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Plan Documents

The following documents can help you get more information about this Medicare Advantage Dual Care Plan (HMO SNP), enroll in a plan and more.

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2018 General Plan Information

Document	Downloadable Materials
2018 Annual Notice of Change	English en Espanõl
2018 Evidence of Coverage	English en Espanõl
2018 Summary of Benefits	English en Espanõl

2018 Prescription Drug Forms

Link to Form	Plan
2018 Mail-Order Physician New Prescription Fax Form
2018 Pharmacy Mail-Order Form
2018 Prescription Drug Claim Form	HMO SNP
2018 Medicare Part B vs. Part D Form

2018 Additional Resources

Link to Form
2018 Authorization to Disclose Protected Health Information (PHI) Form
2018 Automated Premium Payment (ACH) Form
2018 CMS Appointment of Representative Form
Notice of Privacy Practices
Access Additional Privacy Forms

2017 General Plan Information

Document	Downloadable Materials
2017 Annual Notice of Change	English en Espanõl
2017 Evidence of Coverage	English en Espanõl
2017 Summary of Benefits	English en Espanõl

2017 Prescription Drug Forms

Link to Form	Plan
2017 Mail-Order Physician New Prescription Fax Form
2017 Pharmacy Mail-Order Form
2017 Prescription Drug Claim Form	HMO SNP
2017 Medicare Part B vs. Part D Form

2017 Additional Resources

Link to Form
2017 Authorization to Disclose Protected Health Information (PHI) Form
2017 Automated Premium Payment (ACH) Form
2017 CMS Appointment of Representative Form
2017 Multi-language Interpreter Services
2017 Notice of Privacy Practices
Access Additional Privacy Forms