2018 Plan Year Monthly Plan Premium for People Who Get Extra Help From Medicare to Help Pay for Their Prescription Drug Costs

Size: px
Start display at page:

Download "2018 Plan Year Monthly Plan Premium for People Who Get Extra Help From Medicare to Help Pay for Their Prescription Drug Costs"

Transcription

1 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 plan costs, your monthly plan premium will be lower than what it would be if you did not get extra help from Medicare. The amount of extra help you get will determine your total monthly plan premium as a member of our Plan. The table below shows you how much you will pay for your monthly plan premium based on your state, county and your percentage of the subsidized amount. This does not include any Medicare Part B premium you may have to pay. California Los Angeles, Orange, & San Bernardino 100% 75% 50% 25% Anthem Value Plus (HMO) Anthem Value Plus (HMO) premium includes coverage for both medical services and prescription drug coverage. Santa Clara & San Benito 1

2 Anthem Value Plus (HMO) $54.00 $0.10 $9.00 $17.80 $26.70 Anthem Value Plus (HMO) premium includes coverage for both medical services and prescription drug coverage. Stanislaus Anthem Value Plus (HMO) $48.00 $8.20 $16.50 $24.70 Anthem Value Plus (HMO) premium includes coverage for both medical services and prescription drug coverage. Los Angeles, Orange, & San Bernardino 100% 75% 50% 25% Anthem Diabetes (HMO SNP) Anthem Diabetes (HMO SNP) premium includes coverage for both medical services and prescription drug coverage. Santa Clara & San Benito 2

3 Anthem Diabetes (HMO SNP) $55.00 $15.50 $24.40 $33.20 $42.10 Anthem Diabetes (HMO SNP) premium includes coverage for both medical services and prescription drug coverage. Stanislaus Anthem Diabetes (HMO SNP) $59.00 $13.20 $22.10 $30.90 $39.80 Anthem Diabetes (HMO SNP) premium includes coverage for both medical services and prescription drug coverage. Los Angeles, Orange, & San Bernardino 100% 75% 50% 25% Anthem Heart (HMO SNP) Anthem Heart (HMO SNP) premium includes coverage for both medical services and prescription drug coverage. Santa Clara & San Benito 3

4 Anthem Heart (HMO SNP) $55.00 $13.40 $22.30 $31.10 $40.00 Anthem Heart (HMO SNP) premium includes coverage for both medical services and prescription drug coverage. Stanislaus Anthem Heart (HMO SNP) $ % 75% $ % $ % $23.20 Anthem Heart (HMO SNP) premium includes coverage for both medical services and prescription drug coverage. Los Angeles, Orange, & San Bernardino Anthem Breathe (HMO SNP) 100% 75% 50% 25% Anthem Breathe (HMO SNP) premium includes coverage for both medical services and prescription drug coverage. Santa Clara & San Benito 4

5 Anthem Breathe (HMO SNP) $55.00 $19.50 $28.40 $37.20 $46.10 Anthem Breathe (HMO SNP) premium includes coverage for both medical services and prescription drug coverage. Stanislaus Anthem Breathe (HMO SNP) $59.00 $20.00 $28.90 $37.70 $46.60 Anthem Breathe (HMO SNP) premium includes coverage for both medical services and prescription drug coverage. Los Angeles, Orange, & San Bernardino Anthem ESRD (HMO SNP) Anthem ESRD (HMO SNP) premium includes coverage for both medical services and prescription drug coverage. Los Angeles & Santa Clara 5

6 Anthem Connect (HMO SNP) Anthem Connect (HMO SNP) premium includes coverage for both medical services and prescription drug coverage. Los Angeles, Orange, & Santa Clara Anthem Touch (HMO SNP) 100% 75% 50% 25% Anthem Touch (HMO SNP) premium includes coverage for both medical services and prescription drug coverage. Los Angeles, Orange, San Bernardino, Santa Clara, San Benito, and Stanislaus Anthem StartSmart Plus (HMO SNP) Anthem StartSmart Plus (HMO SNP) premium includes coverage for both medical services and prescription drug coverage. Los Angeles, Orange, San Bernardino, Santa Clara, & San Benito 6

7 Anthem Connect Plus (HMO SNP) $33.00 $8.20 $16.50 $24.70 Anthem Connect Plus (HMO SNP) premium includes coverage for both medical services and prescription drug coverage. Los Angeles, Orange, San Bernardino, Santa Clara, San Benito, and Stanislaus If you aren t getting extra help, you can see if you qualify by calling: MEDICARE ( ), or TTY/TDD users should call hours a day, 7 days a week, Your State Medicaid Office, or The Social Security Administration at or TTY/TDD users should call between 7 a.m. and 7 p.m., Monday through Friday. If you have any questions, please call Customer Service at , TTY/TTD 711, 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from October 1 to February 14, and Monday to Friday (except holidays) from February 15 to September 30. Our automated system is available anytime for self-service options, including after hours, weekends, and holidays. Anthem Blue Cross is an HMO/ HMO SNP plan with a Medicare contract. Enrollment in Anthem Blue Cross depends on contract renewal. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, premium and/or copayments/co-insurance may change on January 1 of each year. You must continue to pay your Medicare Part B premium. This policy has exclusions, limitations, and terms under which the policy may be continued in force or discontinued. For costs and complete details of the coverage, contact your insurance agent, Anthem or visit us on the web. ABCLIS18 Y0114_18_33174_U CMS Accepted (MM/DD/YYYY) 7

8 NOTICE OF NON-DISCRIMINATION We comply with applicable Federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability, or sex. We do not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. We: Provide free aids and services to people with disabilities to communicate effectively with us, such as: o Qualifed sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats) Provide free language services to people whose primary language is not English, such as: o Qualifed interpreters o Information written in other languages If you need these services, contact Member Services. If you believe that we have failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can fle a grievance with: Member Services, Appeals & Grievances, Park Plaza Drive, Suite 150, Mailstop 6150, Cerritos, CA 90703, , TTY 711. You can fle a grievance in person or by mail, fax, or . If you need help fling a grievance, Member Services Representative is available to help you. You can also fle 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, D.C , (TDD) Complaint forms are available at Amharic Arabic Armenian Bengali (TTY: 711). Chinese (TTY: 711) English French ATTENTION: If you speak a language other than English, language assistance services, free of charge, are available to you. Call (TTY: 711)

9 German Hindi Hmong (TTY: 711) (TTY: 711). Ilocano Japanese Korean Kru (Bassa) Mon-Khmer, Cambodian Navajo (TTY: 711) (TTY: 711) Persian (Farsi) Punjabi Russian Samoan Serbo-Croatian Spanish Syriac (TTY: 711). Tagalog Thai (TTY: 711) Urdu Vietnamese (TTY: 711). Y0114_18_32484_I _002 (09/01/2017).(TTY: 711) : NOND_CA_NV

Health Net Medicare Advantage Plans 2019 Optional Benefit Individual Enrollment Form

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

More information

2019 Health Net Ruby Select (HMO) H0562:112 Fresno County, CA

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.

More information

2019 Health Net Gold Select (HMO) H0562: Riverside and San Bernardino Counties, CA

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

More information

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 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

More information

Mail all medical claims to: or Mail all behavioral health claims to: Any missing information may cause a delay in processing your request.

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

More information

2019 Health Net Ruby (HMO) H Lane County, OR

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

More information

2019 Health Net Violet 2 (PPO) H Marion and Polk Counties, OR

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.

More information

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 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

More information

Health Net 2019 Individual Enrollment Form

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:

More information

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, 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

More information

Summary of Benefits. Anthem Diabetes (HMO SNP) Anthem Heart (HMO SNP) Anthem Breathe (HMO SNP) Available in San Bernardino County

Summary of Benefits. Anthem Diabetes (HMO SNP) Anthem Heart (HMO SNP) Anthem Breathe (HMO SNP) Available in San Bernardino County Summary of Benefits Anthem Diabetes Anthem Heart Anthem Breathe Available in San Bernardino County SB_ABC_SB_SNP Y0114_18_32747_U_032 CMS Accepted Introduction This is a summary of health services and

More information

Summary of Benefits. Anthem Diabetes (HMO SNP) Anthem Heart (HMO SNP) Anthem Breathe (HMO SNP) Available in Santa Clara & San Benito Counties

Summary of Benefits. Anthem Diabetes (HMO SNP) Anthem Heart (HMO SNP) Anthem Breathe (HMO SNP) Available in Santa Clara & San Benito Counties Summary of Benefits Anthem Diabetes Anthem Heart Available in Santa Clara & San Benito Counties SB_ABC_SCSB_SNP Y0114_18_32747_U_030 CMS Accepted Introduction This is a summary of health services and drugs

More information

Summary of Benefits. Anthem Touch (HMO SNP) Available in Los Angeles County & Orange County

Summary of Benefits. Anthem Touch (HMO SNP) Available in Los Angeles County & Orange County Summary of Benefits Available in Los Angeles County & Orange County SB_ABC_LAOC_TCH Y0114_18_32747_U_003 CMS Accepted (10012017) Introduction This is a summary of health services and drugs covered by from

More information

Summary of Benefits. Anthem Value Plus (HMO) Anthem StartSmart Plus (HMO) Available in Los Angeles County & Orange County

Summary of Benefits. Anthem Value Plus (HMO) Anthem StartSmart Plus (HMO) Available in Los Angeles County & Orange County Summary of Benefits Anthem Value Plus Anthem StartSmart Plus Available in Los Angeles County & Orange County SB_ABC_LAOC_HMO Y0114_18_32747_U_001 CMS Accepted (10012017) Introduction This is a summary

More information

Summary of Benefits. Anthem Connect Plus (HMO) Available in Clark County. SB_ABCBS_NV_CP Y0114_18_32747_U_019 CMS Accepted ( )

Summary of Benefits. Anthem Connect Plus (HMO) Available in Clark County. SB_ABCBS_NV_CP Y0114_18_32747_U_019 CMS Accepted ( ) Summary of Benefits Available in Clark County SB_ABCBS_NV_CP Y0114_18_32747_U_019 CMS Accepted (10012017) Introduction This is a summary of health services and drugs covered by from January 1, 2018 - December

More information

Summary of Benefits. Anthem Diabetes (HMO SNP) Anthem Heart (HMO SNP) Anthem Breathe (HMO SNP) Available in Clark County

Summary of Benefits. Anthem Diabetes (HMO SNP) Anthem Heart (HMO SNP) Anthem Breathe (HMO SNP) Available in Clark County Summary of Benefits Anthem Diabetes Anthem Heart Available in Clark County SB_ABCBS_NV_SNP Y0114_18_32747_U_017 CMS Accepted (10012017) Introduction This is a summary of health services and drugs covered

More information

Summary of Benefits. Anthem Diabetes (HMO SNP) Anthem Heart (HMO SNP) Anthem Breathe (HMO SNP) Available in Los Angeles County & Orange County

Summary of Benefits. Anthem Diabetes (HMO SNP) Anthem Heart (HMO SNP) Anthem Breathe (HMO SNP) Available in Los Angeles County & Orange County Summary of Benefits Anthem Diabetes Anthem Heart Available in Los Angeles County & Orange County SB_ABC_LAOC_SNP Y0114_18_32747_U_002 CMS Accepted (10012017) Introduction This is a summary of health services

More information

Individual Enrollment Form

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

More information

Summary of Benefits. Anthem ESRD (HMO SNP) Available in San Bernardino County. SB_ABC_SB_ESRD Y0114_18_32747_U_008 CMS Accepted ( )

Summary of Benefits. Anthem ESRD (HMO SNP) Available in San Bernardino County. SB_ABC_SB_ESRD Y0114_18_32747_U_008 CMS Accepted ( ) Summary of Benefits Available in San Bernardino County SB_ABC_SB_ESRD Y0114_18_32747_U_008 CMS Accepted (10012017) Introduction This is a summary of health services and drugs covered by from January 1,

More information

Summary of Benefits January 1, 2017 December 31, 2017

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

More information

Summary of Benefits. Anthem MediBlue Local (HMO) Anthem MediBlue Smart Fit (HMO)

Summary of Benefits. Anthem MediBlue Local (HMO) Anthem MediBlue Smart Fit (HMO) Summary of Benefits Anthem MediBlue Local Fit Available in Richmond City, Henrico, Chesterfield, Goochland, Hanover, Powhatan, Colonial Heights City, Hopewell City, and Petersburg City Counties SB_AHK_HMO

More information

These are the Optional Supplemental Benefits you can buy.

These are the Optional Supplemental Benefits you can buy. 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

More information

Request for Redetermination of Medicare Prescription Drug Denial

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

More information

Summary of Benefits. Anthem MediBlue Diabetes (HMO SNP) Anthem MediBlue COPD (HMO SNP)

Summary of Benefits. Anthem MediBlue Diabetes (HMO SNP) Anthem MediBlue COPD (HMO SNP) Summary of Benefits Anthem MediBlue Diabetes Available in Richmond City, Henrico, Chesterfield, Goochland, Hanover, Powhatan, Colonial Heights City, Hopewell City, and Petersburg City Counties SB_AHK_SNP

More information

Please contact Sharp Health Plan if you need information in another language or format (Braille).

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.

More information

Enhanced Rx $10/30/50 - $20/60/100 with $0 Pharmacy Deductible. Blue Shield of California

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

More information

Individual Enrollment Form

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:

More information

Summary of Benefits. Tufts Medicare Preferred PDP PLANS Employer Group Tufts Medicare Preferred PDP3

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

More information

Sharp Advantage Employer Group Enrollment Form

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

More information

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: 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

More information

Coverage Through Employer/Union name Grp# Last Name: First Name: Middle Initial: 9 F

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

More information

Medicare Advantage (MA) Individual Enrollment Request Form

Medicare Advantage (MA) Individual Enrollment Request Form Medicare Advantage (MA) Individual Enrollment Request Form Please contact CareMore Health Plan if you need information in another language or format (Braille). To enroll in CareMore Health Plan, please

More information

Participating Pharmacy 9 Non-Participating Pharmacy 7,8

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

More information

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, 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

More information

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 ( )

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).

More information

Allwell 2019 Individual Enrollment Form

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

More information

2018 Summary of Benefits

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

More information

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 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

More information

Summary of Benefits. Allwell Medicare (HMO) Bexar County, TX H Benefits effective January 1, 2018 H0062_18_2962SB_Accepted

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.

More information

Alternate Phone Number: ( ) Address: Sex: 9 M ( ) 9 F. Permanent Residence Address (P.O. Box is not allowed): City: State: Zip Code:

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).

More information

Summary of Benefits. Allwell Medicare (HMO) Palm Beach, Manatee, Marion and Seminole Counties, Florida H

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

More 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.

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).

More information

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 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

More information

Pharmacy Benefits Member Guide

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

More information

2019 Allwell Medicare (HMO) H Kane County, IL

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

More information

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 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

More information

2018 Individual Enrollment Request Form

2018 Individual Enrollment Request Form 2018 Individual Enrollment Request Form If you have questions, please contact AgeWell New York at: 1-866-586-8044 or TTY 1-800-662-1220 Fax Enrollment form to 1-855-895-0784 Please contact AgeWell New

More information

2018 CareOregon Advantage Star (HMO) Summary of Benefits

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

More information

2019 Short Enrollment Request

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

More information

Summary of Benefits. Allwell Medicare (HMO) Duval, Lake, Pinellas, Polk and Volusia Counties, Florida H H9276_18_2858SB _A Accepted

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

More information

Health Net 2018 Individual Enrollment Form

Health Net 2018 Individual Enrollment Form Health Net 2018 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:

More information

Summary of Benefits. Allwell Medicare Premier (HMO) Duval, Pinellas, Polk, Hernando, Pasco and Volusia Counties, Florida H

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

More information

Health Options Program

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.

More information

Annual Notice of Changes for 2018

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

More information

Summary of Benefits. Allwell Medicare (HMO) Cameron and Hidalgo counties, TX H

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

More information

Summary Of Benefits January 1, December 31, 2019

Summary Of Benefits January 1, December 31, 2019 Summary Of Benefits January 1, 2019 - December 31, 2019 Blue Shield of California Promise Health Plan is an independent licensee of the Blue Shield Association Care1st is an independent licensee of the

More information

Annual Notice of Changes for 2018

Annual Notice of Changes for 2018 Brand New Day Classic Choice for Medi-Medi (HMO) offered by Brand New Day Annual Notice of Changes for 2018 You are currently enrolled as a member of Classic Choice for Medi-Medi. Next year, there will

More information

<Logo> 2019 Allwell Medicare (HMO) H1664: 004 Crawford, Franklin, Jefferson, Lincoln, St. Charles, Warren, and Washington Counties, MO

<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

More information

Annual Notice of Changes for 2018

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

More information

Evidence of Coverage:

Evidence of Coverage: Brand New Day Embrace Care Drug Savings (HMO SNP) offered by Brand New Day January 1 December 31, 2018 Evidence of Coverage: Your Medicare Health Benefits and Services and Prescription Drug Coverage as

More information

2017 Summary of Benefits

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

More information

Medicare Made Simple. A guide to your health plan options

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

More information

Allwell 2019 Individual Enrollment Form

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

More information

2017 Summary of Benefits

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

More information

Please check which plan you want to enroll in: Health Net Healthy Heart (HMO) (includes prescription drug coverage)

Please check which plan you want to enroll in: Health Net Healthy Heart (HMO) (includes prescription drug coverage) 2016 Medicare Advantage Individual Enrollment Request Form Please contact Health Net if you need information in another language or format (Braille). To Enroll in Health Net, Please Provide the Following

More information

Evidence of Coverage:

Evidence of Coverage: January 1 December 31, 2017 Evidence of Coverage: Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of Health Net Jade (HMO SNP) This booklet gives you the details about

More information

2018 Summary of Benefits

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

More information

Evidence of Coverage:

Evidence of Coverage: January 1 December 31, 2018 Evidence of Coverage: Your Medicare Health Benefits and Services and Prescription Drug Coverage as a Member of Health Net Gold Select (HMO) This booklet gives you the details

More information

Humana Medicare Employer Plan

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

More information

NOTIFICATION FROM EMPLOYEE BENEFITS

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

More information

Tufts Medicare Preferred Supplement. IMportant information. PO Box 9178 Watertown, MA 02472

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,

More information

Summary of Benefits. Allwell Medicare Essentials II (HMO) Maricopa County, Arizona H

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

More information

2018 Summary of Benefits

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

More information

$6,750 single / $13,500 family $25,000 single / $50,000 family Professional services

$6,750 single / $13,500 family $25,000 single / $50,000 family Professional services IFP PPO is available directly through Health Net in Contra Costa, Marin, Merced, Napa, Orange, San Diego, San Francisco, San Joaquin, San Mateo, Santa Clara, Santa Cruz, Solano, Sonoma, Stanislaus, and

More information

Your Vision Website from Health Net

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

More information

Summary of Benefits. Allwell Medicare Premier (HMO) Pinal County, Arizona H

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

More information

Medicare Made Simple. A guide to your health plan options

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.

More information

Membership Change Form

Membership Change Form Membership Change Form Medicare Supplement Plans Maryland, District of Columbia and Virginia Residents Mailroom Administrator P.O. Box 14651, Lexington, KY 40512 Fax: 410-505-2901 or toll free 800-305-1351

More information

EVIDENCE OF COVERAGE. AdvantageOptimum Coordinated Choice Plan (HMO)

EVIDENCE OF COVERAGE. AdvantageOptimum Coordinated Choice Plan (HMO) 2018 FRESNO LOS ANGELES MERCED ORANGE RIVERSIDE SAN BERNARDINO SANTA CLARA SAN DIEGO SAN JOAQUIN STANISLAUS COUNTIES EVIDENCE OF COVERAGE AdvantageOptimum Coordinated Choice Plan (HMO) H5928_18_006_EOC_CC

More information

Allwell 2019 Individual Enrollment Form

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

More information

2018 Summary of Benefits

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

More information

Medicare Advantage Individual

Medicare Advantage Individual Medicare Advantage Individual Enrollment Election Form Please contact Care1st if you need information in another language or format (Braille). To Enroll in Care1st, Please Provide the Following Information:

More information

2018 Summary of Benefits

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

More information

EASY CHOICE MEDICARE ADVANTAGE PLANS

EASY CHOICE MEDICARE ADVANTAGE PLANS EASY CHOICE MEDICARE ADVANTAGE PLANS 2017 INDIVIDUAL ENROLLMENT FORM 1 2 3 4 5 How to Enroll with Easy Choice Please read this entire enrollment form to make sure you understand the information. When you

More information

Individual Enrollment Request Form

Individual Enrollment Request Form Individual Enrollment Request Form 3800 Kilroy Airport Way, Suite 100 Long Beach, CA 90806 Please contact SCAN Health Plan if you need information in another language or format (Braille). To enroll in

More information

2018 Summary of Benefits

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,

More information

2018 Summary of Benefits

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

More information

Annual Notice of Changes for 2018

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

More information

Summary of Benefits. Allwell Dual Medicare (HMO SNP)

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,

More information

Medicare Advantage HMO plans

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

More information

2019 SUMMARY OF BENEFITS

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

More information

Individual Enrollment Request Form

Individual Enrollment Request Form Individual Enrollment Request Form 3800 Kilroy Airport Way, Suite 100 Long Beach, CA 90806 Please contact SCAN Health Plan if you need information in another language or format (Braille). To enroll in

More information

Any missing information may cause a delay in processing your request.

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

More information

Name of Plan You are Enrolling In: Health Net Healthy Heart (HMO) (includes prescription drug coverage)

Name of Plan You are Enrolling In: Health Net Healthy Heart (HMO) (includes prescription drug coverage) Health Net Medicare Advantage Plans 2016 Medicare Advantage Short Enrollment Request Form Name of Plan You are Enrolling In: Health Net Healthy Heart (HMO) (includes prescription drug coverage) Alameda,

More information

Medicare Advantage HMO plans

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?

More information

Plan Comparison Chart. Includes medical and prescription drug (Rx) benefit information

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

More information

Health Maintenance Organization (HMO)

Health Maintenance Organization (HMO) Health Maintenance Organization (HMO) Blue Shield 65 Plus (HMO) Evidence of Coverage Effective January 1, 2014 Blue Shield of California is an HMO plan with a Medicare contract. Enrollment in Blue Shield

More information

MEDICARE ADVANTAGE INDIVIDUAL ENROLLMENT ELECTION FORM

MEDICARE ADVANTAGE INDIVIDUAL ENROLLMENT ELECTION FORM MEDICARE ADVANTAGE INDIVIDUAL ENROLLMENT ELECTION FORM Please contact Care1st if you need information in another language or format (Braille). To Enroll in Care1st, Please Provide the Following Information:

More information

Prescription Drug Claim Form

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

More information

$0 per month q AZ, Pima County. q CA, Los Angeles/Orange Counties $0 per month q CA, Los Angeles/Orange Counties $0 per month.

$0 per month q AZ, Pima County. q CA, Los Angeles/Orange Counties $0 per month q CA, Los Angeles/Orange Counties $0 per month. Medicare Advantage (MA) Individual Enrollment Request Form Please contact CareMore Health Plan if you need information in another language or format (Braille). To enroll in CareMore Health Plan, please

More information