Plan Documents


Print

The following documents can help you get more information about this Medicare Advantage plan, enroll in a plan and more.


General Plan Information 
Annual Notice of Change Basic (HMO) English PDF Document 
en Espanol PDF Document
Annual Notice of Change Basic Plus (HMO-POS) English PDF Document 
en Espanol PDF Document
Annual Notice of Change Premier Plus (HMO-POS) English PDF Document 
en Espanol PDF Document
Annual Notice of Change Choice Plus (PPO) English PDF Document 
en Espanol PDF Document
Annual Notice of Change Choice Premier (PPO) English PDF Document 
en Espanol PDF Document
Evidence of Coverage Basic (HMO) English PDF Document 
en Espanol PDF Document
Evidence of Coverage Basic Plus (HMO-POS) English PDF Document 
en Espanol PDF Document
Evidence of Coverage Premier Plus (HMO-POS) English PDF Document 
en Espanol PDF Document
Evidence of Coverage Choice Plus (PPO) English PDF Document 
en Espanol PDF Document
Evidence of Coverage Choice Premier (PPO) English PDF Document 
en Espanol PDF Document
Summary of Benefits (HMO/HMO-POS)  English PDF Document 
en Espanol PDF Document
Summary of Benefits (PPO) English PDF Document 
en Espanol PDF Document
Prescription Drug Forms
Mail- Order Physician New Prescription Fax Form
Pharmacy Mail-Order Form
Prescription Drug Claim Form (HMO)  
Prescription Drug Claim Form (HMO-POS)
Prescription Drug Claim Form (PPO)
Medicare Part B vs. Part D Form
Additional Resources 
Authorization to Disclose Protected Health Information (PHI) Form PDF Document 
Automated Premium Payment (ACH) Form PDF Document 
CMS Appointment of Representative Form PDF Document
Multi-language Interpreter Services PDF Document
Notice of Privacy Practices PDF Document