2018 PLAN CHANGE PACKET

Transcription

1 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 company) sent you an Annual Notice of Change packet that listed all the changes in your plan for Review that carefully. If you do not need to make any changes, there is no need to complete these forms. Your plan will auto-renew. If you are unhappy with the changes in your plan for 2018, then complete these forms and return to us using instructions below. How to Complete the Drug List form: See instructions at top of the Drug List form page. Note: You are not required to provide a list of medications to get our help. However, we use this information to find you the most cost-effective plan for you and your specific drug needs. How to Complete the Scope of Sales Appointment Form: 1. CHECKMARK the appropriate box in the top section. If you are unsure or want to consider all options, it is okay to initial each of them. 2. SIGN and DATE the Beneficiary section (you are the Medicare beneficiary) where it says Signature. (typed name is NOT allowed, must be a handwritten signature NO DOCUSIGN DOCUMENTS) 3. PRINT your name & address in bottom section where it says Beneficiary Name & Address. Important! (in case we can t read your signature) 4. SCAN & completed forms in PDF FORMAT to drughelp@boomerbenefits.com. No JPGs or photos of the forms PDF only. Use cover sheet provided. It may take our office several days to get back to you as we expect to process several thousand forms this fall. We appreciate your patience. If you have not heard from us by December 1 st, then call to follow-up.

2 Cover Sheet for Returning Your Forms to Boomer Benefits in PDF FORMAT (NO JPGs or photos) to: OR send via Fax : To: Boomer Benefits From: (print your name) I have included BOTH required forms Drug List and Scope of Appointment I am sending in PDF format not a photo or JPG. I have signed with my handwritten signature not a computer signature or Docusign document. I understand that Boomer Benefits will not contact me unless both forms are completed, with handwritten wet signatures, and returned in PDF Format.

3 Full Name: Phone #: Zip Code: Preferred Pharmacy: Current Part D or Med Advantage Company: Instructions for this DRUG LIST FORM: DO NOT LIST VITAMINS or supplements as those are not covered by Medicare Part D. List the entire drug name that appears on your RX bottle. Do not attach a list use our form below so that you can indicate dosage & frequency. Write whether it is a tablet OR capsule. This affects the drug price. You may also write in cream/shampoo/injection, etc Circle yes or no to CONFIRM that the pill you are taking is the generic form Prescription Medications I am Currently Taking Drug Name Dosage Frequency Tab or Capsule? Generic? Example: Doxazosin 40mg Once per day TAB Yes/No Yes/No I understand that I am responsible for providing an accurate list of medications, otherwise the analysis we provide may be skewed. Also, while Boomer Benefits will help with recommendations for suitable plans, I understand that I am ultimately responsible for deciding on and enrolling into the plan I feel is most suitable for me before my election period ends. Signature: X Date: These forms are NOT an application for Part D. They will help us analyze plan options. However, you have not enrolled until you complete a Part D application form from the insurance company we find for you.

4 Scope of Appointment Confirmation Form Medicare requires Licensed Sales Representatives to document the scope of an appointment prior to any sales meeting to ensure understanding of what will be discussed between them and the Medicare beneficiary (or their authorized representative). All information provided on this form is confidential. A separate form should be completed for each Medicare beneficiary. To ensure your appointment focuses only on those Medicare and health-related products you want to discuss with your licensed sales representative, please indicate by checking the appropriate box(es) beside the product(s) in which you are interested. Stand-alone Medicare Prescription Drug Plans (Part D) Medicare Advantage Plans (Part C) and Cost Plans Dental/Vision/Hearing Products By signing this form, you agree to a meeting with a Licensed Sales Representative to discuss the types of products you checked above. Please note, the person who will discuss the products is either employed or contracted by a Medicare plan. They do not work directly for the federal government. This individual may also be paid based on your enrollment in a plan. Signing this form does NOT obligate you to enroll in a plan, affect your current or future Medicare enrollment, or enroll you in a Medicare plan. Beneficiary or Authorized Representative Signature and Signature Date: Signature Signature Date M M / D D / Y Y Y Y If you are the authorized representative, please sign above and print clearly and legibly below: Name (First_Last) Relationship to Beneficiary Page 1 of 2 Hospital Indemnity Products Medicare Supplement or (Medigap) Products To be completed by Licensed Sales Representative (please print clearly and legibly) Licensed Sales Representative Licensed Sales Representative Phone Licensed Sales Name (First_Last) Representative ID Beneficiary Name (First_Last) Beneficiary Address (Optional) Beneficiary Phone (Optional) Date Appointment will be Completed M M / D D / Y Y Y Y Initial Method of Contact Plan(s) the Licensed Sales Representative will Represent During the Meeting Licensed Sales Representative Signature Scope of appointment (SOA) is subject to Medicare Record Retention Requirements Licensed Sales Representative: If applicable, please explain why SOA was not documented and signed by beneficiary prior to meeting. Check all that apply. Unplanned Attendee New SOA required (consumer requested other Health Product information) Walk-in Other (please explain): Fax to:

5 Page 2 of 2 Stand-alone Medicare Prescription Drug Plans (Part D) Medicare Prescription Drug Plan (PDP) A stand-alone drug plan that adds prescription drug coverage to Original Medicare, some Medicare Cost Plans, some Medicare Private Fee-For-Service Plans, and Medicare Medical Savings Account Plans. Medicare Advantage Plans (Part C) and Cost Plans Medicare Health Maintenance Organization (HMO) A Medicare Advantage Plan that prescription drug coverage. In most HMOs, you can only get your care from doctors or hospitals in the plan s network (except in emergencies). Medicare HMO Point-of-Service (HMO-POS) Plans A Medicare Advantage Plan that prescription drug coverage. HMO-POS plans may allow you to get some services out of network for a higher copayment or coinsurance. Medicare Preferred Provider Organization (PPO) Plan A Medicare Advantage Plan that prescription drug coverage. PPOs have network doctors, providers and hospitals but you can also use out-of-network providers, usually at a higher cost. Medicare Private Fee-For-Service (PFFS) Plan A Medicare Advantage Plan in which you may go to any Medicare-approved doctor, hospital and provider that accepts the plan s payment, terms and conditions and agrees to treat you not all providers will. If you join a PFFS Plan that has a network, you can see any of the network providers who have agreed to always treat plan members. You will usually pay more to see out-of-network providers. Medicare Special Needs Plan (SNP) A Medicare Advantage Plan that has a benefit package designed for people with special health care needs. Examples of the specific groups served include people who have both Medicare and Medicaid, people who reside in nursing homes, and people who have certain chronic medical conditions. Medicare Medical Savings Account (MSA) Plan MSA Plans combine a high deductible health plan with a bank account. The plan deposits money from Medicare into the account. You can use it to pay your medical expenses until your deductible is met. Medicare Cost Plan In a Medicare Cost Plan, you can go to providers both in and out of network. If you get services outside of the plan s network, your Medicare-covered services will be paid for under Original Medicare but you will be responsible for Medicare coinsurance and deductibles. Other Related Products Dental/Vision/Hearing Products Plans offering additional benefits for consumers who are looking to cover needs for dental, vision, or hearing. These plans are not affiliated or connected to Medicare. Hospital Indemnity Products Plans offering additional benefits; payable to consumers based upon their medical utilization; sometimes used to defray co-pays/co-insurance. These plans are not affiliated or connected to Medicare. Medicare Supplement (Medigap) Products Insurance plans that help pay some of the out-of-pocket costs not paid by Original Medicare (Parts A and B) such as deductibles and co-insurance amounts for Medicare approved services. Plans are insured through UnitedHealthcare Insurance Company or one of its affiliated companies, a Medicare Advantage organization with a Medicare contract and a Medicare-approved Part D sponsor. Enrollment in these plans depends on the plan s contract renewal with Medicare. UnitedHealthcare Insurance Company complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al (TTY: 711). 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 (TTY: 711). Y0066_160703_ Accepted UHEX17MP _000