2022 Forms, Plan Information, and Policies

Summary of Benefits

• 2022 Senior Care HMO Plans 1-3 Summary of Benefits
• 2022 MediCare PPO Plans 1-2 Summary of Benefits
• 2022 Dual Plus (HMO D-SNP) Summary of Benefits 004
• 2022 Dual Plus HMO D-SNP Summary of Benefits 005
  

Evidence of Coverage (EOC)

• 2022 Senior Care Plan 1 (HMO) Evidence of Coverage (EOC)
• 2022 Senior Care Plan 2 with Rx (HMO) Evidence of Coverage (EOC)
• 2022 Senior Care Plan 3 with Rx (HMO) Evidence of Coverage (EOC)
• 2022 MediCare PPO Plan 1 Evidence of Coverage (EOC)
• 2022 MediCare PPO Plan 2 with Rx Evidence of Coverage (EOC)
• 2022 Dual Plus (HMO D-SNP) Evidence of Coverage (EOC) 004
• 2022 Dual Plus (HMO D-SNP) Evidence of Coverage (EOC) 005

Annual Notice of Change (ANOC)

• 2022 Senior Care Plan 1 (HMO) Annual Notice of Change (ANOC)
• 2022 Senior Care Plan 2 with Rx (HMO) Annual Notice of Change (ANOC)
• 2022 Senior Care Plan 3 with Rx (HMO) Annual Notice of Change (ANOC)
• 2022 MediCare PPO Plan 1 Annual Notice of Change (ANOC)
• 2022 MediCare PPO Plan 2 with Rx Annual Notice of Change (ANOC)
• 2022 Dual Plus (HMO D-SNP) Annual Notice of Change (ANOC) 004
• 2022 Dual Plus (HMO D-SNP) Annual Notice of Change (ANOC) 005

Provider Directories

• 2022 Senior Care (HMO) Provider Directory
• 2022 MediCare PPO Provider Directory
• 2022 Dual Plus (HMO D-SNP) Provider Directory

Star Ratings

• Senior Care (HMO) and Dual Plus (HMO D-SNP) Star Rating
• MediCare PPO Star Rating

Additional Resources

• Nondiscrimination Notice
• Multi-Language Interpreter Services
• Important Information Regarding Your Hospice Services, Presbyterian Senior Care (HMO) Plans 1, 2 and 3 only

• Rights and Responsibilities
• Privacy Notice

Formularies (Drug Lists) and Plan Information

• 2022 Medicare Formulary (List of Covered Drugs) - Updated 10/15/21
• 2022 Presbyterian Dual Plus (HMO D-SNP) Formulary (List of Covered Drugs) - Updated 10/15/21
• 2022 Medicare Drug Formulary Changes
• 2022 Medicare Drug Prior Authorization Criteria - Updated 10/15/21
• 2022 Medicare Quantity Limits Criteria - Updated 10/15/21
• 2022 Medicare Step Therapy Criteria - Updated 10/15/21

• Part D Drug Formulary Exceptions

Forms

• Form for OptumRx Mail Order Prescriptions
• Form to Make a Medical or Pharmacy Reimbursement Claim
• Form for Drug Coverage Determination Request

• Online Member Appeals Request Form

Extra Help for Prescription Drugs

• 2022 Senior Care (HMO) Extra Help Premium Summary
• 2022 Medicare PPO Extra Help Premium Summary
• 2022 Dual Plus (HMO D-SNP) Extra Help Premium Summary

Forms

• 2022 Form to Enroll in Senior Care (HMO)
• 2022 Form to Enroll in MediCare PPO
• 2022 Form to Enroll in Dual Plus (HMO D-SNP)

Forms

• Form to Make a Medical or Pharmacy Reimbursement Claim

• How to Obtain Information on Grievances, Appeals, and Exceptions
• Online Member Appeals Request Form
• Medicare Complaints Form

• Form to Release General Health Records
• Medicare Appointment of Representative

If Medicare changes your benefits during the year, we'll post notices here.

• Policy for Medicare Part D Drug Transitions

• CMS Best Available Evidence Policy