Form Section 1: Please Read This Important Information Typically, you may enroll in a Medicare
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
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.
2019 SilverScript Insurance Company SilverScript Employer PDP sponsored by Health Net (SilverScript) Medicare Part D Enrollment Form
2019 SilverScript Insurance Company SilverScript Employer PDP sponsored by Health Net (SilverScript) Medicare Part D Enrollment Form Section 1: Please Read This Important Information Typically, you may
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
Kern Choice Plan (HMO) PRE-EnRollmEnT Book 2014
CARE1ST Kern Choice Plan (HMO) PRE-EnRollmEnT Book 2014 KERN COUNTY H5928_14_115_MKB2 Accepted Thank you for Your Interest in Care1st TABLE OF CONTENTS 1. Thank you for Your Interest in Care1st / Table
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
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:
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:
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.
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
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 2015
P.O. Box 52424, Phoenix, AZ 85072-2424 SilverScript Plus (PDP) offered by SilverScript Insurance Company Annual Notice of Changes for 2015 You are currently enrolled as a member of BlueRx Enhanced (PDP).
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
Application Instructions
Application Instructions Thank you for your interest in Geisinger Gold. Please read carefully before completing each section of this enrollment application to help ensure quick processing of your new Geisinger
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
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
YOUR DRUG(S) IS NOT ON OUR LIST OF COVERED DRUGS (FORMULARY) OR IS SUBJECT TO CERTAIN LIMITS
Aetna Better Health of Virginia (HMO SNP) 9881 Mayland Drive Richmond, VA 23233 YOUR DRUG(S) IS NOT ON OUR LIST OF COVERED DRUGS (FORMULARY) OR IS SUBJECT
2019 Benefit Highlights
San Diego County 2019 Benefit Highlights Scripps Classic (HMO), Scripps Heart First (HMO SNP) and Scripps Signature (HMO) Medicare Advantage Plans Plan Details Monthly Plan Premium $0 $26 $74 Annual Plan
To Enroll in Liberty Advantage, Please Provide the Following Information:
Please contact Liberty Advantage if you need information in another language or format (Braille). To Enroll in Liberty Advantage, Please Provide the Following Information: LAST name: FIRST Name: Middle
Summary Of Benefits. January 1, December 31, Blue Shield Promise TotalDual Plan (HMO SNP)
Summary Of Benefits Blue Shield of California Promise Health Plan is an independent licensee of the Blue Shield Association Care1st is an independent licensee of the Blue Shield Association January 1,
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 SHBP Benefts at a Glance
UnitedHealthcare SHBP Members State of Georgia 2019 SHBP Benefts at a Glance For more coverage details for each of these plans, please visit welcometouhc.com/shbp or call 888-364-6352. Medical Choice HMO
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
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
PSC-CUNY Welfare Fund Medicare-Eligible Retirees Drug Plan 2016 Silverscript Insurance Company Enrollment Form Instructions, 2016
PSC-CUNY Welfare Fund Medicare-Eligible Retirees Drug Plan 2016 Silverscript Insurance Company Enrollment Form Instructions, 2016 Members will check only these boxes: Section 1 Reasons for Special Enrollment
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
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
"'9" MEDICAL PLAN INC.- Individual Enrollment Request Form
- DENVER HEALTH I Medicare Advantage "'9" MEDICAL PLAN INC.- Individual Enrollment Request Form Please contact Denver Health Medical Plan, Inc. if you need information in another language or format (Braille).
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
Enrollment Request Form Washington
Enrollment Request Form Washington HMO and POS Plans for county. January 1, 2017 December 31, 2017 2017 Toll-free 1-877-642-3331 TTY 711 HealthAllianceMedicare.org One Step at a Time Follow these simple
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,
SilverScript Insurance Company 2019 Medicare Prescription Drug Plan Individual Enrollment Form
2019 SilverScript Section 1: Please Read This Important Information Typically, you may enroll in a Medicare Prescription Drug Plan only during the Annual Enrollment Period between October 15 and December
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
Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of Clover Health Prestige (PPO)
Clover January 1 December 31, 2016 Evidence of Coverage: Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of Clover Health Prestige (PPO) This booklet gives you the
2016 Summary of Benefits
P.O. Box 52424, Phoenix, AZ 85072-2424 2016 Summary of Benefits Employer PDP sponsored by REHP () A Medicare Prescription Drug Plan (PDP) offered by Insurance Company with a Medicare contract January 1,
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
GROUP MEDICARE PLANS AT A GLANCE FOR EMPLOYER GROUPS. Toll-free , ext TTY: 711 HealthAlliance.org
GROUP MEDICARE PLANS AT A GLANCE FOR EMPLOYER GROUPS 2017 Toll-free 1-800-851-3379, ext. 8024 TTY: 711 HealthAlliance.org This information is not a complete description of benefits. Contact the plan for
Summary Of Benefits. January 1, December 31, Blue Shield Promise Coordinated Choice Plan (HMO)
Summary Of Benefits Blue Shield of California Promise Health Plan is an independent licensee of the Blue Shield Association Care1st is an independent licensee of the Blue Shield Association January 1,
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
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
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
ANNUAL NOTICE OF CHANGES FOR 2017
Cigna-HealthSpring Rx Secure-Extra (PDP) offered by Cigna-HealthSpring ANNUAL NOTICE OF CHANGES FOR 2017 You are currently enrolled as a member of Cigna-HealthSpring Rx Secure-Extra (PDP). 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
2019 Benefit Highlights
Riverside County 2019 Benefit Highlights SCAN Prime (HMO) Medicare Advantage Plan NEW PLAN FEATURED BENEFITS Over-the-Counter Drugs VIAGRA (generic) Telehealth Dental Coverage Included Plan Details Monthly
Evidence of Coverage:
P.O. Box 52424, Phoenix, AZ 85072-2424 January 1, 2017 - December 31, 2017 Evidence of Coverage: Your Medicare Prescription Drug Coverage as a Member of SilverScript Employer PDP sponsored by The Group