Optional Supplemental Benefits 2018 Individual Enrollment Form
|
|
|
- Whitney Blankenship
- 6 years ago
- Views:
Transcription
1 Optional Supplemental Benefits 2018 Individual Enrollment Form Health Net Medicare Advantage Plans Health Net offers Optional Supplemental Benefits (OSB) for an additional monthly premium. Members who wish to add an Optional Supplemental Benefits Package to their existing Health Net Medicare Advantage plan may use this OSB enrollment form. Members currently enrolled in an OSB may use this form to switch or add a different OSB option, if available. Please select from the plan package options listed below before enrolling. Please do not use this form to change Health Net Medicare Advantage plans. Please print Last name (as it appears on Medicare card): First: MI: Permanent residence address: Apt. #: City: State: ZIP: County of permanent residence address: Telephone #: Mailing address (if different from above): Apt. #: City: State: ZIP: address: Birth date: / / (M M D D Y Y Y Y) Medicare #: Health Net member/subscriber reference #: After you have completed this form, please mail it to: Enrollment Services, Health Net Medicare Programs, PO Box 2020, Farmington, MO Please check the Optional Supplemental Benefit (OSB) package(s) that you wish to enroll in. Ruby (HMO) Benton, Clackamas, Douglas, Jackson, Josephine, Lane, Linn, Marion, Multnomah, Polk, Washington, and Yamhill counties, OR Choose one: Preventive dental and hearing ($16 per month premium) or Comprehensive dental and hearing ($40 per month premium) Violet 1 (PPO) Benton, Clackamas, Douglas, Jackson, Josephine, Lane, Linn, Marion, Multnomah, Polk, Washington, and Yamhill counties, OR; Clark County, WA Y0020_18_3746FORM_FINAL_3883 Approved of 5 (continued)
2 Please check the Optional Supplemental Benefit (OSB) package(s) that you wish to enroll in. (cont d) Violet 2 (PPO) Benton, Clackamas, Lane, Linn, Marion, Multnomah, Polk, Washington, and Yamhill counties, OR; Clark County, WA ; and/or choose Routine vision ($6 per month premium) Douglas, Jackson and Josephine counties, OR Violet 3 (PPO) Douglas and Josephine counties, OR Aqua (PPO) Benton, Clackamas, Douglas, Jackson, Josephine, Lane, Linn, Marion, Multnomah, Polk, Washington, and Yamhill counties, OR; Clark County, WA PPO plans Preventive dental Comprehensive dental Routine vision (not available for all PPO plans) Monthly premium $15 $39 $6 Benefits Preventive dental services Preventive, restorative and major dental services Routine eye exam and routine eyewear allowance Ruby (HMO) Preventive dental and hearing Comprehensive dental and hearing Monthly premium $16 $40 Benefits Preventive dental services, routine hearing exam and hearing aids Preventive, restorative and major dental services, routine hearing exam and hearing aids Please refer to your Evidence of Coverage (EOC) for full benefit details. I understand that to be eligible for an Optional Supplemental Benefits Package, I must remain a member of a Health Net Medicare Advantage plan. If I disenroll from my plan, I will be automatically disenrolled from the Optional Supplemental Benefits Package(s). If I discontinue payment of the Optional Supplemental Benefits Package(s), my membership in the Optional Supplemental Benefits Package(s) will be terminated. However, I will remain enrolled in my standard Health Net Medicare Advantage (medical) plan. The open enrollment periods for Optional Supplemental Benefits for current Health Net Medicare Advantage members are from October 15, 2017, through December 31, 2017, for a January 1, 2018, effective date and from January 1, 2018, through January 31, 2018, for a February 1, 2018, effective date. New members can enroll until the end of the first month of initial enrollment. Benefits will become effective the first of the following month. Members may disenroll at any time from an Optional Supplemental Benefits Package by providing written notice to Health Net. The disenrollment date will be the first day of the month following Health Net s receipt of the disenrollment request. Once disenrolled, members must wait until the next open enrollment period to enroll for a January 1 effective date. If a Health Net provider denies a request for service or payment of a claim, you may appeal the denial decision by using the Medicare appeals process as described in your Evidence of Coverage (EOC). Health Net will notify you when your effective date of coverage begins. 2 of 5
3 Release of information I allow the Centers for Medicare & Medicaid Services (CMS) to give information to the plan, and I allow the Plan, Plan s doctors and clinics, or anyone else with medical or other relevant information about me to give CMS or CMS s agents the information needed to run the Medicare program. I also give the Plan authorization to release necessary or other relevant information about me to service providers. I understand that my signature on this application means that I have read and understand the contents of this application and agree to abide by the plan rules concerning the Optional Supplemental Benefits Plans. (Please read your Evidence of Coverage document to know what rules you must follow in order to receive coverage with Health Net.) / / Signature of beneficiary (M M D D Y Y Y Y) Health Net representative s signature If you are the authorized representative, you must provide the following information: Name: Address: Phone #: Relationship to enrollee: Thank you for choosing Health Net. If you have questions, please call us at (TTY users should call 711). From October 1 to February 14, you can call us 7 days a week from 8 a.m. to 8 p.m. From February 15 to September 30, you can call us Monday through Friday from 8 a.m. to 8 p.m. A messaging system is used after hours, weekends, and on federal holidays. Office use only Group #: Effective date: Correction of member information: Health Net has a contract with Medicare to offer HMO, PPO and HMO SNP plans. Enrollment in a Health Net Medicare Advantage plan depends on the renewal of these contracts. You must continue to pay your Medicare Part B premium. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments and restrictions may apply. Benefits, premiums and/or copayments/coinsurance may change on January 1 of each year. FRM012970EO00 (8/17) 3 of 5
4 Health Net complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Health Net does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. Health Net: Provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print, accessible electronic formats, other formats). Provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, contact Health Net s Customer Contact Center at: (HMO and PPO) (TTY: 711). From October 1 to February 14, you can call us 7 days a week from 8 a.m. to 8 p.m. From February 15 to September 30, you can call us Monday through Friday from 8 a.m. to 8 p.m. A messaging system is used after hours, weekends, and on federal holidays. If you believe that Health Net 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 by calling the number above and telling them you need help filing a grievance; Health Net s Customer Contact Center 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 20201, (TDD: ). Complaint forms are available at 4 of 5
5 Health Net complies with ATENCIÓN: applicable si federal habla civil español, rights laws tiene and a does su disposición not discriminate servicios on the gratuitos basis of de SPANISH asistencia lingüística. Llame al (HMO and PPO) (TTY: 711). VIETNAMESE CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số (HMO and PPO) (TTY: 711). CHINESE 注意 : 如果您說中文, 您可以免費獲得語言援助服務 請致電 (HMO and PPO) (TTY: 711) ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны RUSSIAN бесплатные услуги перевода. Звоните (HMO and PPO) (TTY: 711). KOREAN 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 (HMO and PPO) (TTY: 711) 번으로전화해주십시오. УВАГА! Якщо ви розмовляєте українською мовою, ви можете звернутися до UKRAINIAN безкоштовної служби мовної підтримки. Телефонуйте за номером (HMO and PPO) (TTY: 711). 注意事項 : 日本語を話される場合 無料の言語支援をご利用いただけ JAPANESE ます (HMO and PPO) (TTY: 711) まで お電話にてご連絡 ください ARABIC تنبيھ: إذا كنت تتحدث العربية فإن خدمات المساعدة اللغوية المجانية متاحة لك. ي رجى االتصال بالرقم. PPO) (HMO and (مكبالو مصال فتاھ مقر:.(711 ROMANIAN MON-KHMER CAMBODIAN ATENȚIE: Dacă vorbiți limba română, vă stau la dispoziție servicii de asistență lingvistică, gratuit. Sunați la (HMO and PPO) (TTY: 711). ច ណ ប អ រមមណ ប ស នអនកន យ យភ ស ខមរ សវ ជ ន យភ ស ដ យឥតគ ត ថល គ ម នស រ ប អនក ស ម ទ រស ពទ ទ លខ (HMO and PPO) (TTY: 711) CUSHITE GERMAN PERSIAN FRENCH THAI XIYYEEFFANNAA: Afaan dubbattu Oroomiffa, tajaajila gargaarsa afaanii, kanfaltiidhaan ala, ni argama. Bilbilaa (HMO and PPO) (TTY: 711). ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: (HMO and PPO) (TTY: 711). توجھ : اگر بھ زبان فارسی گفتگو می کنيد تسھيالت زبانی بصورت رايگان برای شما فراھم می باشد. با 711) (TTY: (HMO and PPO) تماس بگيريد. ATTENTION : Si vous parlez français, des services d aide linguistique vous sont proposés gratuitement. Appelez le (HMO and PPO) (TTY: 711). เร ยน: ถ าค ณพ ดภาษาไทยค ณสามารถใช บร การช วยเหล อทางภาษาได ฟร โทร (HMO and PPO) (TTY: 711). 5 of 5
6
Any missing information may cause a delay in processing your request.
Member Reimbursement Claim Form This form may be used for Trillium Medicare Advantage products. Important: Complete a separate Member Reimbursement Claim Form for each member asking for reimbursement for
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
2019 Individual Enrollment Form
Trillium Medicare Advantage 2019 Individual Enrollment Form Please contact Trillium Medicare Advantage if you need information in another language or format (Braille). To enroll in Trillium Medicare Advantage,
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 *1989* 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
This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, call.
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage for: Plan Type: This is only a summary. For more information about your coverage, or to get a copy of
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
2018 Optional Benefit Individual Enrollment Form
Allwell Medicare s 2018 Optional Benefit Individual Enrollment Fm Allwell Medicare offers optional benefits f an additional monthly plan premium. This fm may be used only by our current members who are
ATRIO Health Plans: ATRIO Bronze Pioneer Plan Summary of Benefits and Coverage: What this plan Covers and What it Costs
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.atriohp.com or by calling 1-877-672-8620. Important Questions
Introduction to the Health Options Online Payment System. October 2016
Introduction to the Health Options Online Payment System October 2016 NON-DISCRIMINATION NOTICE Community Health Options does not view or treat people differently because of their race, color, national
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 *1989* 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
ATRIO Health Plans: Silver Choice 2500 Summary of Benefits and Coverage: What this plan Covers and What it Costs
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan d document at www.atriohp.com or by calling 1-877-672-8620. Important
Allwell Medicare Plans Disenrollment Form
Allwell Medicare Plans Disenrollment Form If you request disenrollment, you must continue to get all medical care from Allwell until the effective date of disenrollment. Contact us to verify your disenrollment
2019 Oregon Application for Individual & Family Insurance
2019 Oregon Application for Individual & Family Insurance Thank you for choosing Providence Health Plan (PHP) for your individual health insurance coverage. You can compare plans, check rates and apply
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
Summary of Benefits and Coverage:
Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2018-12/31/2018 Providence Health Plan: Connect 2500 Silver Coverage for: Individual+Family
AMENDMENT NUMBER 1 TO TEAMSTERS LOCAL 294- ALBANY AREA TRUCKING AND ALLIED INDUSTRIES HEALTH & WELFARE FUND HEALTH REIMBURSEMENT ARRANGEMENT
AMENDMENT NUMBER 1 TO TEAMSTERS LOCAL 294- ALBANY AREA TRUCKING AND ALLIED INDUSTRIES HEALTH & WELFARE FUND HEALTH REIMBURSEMENT ARRANGEMENT The Teamsters Local 294- Albany Area Trucking and Allied Industries
2019 Summary of Benefits PrimeTime Health Plan. PCC Airfoils (HMO-POS) E30040
2019 Summary of Benefits PrimeTime Health Plan PCC Airfoils (HMO-POS) E30040 This is a summary of drug and health services covered by PrimeTime Health Plan PCC Airfoils from January 1, 2019 December 31,
Idaho MedPlus. Care Plus. Benefit Guide. Blue Cross of Idaho Care Plus, Inc. An Independent Licensee of the Blue Cross and Blue Shield Association
Care Plus 2017 Benefit Guide Blue Cross of Care Plus, Inc. An Independent Licensee of the Blue Cross and Blue Shield Association Form No. 16-707 (09-16) Policy Form No. 18-544 (01-17) Policy Form No. 18-545
Summary of Benefits. Allwell Medicare (HMO) Pima County, Arizona H
2018 Summary of Benefits Allwell Medicare (HMO) Pima County, Arizona H0351 -- 044-001 Benefits effective January 1, 2018 H0351_18_3084SB_Accepted 09102017 1 This booklet provides you with a summary of
Summary of Benefits. Allwell Medicare Essentials I (HMO) Maricopa County, Arizona H
2018 Summary of Benefits Allwell Medicare Essentials I (HMO) Maricopa County, Arizona H9287-004 Benefits effective January 1, 2018 H9287_18_3039SB_A Accepted 09172017 1 This booklet provides you with a
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 *1989* 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
Important Questions Answers Why this Matters:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.providencehealthplan.com or by calling 1-800-878-4445.
Providence Health & Services: HSA Medical Plan Coverage Period: 01/01/ /31/2017
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.providencehealthplan.com/phs-caregivers or by calling
Providence Health Plan: Providence Oregon Standard Silver Plan Coverage Period: 01/01/ /31/2017
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.providencehealthplan.com or by calling 1-800-878-4445.
2019 Summary of Benefits PrimeTime Health Plan School Employees Retirement System (HMO-POS) E10120
2019 Summary of Benefits PrimeTime Health Plan School Employees Retirement System (HMO-POS) E10120 This is a summary of drug and health services covered by PrimeTime Health Plan SERS for January 1, 2019
Summary of Benefits. Allwell Medicare (HMO) Cochise County, Arizona H
2018 Summary of Benefits Allwell Medicare (HMO) Cochise County, Arizona H0351 -- 044-002 Benefits effective January 1, 2018 H0351_2018_3085SB_Accepted 09092017 1 This booklet provides you with a summary
Important Questions Answers Why this Matters:
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at https://healthplans.providence.org/members/member-groups/saif/
Summary of Benefits. Allwell Cardio Medicare (HMO SNP) Maricopa and Pinal Counties, Arizona H
2018 Summary of Benefits Allwell Cardio Medicare (HMO SNP) Maricopa and Pinal Counties, Arizona H0351-042 Benefits effective January 1, 2018 H0351_18_3005SB_Accepted 09102017 1 This booklet provides you
2019 OUTLINE OF COVERAGE Idaho MedPlus Medicare
Idaho 2019 OUTLINE OF COVERAGE Idaho Form No. 18-643 (01-19) Policy Form No. 18-544 (01-19), 18-545 (01-19), 18-546 (01-19), 18-547 (01-19), 18-912 (01-19) OUTLINE OF MEDICARE SUPPLEMENT COVERAGE The chart
2019 Summary of Benefits PrimeTime Health Plan. Aultman Hospital Basic (HMO-POS) E10111
2019 Summary of Benefits PrimeTime Health Plan Aultman Hospital Basic (HMO-POS) E10111 This is a summary of drug and health services covered by PrimeTime Health Plan Aultman Hospital Basic for January
Providence Health & Services: HRA Medical Plan Coverage Period:01/01/ /31/2017
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.providencehealthplan.com/phs-caregivers or by calling
Welcome to Cigna Vision Schedule of Vision Coverage
Summary of Benefits Cigna Health and Life Insurance Company Cigna Vision Arlington County Government Welcome to Cigna Vision Schedule of Vision Coverage Coverage In-Network Benefit Out-of-Network Benefit
Summary of Benefits. Allwell CHF (Chronic Heart Failure)/Diabetes Medicare (HMO SNP) Maricopa and Pinal Counties, Arizona H
2018 Summary of Benefits Allwell CHF (Chronic Heart Failure)/Diabetes Medicare (HMO SNP) Maricopa and Pinal Counties, Arizona H0351-038 Benefits effective January 1, 2018 H0351_18_2991SB_Accepted 09092017
Providence Health Plan: PEBB Providence Choice Plan (PT)+100 Coverage Period: 01/01/ /31/2017
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.providencehealthplan.com\pebb or by calling 1-800-878-4445.
2018 Optional Benefit
Health Net Medicare Advantage Plans 2018 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
Providence Health Plan: Choice 7150 Bronze Coverage Period: 01/01/ /31/2017
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.providencehealthplan.com or by calling 1-800-878-4445.
2018 Summary of Benefits: Presbyterian MediCare PPO Plan 1, Plan 2 with Rx
2018 Summary of Benefits: Presbyterian MediCare PPO Plan 1, Plan 2 with Rx This is a summary of health and drug services covered by Presbyterian MediCare PPO January 1, 2018 to December 31, 2018. To enroll
Kadlec Regional Medical Center: Kadlec HSA Medical Plan Coverage Period: 01/01/ /31/2017
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.providencehealthplan.com/kadlec-caregivers or by calling
Your Benefit Summary for PEBB Providence Choice Part-Time members
Your Benefit Summary for PEBB Providence Choice Part-Time members What You What You Pay Pay Out-of-Network Covered in full / $40 (after coinsurance (after deductible; UCR applies) Out-of-Pocket (after
Kadlec Regional Medical Center: Kadlec HRA Medical Plan Coverage Period: 01/01/ /31/2017
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.providencehealthplan.com/kadlec-caregivers or by calling
2019 Summary of Benefits: Presbyterian MediCare PPO Plan 1, Plan 2 with Rx
2019 Summary of Benefits: Presbyterian MediCare PPO Plan 1, Plan 2 with Rx This is a summary of health and drug services covered by Presbyterian MediCare PPO January 1, 2019 to December 31, 2019. To enroll
Your Benefit Summary for PEBB Statewide Plan members
Your Benefit Summary for PEBB Statewide Plan members What You What You Pay Pay Covered in full / (after deductible) coinsurance (after deductible; UCR applies) Out-of-Pocket (after deductible) $1,900 per
Providence Health Plan: PEBB Providence Choice Plan (FT)+100 Coverage Period: 01/01/ /31/2017
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.providencehealthplan.com\pebb or by calling 1-800-878-4445.
Summary of Material Modifications 11/1/2018 SUMMARY OF MATERIAL MODIFICATIONS PLAN BENEFIT CHANGES TO: All Covered Plan Participants
11/1/2018 SUMMARY OF MATERIAL MODIFICATIONS TO: All Covered Plan Participants FROM: The Writers Guild- Industry Health Fund This document is a Summary of (SMM), intended to notify you of changes to your
Enrollment form. Individual Plan. How to fill out this form. Next steps. Georgia Region Individual Plan
Kaiser Permanente Senior Advantage (HMO) or Kaiser Permanente Senior Advantage Medicare Medicaid Plan (HMO SNP) Individual Plan Enrollment form Georgia Region Individual Plan Have you thought about enrolling
Advantage Plus Enrollment Form
Page 1 of 6 Advantage Plus Enrollment Form Colorado Region Thank you for your interest in our Advantage Plus plans. Combining the benefits of Advantage Plus with your Kaiser Permanente Senior Advantage
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
2018 Summary of Benefits: Presbyterian Senior Care (HMO) Plan 1, Plan 2 with Rx, Plan 3 with Rx
2018 Summary of Benefits: Presbyterian Senior Care (HMO) Plan 1, Plan 2 with Rx, Plan 3 with Rx This is a summary of health and drug services covered by Presbyterian Senior Care (HMO) January 1, 2018 to
2017 Summary of Benefits: Presbyterian Senior Care (HMO) Plan 1, Plan 2 with Rx, Plan 3 with Rx
2017 Summary of Benefits: Presbyterian Senior Care (HMO) Plan 1, Plan 2 with Rx, Plan 3 with Rx This is a summary of health and drug services covered by Presbyterian Senior Care (HMO) January 1, 2017 to
2018 Summary of Benefits: Presbyterian Dual Plus (HMO SNP)
MEDICARE ADVANTAGE PLANS 2018 Summary of Benefits: Presbyterian Dual Plus (HMO SNP) This is a summary of health and drug services covered by Presbyterian Dual Plus (HMO SNP) January 1, 2018 to December
Cigna Health and Life Insurance Company. Welcome to Cigna Vision Schedule of Vision Coverage. Benefit
Summary of Benefits Cigna Health and Life Insurance Company Cigna Vision UT Graduate Medical Education Program - Vision Welcome to Cigna Vision Schedule of Vision Coverage Coverage In-Network Benefit Out-of-Network
COBRA CONTINUATION COVERAGE ELECTION FORM
Instructions: To elect COBRA continuation coverage, complete this Election Form and return it to us. Under federal law, you have 60 days after the date of this notice to decide whether you want to elect
REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION
REQUEST FOR MEDICARE PRESCRIPTION DRUG COVERAGE DETERMINATION This form may be sent to us by mail or fax: Address: Fax Number: Blue Cross Medicare Advantage SM 1-800-693-6703 Attn: Clinical Review Department
Medicare Supplement Application
Medicare Supplement Application Applicant Information Your Name (first, initial, last) Date of Birth (mm/dd/yy) Age Height Weight Male Female Physical Address (street or route) City, State, Zip Code County
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 PO Box 419069 Rancho, Cordova 95741 Fax
Enrollment form. Individual Plan. How to fill out this form. Next steps. Colorado Region Individual Plan
Kaiser Permanente Senior Advantage (HMO) or Kaiser Permanente Senior Advantage Medicare Medicaid Plan (HMO SNP) Individual Plan Enrollment form Colorado Region Individual Plan Have you thought about enrolling
2018 Summary of Benefits
Medicare GenerationRx (Employer PDP) 2018 Summary of Benefits January 1, 2018 - December 31, 2018 S9579 For the NEA Group Part D Program Advanced Plan 2 This is a summary of prescription drug services
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:
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 *1989* 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
MEDICARE. Go365 Mall Catalog MAKE HEALTHIER CHOICES
MAKE HEALTHIER CHOICES MEDICARE Go365 Mall Catalog With Go365 by Humana, you re on the path to achieving a healthier lifestyle for you and the people you love. You re also on the way to earning Go365 Bucks,
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 Authorizaton Department PO Box 419069 Rancho Cordova, CA 95741 Fax
MEDICARE SUPPLEMENT APPLICATION
MEDICARE SUPPLEMENT APPLICATION APPLICANT INFORMATION Your Name (first, initial, last) Date of Birth (mm/dd/yy) Age Height Weight Male Female Physical Address (street or route) City, State, Zip Code County
2019 Summary of Benefits: Presbyterian Dual Plus (HMO SNP)
2019 Summary of Benefits: Presbyterian Dual Plus (HMO SNP) This is a summary of health and drug services covered by Presbyterian Dual Plus (HMO SNP) January 1, 2019 to December 31, 2019. To enroll in Presbyterian
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. Health Net Seniority Plus Green (HMO) Los Angeles, Riverside and San Bernardino Counties, CA H
2018 Summary of Benefits Los Angeles, Riverside and San Bernardino Counties, CA H0562-044 Benefits effective January 1, 2018 H0562_18_3027SB_Accepted 09102017 This booklet provides you with a summary of
2018 Summary of Benefits. Health Net Ruby Select (HMO) Fresno County, CA H
2018 Summary of Benefits Health Net Ruby Select (HMO) Fresno County, CA H0562-112 Benefits effective January 1, 2018 H0562_18_3130SB_Accepted 09102017 This booklet provides you with a summary of what we
Enrollment form. Individual Plan. How to fill out this form. Next steps. Northwest Region Individual Plan. Kaiser Permanente Senior Advantage (HMO)
Individual Plan Kaiser Permanente Senior Advantage (HMO) Enrollment form Northwest Region Individual Plan Have you thought about enrolling on kp.org/enrollonline instead? It s a fast, secure, and easy
SUMMARY of BENEFITS $10/$25/$60/25% Group MedicareBlue SM Rx (PDP) S5743_073018GFF02_M Final 01
2019 SUMMARY of BENEFITS $10/$25/$60/25% Group MedicareBlue SM Rx (PDP) January 1, 2019 December 31, 2019 S5743_073018GFF02_M Final 01 INTRODUCTION This guide is a summary of the prescription drug services
Preventive Care Periodic health exams and well-baby care
Your Benefit Summary Oregon Standard Silver Plan - Signature Network Providence Signature Network Individual Calendar Year Deductible (family amount is 2 times individual) Individual Out-of-Pocket Maximum
2019 Summary of Benefits
January 1 December 31, 2019 2019 Summary of Benefits Kaiser Permanente Senior Advantage Medicare Medi-Cal South Plan (HMO SNP) H0524_19SB029_M PBP 029 60872311 S 029 About this Summary of Benefits Thank
Your Benefit Summary Oregon Standard Gold Plan - Choice Network
Your Benefit Summary Oregon Standard Gold Plan - Choice Network Providence Choice Network Individual Calendar Year Deductible (family amount is 2 times individual) Individual Out-of-Pocket Maximum (family
Enrollment form. Group Plan. How to fll out this form. Next steps. Northwest Region Group Plan. Kaiser Permanente Senior Advantage (HMO)
Group Plan Kaiser Permanente Senior Advantage (HMO) Enrollment form Northwest Region Group Plan Filling out and returning the enrollment form is your frst step to becoming a Kaiser Permanente Senior Advantage
Your Benefit Summary Oregon Standard Bronze HSA Plan - Signature Network
Your Benefit Summary Oregon Standard Bronze HSA Plan - Signature Network Providence Signature Network Individual Calendar Year Deductible (family amount is 2 times individual) Individual Out-of-Pocket
2018 Summary of Benefits. Health Net Jade (HMO SNP) Kern, Los Angeles and Orange Counties, CA H
2018 Summary of Benefits Health Net Jade (HMO SNP) Kern, Los Angeles and Orange Counties, CA H0562-092 Benefits effective January 1, 2018 H0562_18_3046SB_Accepted 09092017 This booklet provides you with
Summary of Benefits. Humana Preferred Rx Plan (PDP) State of North Carolina. Our service area includes the following state(s): North Carolina.
SBOSB026 2018 Summary of Benefits Humana Preferred Rx Plan (PDP) State of North Carolina Our service area includes the following state(s): North Carolina. GNHH4HIEN_18 S5884133000SB18 2018 Summary of
Medicare Supplement Insurance
Medicare Supplement Insurance Iowa Outline of Coverage AveraHealthPlans.com Effective: July 2018 Benefit Chart of Medicare Supplement Insurance Plans Standard Medicare Supplement Plans A, B, C, F, G and
Bucyrus Hospital - Galion Hospital - Avita Ontario - Avita Physicians
Bucyrus Hospital - Galion Hospital - Avita Ontario - Avita Physicians Applicant Name: Family s Street Address: City State Zip Phone Alternate Phone Date(s) of Service* *Separate applications must be completed
UCare for Seniors (HMO-POS) Short Enrollment Request Form
UCare for Seniors (HMO-POS) Short Enrollment Request Form Name of plan you are enrolling in: Name: Member or Medicare number: Home phone number: Permanent street address (P.O. Box not allowed): City: State:
Delta Dental Individual and Family SM
Delta Dental Individual and Family SM ENROLLMENT FORM The effective date of your individual dental plan will be the first of the month following receipt of this completed enrollment form and payment, so
2018 Summary of Benefits. Health Net Seniority Plus Sapphire (HMO) Kern County, CA H
2018 Summary of Benefits Kern County, CA H0562-111-002 Benefits effective January 1, 2018 H0562_18_3043SB_Accepted 09102017 This booklet provides you with a summary of what we cover and your cost-sharing.
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
Coverage for: Individual, Individual + Family Plan Type: HMO
Summary of Benefits and Coverage: What this plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2019-12/31/2019 CHRISTUS Health Plan: New Mexico Silver Low-Deductible Limited CS Coverage
2018 Drug List Negative Changes Updated 08/30/2018
2018 Drug List Negative Changes Updated 08/30/2018 If you are taking a drug that is removed from the formulary (also known as the Drug List), we will tell you. We will also tell you if we add any restrictions
$0 at IHCP or with IHCP referral at non-ihcp; $2,400/individual or $4,800/family. Doesn t apply to Preventive care.
Summary of Benefits and Coverage: What this plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2019-12/31/2019 CHRISTUS Health Plan: New Mexico American Indian Gold Statewide Limited
Accenture Leadership United States Benefit Plans Summary Plan Description
Accenture Leadership United States Benefit Plans Summary Plan Description (Effective January 1, 2017) TABLE OF CONTENTS INTRODUCTION 1 BECOMING ACCENTURE LEADERSHIP 1 VOLUNTARY COVERAGE 1 Choices 1 Life
2018 Summary of Benefits
2018 Summary of Benefits Fresno, Los Angeles, Orange, San Diego, and San Francisco Counties, CA H3561-002 Benefits effective January 1, 2018 H3561_18_2998SB_Accepted 09092017 This booklet provides you
2017 Benefit Highlights
2017 Benefit Highlights Bridgeway Health Solutions Medicare Advantage (HMO) Pinal County, AZ Plan benefits Copays/Coinsurance Monthly plan premium $35.10 Maximum out-of-pocket (MOOP) $6,700 Doctor office
2018 Summary of Benefits. Health Net Jade (HMO SNP) San Diego County, CA H
2018 Summary of Benefits Health Net Jade (HMO SNP) San Diego County, CA H0562-114 Benefits effective January 1, 2018 H0562_18_3047SB_Accepted 09112017 This booklet provides you with a summary of what we
Dear Health First Health Plans Member:
Dear Health First Health Plans Member: You are enrolled in a Medicare Advantage plan offered by Health First Health Plans. A snapshot of the 2017 plans can be found on the first page of the attached form.
2018 Summary of Benefits. Health Net Healthy Heart (HMO) San Diego County, CA H
2018 Summary of Benefits Health Net Healthy Heart (HMO) San Diego County, CA H0562-012 Benefits effective January 1, 2018 H0562_18_3075SB_Accepted 09092017 This booklet provides you with a summary of what
IMPORTANT NOTICE: Your Medicare plan won t be offered in 2018
IMPORTANT NOTICE: Your Medicare plan won t be offered in 2018 Keep this letter. It s proof that you have a special right to buy a Medigap policy
2018 Summary of Benefits
January 1 December 31, 2018 2018 Summary of Benefits Kaiser Permanente Senior Advantage Marin and San Mateo Counties Plan (HMO) H0524_18SB031 accepted PBP 31 60572720 N 031 About this Summary of Benefits
2018 Summary of Benefits. Health Net Gold Select (HMO) Riverside and San Bernardino Counties, CA H
2018 Summary of Benefits Riverside and San Bernardino Counties, CA H0562-101-002 Benefits effective January 1, 2018 H0562_18_3082SB_Accepted 09092017 This booklet provides you with a summary of what we
TRS-CARE. enrollment guide. for Non-Medicare Eligible Retirees. Plan Year: Sept. 1, 2016 Dec. 31, TRScarestandardaetna.com
TRS-CARE enrollment guide for Non-Medicare Eligible Retirees Plan Year: Sept. 1, 2016 Dec. 31, 2017 TRScarestandardaetna.com This guide provides an overview of the TRS-Care eligibility requirements, enrollment,
Group HMO Silver 4 Sub On Exchange Coverage Period: 01/01/ /31/2017
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.phs.org. or by calling 1-800-923-6980. Important Questions
Summary of Benefits. Allwell Medicare Premier (HMO) Broward County, Florida H
2018 Summary of Benefits Broward County, Florida H9276-013 Benefits effective January 1, 2018 H9276_18_2781SB_A_Accepted 09172017 1 This booklet provides you with a summary of what we cover and your cost-sharing.
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
2018 Summary of Benefits. Health Net Gold Select (HMO) Los Angeles and Orange Counties, CA H
2018 Summary of Benefits Los Angeles and Orange Counties, CA H0562-101-001 Benefits effective January 1, 2018 H0562_18_3080SB_Accepted 09092017 This booklet provides you with a summary of what we cover
2018 Summary of Benefits. Health Net Healthy Heart (HMO) Los Angeles and Orange Counties, CA H
2018 Summary of Benefits Health Net Healthy Heart (HMO) Los Angeles and Orange Counties, CA H0562 100-001 Benefits effective January 1, 2018 H0562_18_3076SB_Accepted 09092017 This booklet provides you
2019 Summary of Benefits
January 1 December 31, 2019 2019 Summary of Benefits Kaiser Permanente Senior Advantage Stanislaus County Basic Plan (HMO) and Kaiser Permanente Senior Advantage Stanislaus County Enhanced Plan (HMO) H0524_19SB040041_M