Upcoming Changes to Santa Clara Family Health Plan Cal MediConnect Plan (Medicare-Medicaid Plan) 2018 Drug List. Updated 4/1/2018
|
|
|
- Roxanne Fleming
- 5 years ago
- Views:
Transcription
1 Upcoming Changes to Santa Clara Family Health Plan Cal MediConnect Plan (Medicare-Medicaid Plan) 2018 Drug List Updated 4/1/2018 Santa Clara Family Health Plan (SCFHP) Cal MediConnect Plan (Medicare-Medicaid Plan) may add or remove drugs from our formulary (drug list) during the year, or add rules about whether or when certain drugs are covered. If SCFHP removes a covered drug or makes any changes to the drug list, SCFHP will post the changes on our website and notify affected members at least sixty (60) calendar days prior to the effective date of the change. However, if the Food and Drug Administration (FDA) says a drug that you are taking is not safe, or if the drug s maker removes the drug from the market, we will take the drug off the drug list right away. We will also send you a letter telling you that. The chart below contains upcoming changes to the SCFHP Cal MediConnect Plan drug list. These changes may impact you. Effective Date BUPHENYL 500 MG ORAL Drug Name Type of Change Reason for Change Alternate Drugs BUTRANS 7.5 MCG/HR TRANSDERM. CANCIDAS 50 MG INTRAVEN. CANCIDAS 70 MG INTRAVEN. COPAXONE 40 MG/ML SUBCUTANE. SODIUM PHENYLBUTYRATE 500 MG TABLET - TIER 1 BUPRENORPHINE 7.5 MCG/HR PATCH TDWK - TIER 1 CASPOFUNGIN ACETATE 50 MG VIAL - TIER 2 CASPOFUNGIN ACETATE 70 MG VIAL - TIER 2 GLATIRAMER ACETATE 40 MG/ML SYRINGE - TIER 1 H7890_13060E_FINAL_ Accepted Page 1 of 4
2 Effective Date EFFIENT 10 MG ORAL EFFIENT 5 MG ORAL ESTRACE 0.01 % VAGINAL LEXIVA 700 MG ORAL RENVELA 800 MG ORAL REYATAZ 150 MG ORAL REYATAZ 200 MG ORAL REYATAZ 300 MG ORAL SABRIL 500 MG ORAL Drug Name Type of Change Reason for Change Alternate Drugs PRASUGREL HCL 10 MG TABLET - TIER 1 PRASUGREL HCL 5 MG TABLET - TIER 1 ESTRADIOL 0.01 % CREAM/APPL - TIER 1 FOSAMPRENAVIR CALCIUM 700 MG TABLET - TIER 1 SEVELAMER CARBONATE 800 MG TABLET - TIER 1 ATAZANAVIR SULFATE 150 MG CAPSULE - TIER 1 ATAZANAVIR SULFATE 200 MG CAPSULE - TIER 1 ATAZANAVIR SULFATE 300 MG CAPSULE - TIER 1 VIGABATRIN 500 MG POWD PACK - TIER 1 Page 2 of 4
3 Effective Date SUSTIVA 200 MG ORAL SUSTIVA 50 MG ORAL SUSTIVA 600 MG ORAL Drug Name Type of Change Reason for Change Alternate Drugs TRANSDERM-SCOP 1 MG/3 DAY TRANSDERM. VIGAMOX 0.5 % OPHTHALMIC VIREAD 300 MG ORAL ZIAGEN 20 MG/ML ORAL EFAVIRENZ 200 MG CAPSULE - TIER 1 EFAVIRENZ 50 MG CAPSULE - TIER 1 EFAVIRENZ 600 MG TABLET - TIER 1 SCOPOLAMINE 1 MG/3 DAY PATCH TD 3 - TIER 1 MOXIFLOXACIN 0.5 % DROPS - TIER 1 TENOFOVIR DISOPROXIL FUMARATE 300 MG TABLET - TIER 1 ABACAVIR 20 MG/ML SOLUTION - TIER 1 Page 3 of 4
4 What you and your doctor can do We are telling you about these changes now, so that you and your doctor will have time (at least 60 days) to decide what to do. Depending on the type of change, there may be different options to consider. For example: Perhaps your doctor can find a different drug on the SCFHP Cal MediConnect drug list that might work just as well for you. You and your doctor can ask the plan to make an exception for you. This means asking us to agree that the upcoming change in coverage of a drug does not apply to you. o Your doctor will need to tell us why making an exception is medically necessary for you. o To learn what you must do to ask for an exception, see the SCFHP Cal MediConnect Member Handbook. If you disagree with our decision to remove or change coverage for any of these drugs, you may also file a grievance with us. Please call Customer Service if you want to file a grievance. You may also send your grievance to us in writing by mail to: Attn: Grievances and Appeals Santa Clara Family Health Plan 210 East Hacienda Avenue Campbell, CA For more information on filing a grievance, see the SCFHP Cal MediConnect Member Handbook. If you have questions Call , Monday through Friday, 8 a.m. to 8 p.m. TTY/TDD users should call or 711. The call is free. Santa Clara Family Health Plan Cal MediConnect Plan (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees. Limitations, copays, and restrictions may apply. For more information, call SCFHP Customer Service or read the SCFHP Cal MediConnect Member Handbook. Benefits and/or copays may change on January 1 of each year. The List of Covered Drugs 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 formats, such as large print, braille, or audio. Call , Monday through Friday, 8 a.m. to 8 p.m. PT. TTY/TDD users call or 711. The call is free. Page 4 of 4
5 Discrimination is Against the Law Santa Clara Family Health Plan (SCFHP) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. SCFHP does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. SCFHP: Provides free aids and services to people with disabilities to communicate effectively with us, such as: o Qualified sign language interpreters o Written information in other formats (large print, audio, accessible electronic formats, other formats) Provides free language services to people whose primary language is not English, such as: o Qualified interpreters o Information written in other languages If you need these services, contact Customer Service at , Monday through Friday, 8 a.m. to 8 p.m. TTY/TDD users call or E Cal MediConnect
6 If you believe that SCFHP has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with: Attn: Appeals and Grievances Department Santa Clara Family Health Plan 210 East Hacienda Avenue Campbell, CA Phone: TTY/TDD: or 711 Fax: CalMediConnectGrievances@scfhp.com You can file a grievance in person or by mail, fax, or . If you need help filing a grievance, a Customer Service representative is available to help you. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at or by mail or phone at: U.S. Department of Health and Human Services 200 Independence Avenue SW Room 509F, HHH Building Washington, DC Phone: TDD: Complaint forms are available at E Cal MediConnect
7
8
9
2018 Formulary Notice of Change Medicare Advantage Plans
2018 Formulary Notice of Change Medicare Advantage Plans Easy Choice Health Plan Plan in the following state: CA Easy Choice Best Plan (HMO) H5087-005-000 Easy Choice may add or remove drugs from our formulary
2018 Formulary Notice of Change Prescription Drug Plans
2018 Formulary Notice of Change Prescription Drug Plans WellCare Prescription Insurance, Inc. Plans in all states: WellCare Classic (PDP) WellCare may add or remove drugs from our formulary during the
2018 Formulary Notice of Change Medicare Advantage Plans
2018 Formulary Notice of Change Medicare Advantage Plans WellCare Health Plans Plans in the following states: AR, FL, GA, KY, MS, NC, NY, SC, TN WellCare Access (HMO SNP), WellCare Liberty (HMO SNP) WellCare
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
2018 Formulary Notice of Change Medicare Advantage Plans
2018 Formulary Notice of Change Medicare Advantage Plans WellCare/ Ohana Plans in the following state: IL WellCare Choice (HMO-POS), WellCare Plus (HMO), WellCare Rx (HMO) Plans in the following states:
Notice of Mid-Year Changes to 2018 Paramount Enhanced Formulary. Reason for
Notice of Mid-Year s to 2018 Paramount Enhanced Formulary Paramount Elite (HMO) may add or remove drugs from our formulary during the year. If we remove drugs from our formulary, or add prior authorization,
2018 Formulary Notice of Change Medicare Advantage Plans
2018 Formulary Notice of Change Medicare Advantage Plans WellCare/ Ohana Plans in the following state: IL WellCare Choice (HMO-POS), WellCare Plus (HMO), WellCare Rx (HMO) Plans in the following states:
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.
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
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
Changes to the Johns Hopkins Advantage MD (PPO) Formulary Please retain this with your formulary
Changes to the Johns Hopkins Advantage MD (PPO) Please retain this with your formulary Changes may have occurred since the printing of the Johns Hopkins Advantage MD (PPO) formulary. Medications added
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.
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
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
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
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
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
2018 Plan Year Monthly Plan Premium for People Who Get Extra Help From Medicare to Help Pay for Their Prescription Drug Costs
2018 Plan Year Monthly Plan for People Who Get Extra Help From Medicare to Help Pay for Their Prescription Drug Costs If you get extra help from Medicare to help pay for your Medicare prescription drug
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
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
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
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
Individual Enrollment Form
Please contact Peach State Health Plan if you need information in another language or format (Braille). To enroll in Peach State Health Plan, please provide the following information: Please check which
Summary of Benefits. Allwell 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
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
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
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
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
2019 Allwell Medicare (HMO) H Kane County, IL
2019 Allwell Medicare (HMO) H1475 -- 002 Kane County, IL H1475_19_7967SB_002_M Accepted 09282018 This booklet provides you with a summary of what we cover and your cost-sharing responsibilities. It does
2019 Allwell Medicare (HMO) H2915: 005 Clarion, Clearfield, Crawford, Elk, Erie, Forest, Jefferson, McKean, Mercer, Venango, and Warren Counties, PA
2019 Allwell Medicare (HMO) H2915: 005 Clarion, Clearfield, Crawford, Elk, Erie, Forest, Jefferson, McKean, Mercer, Venango, and Warren Counties, PA H2915_19_8121SB_005_M Accepted 09072018 This booklet
2019 Health Net Ruby Select (HMO) H0562:112 Fresno County, CA
2019 Health Net Ruby Select (HMO) H0562:112 Fresno County, CA H0562_19_7914SB_112_M_Accepted 09072018 1 This booklet provides you with a summary of what we cover and your cost-sharing responsibilities.
Summary of Benefits. Allwell Medicare 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
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
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
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.
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
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
Updates to your prescription benefits
Updates to your prescription benefits Effective July 1, 2018 Update Summary Within the Prescription Drug List (PDL), medications are grouped by tier. The tier indicates the amount you pay when you fill
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
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
2018 Summary of Benefits
2018 Summary of Benefits Allwell Medicare Select (HMO) Benton, Washington counties, AR H9630--003 Benefits effective January 1, 2018 H9630_18_2915SB Accepted 09302017 This booklet provides you with a summary
2019 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
Prescription Drug Schedule Humana Medicare Employer Plan
PUB Name: GSB0012 2018 Prescription Drug Schedule Humana Medicare Employer Plan Rx 269 University of Richmond Y0040_GHHK48XEN18 (Pending CMS Approval) Rx 269 Let's talk about Humana Medicare Employer
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
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
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
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
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:
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
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
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).
2018 Outline of Coverage McLaren Medicare Supplement Plans A, C, F, High Deductible-F, G & N
2018 Outline of Coverage McLaren Medicare Supplement Plans A, C, F, High Deductible-F, G & N McLarenHealthPlan.com/MedicareSupplement Call us toll-free (888) 327-0671, Monday - Friday from 8 a.m. 6 p.m.
<Logo> 2019 Allwell Medicare (HMO) H1664: 004 Crawford, Franklin, Jefferson, Lincoln, St. Charles, Warren, and Washington Counties, MO
2019 Allwell Medicare (HMO) H1664: 004 Crawford, Franklin, Jefferson, Lincoln, St. Charles, Warren, and Washington Counties, MO H1664_19_7896SB_004_M_Accepted 09082018 This booklet provides you
2019 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
RE: Your Massachusetts State & Federal Medical Loss Ratio Rebate Important Information
Group Name Address 1 Address 2 City State Zip August 2018 RE: Your Massachusetts State & Federal Medical Loss Ratio Rebate Important Information Group Name: Group Number: Dear
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
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,
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
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
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
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.
MA BENEFIT COMPARISON PLAN OPTIONS FOR MA-SMGP-COMP-1216
MA BENEFIT COMPARISON PLAN OPTIONS FOR -MA-SMGP-COMP-1216 Massachusetts Small Group Plan Design Comparison uctible Medical// / HMO Copay Plans HMO Value Platinum - $0/$0 0/ $7000 5 5 CIF 0 $200 $40 $70
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).
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,
Updates to your prescription benefits
Updates to your prescription benefits Effective July 1, 2018 Update Summary Within the Prescription Drug List (PDL), medications are grouped by tier. The tier indicates the amount you pay when you fill
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
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).
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
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
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
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
Tufts Health Plan Tufts Medicare Preferred HMO Prime For Working-Aged Employees
Check if Complete Tufts Health Plan Tufts Medicare Preferred HMO Prime For Working-Aged Employees To ensure that your applications are processed as quickly as possible, just follow this checklist Employer
Member Appeal and Grievance Process
Standard Member Appeal and Grievance Process Carefully read the information in this packet and keep it for future reference. It has important information about how to appeal/grieve decisions Blue Cross
CarePartners of Connecticut HMO Plans Buyer s Guide. Includes a chart comparing all HMO plan options
CarePartners of Connecticut HMO Plans 2019 Buyer s Guide Includes a chart comparing all HMO plan options Service Area: to join a CarePartners of Connecticut plan, you must live in our service area: Hartford,
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
In keeping with its mission and core values, we are committed to providing health care for people regardless of their ability to pay.
Dear Patient and Family: In keeping with its mission and core values, we are committed to providing health care for people regardless of their ability to pay. Our Charity Care/Financial Assistance: Medical
Allwell 2019 Individual Enrollment Form
Allwell 2019 Individual Enrollment Form Please contact Allwell if you need information in another language or format (Braille). To enroll in Allwell, please provide the following information: Please check
2019 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
Updates to your prescription benefits
Updates to your prescription benefits Effective Jan. 1, 2019 Enhanced Three-Tier PDL Update Summary Within the Prescription Drug List (PDL), medications are grouped by tier. The tier indicates the amount
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
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
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
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
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
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
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
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
«Member_Name» «Member_Address_Line_1» «Member_Address_Line_2» «Member_City», «Member_State» «Member_Zip»
*** October 2018 «Member_Name» «Member_Address_Line_1» «Member_Address_Line_2» «Member_City», «Member_State» «Member_Zip» Dear «Member_First», Subscriber ID#: «Subscriber_ID» Good News! We will automatically
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.
EnhancedCare PPO Gold Value Plan Overview
California Small Business Group Health Net Life Insurance Company (Health Net) EnhancedCare PPO Gold Value Plan Overview This matrix is intended to be used to help you compare coverage benefits and is
Children s Mercy Financial Assistance Application (Page 1 of 5) (03/18)
(Page 1 of 5) Some key requirements to be eligible for financial assistance are: 1. You must be a resident in the state of Kansas or Missouri. 2. You have a household income (adjusted for family size)
Silver 70 EnhancedCare PPO 2000/55 + Child Dental Plan Overview
California Small Business Group Health Net Life Insurance Company (Health Net) Silver 70 EnhancedCare PPO 2000/55 + Child Dental Plan Overview This matrix is intended to be used to help you compare coverage
2018 Community Blue Medicare PPO Summary of Benefits
2018 Community Blue Medicare PPO Summary of Benefits Residents of the following counties: Allegheny, Beaver, Butler, Erie, Greene, Fayette, Washington, Westmoreland, please click here. Residents of the
Summary of Benefits. Community Blue Medicare HMO. Western Pennsylvania. January 1, 2018 December 31, Service Area
Western Pennsylvania Community Blue Medicare HMO Summary of Benefits January 1, 2018 December 31, 2018 Service Area Our service area includes the following counties in Pennsylvania: Allegheny, Armstrong,
Health Options Program Option Selection Period FAQs
Health Options Program Option Selection Period FAQs The Health Options Program Q What is a Qualifying Event? A A Qualifying Event is what makes you eligible for enrollment in the Health Options Program.
NEWS For Retirees Eligible for Premium Assistance Winter 2017
Pennsylvania Public School Employees Retirement System (PSERS) NEWS For Retirees Eligible for Premium Assistance Winter 2017 Protect Your Family; Document Your Health History Have you considered starting
Enrollment Request Form
Employer name: Coverage effective date: Employer group number (Medical): Important Please print all sections in black ink. For the application to be valid, you must submit all applicable pages. 1. Select
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
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,
OUTLINE OF MEDICARE SUPPLEMENT COVERAGE BENEFIT CHART OF MEDICARE SUPPLEMENT PLANS SOLD FOR EFFECTIVE DATES ON OR AFTER JUNE 1, 2010
A Medicare Supplement Program This chart shows the benefits included in each of the standard Medicare supplement plans. Every company must make Plan A available. Some plans may not be available in Louisiana.