Summary of Benefits
Evidence of Coverage
Medicare beneficiaries may also enroll in this plan through the CMS Medicare Online Enrollment Center, located at www.Medicare.gov (by clicking on this link you will be leaving our website)
Annual Notice of Change
Provider Directory / Directorio de proveedores
Medicare Star Ratings
City of Houston Employer Group Medicare Star Ratings
Multilanguage information - Translation Services
Appointment of Representative form
Once the Appointment of Representative Form is filled out in its entirety, fax it to us at 1-800-817-3516 or call us at the number on the back of your Member ID card for more information on submitting the form.
In lieu of calling 1-800-Medicare, beneficiaries may file a complaint online by filing out the Medicare Complaint Form (by clicking on this link you will be leaving our website)
Pharmacy (Part D) Forms and Information
This plan covers part or all of prescription drugs covered under Medicare Part B; see the Summary of Benefits for specific details. For drugs covered under Medicare Part D, this plan uses a formulary (a list of covered drugs). We have formed a network of pharmacies. To receive plan prescription drug benefits, you must use a network pharmacy, except in non-routine circumstances, and quantity limitations and restrictions may apply.
For the most recent list of drugs click on the link above or call the number on the back of your Member ID card or call 1-866-249-8668, 8:00 a.m. to 8:00 p.m. in your local time zone (TTY users 711) 7 days a week.
Part D Prescription Drug Coverage Forms
Prescription Mail-Order Form
Find out more about Mail Order Benefits
Medicare Part D Prescription Claim Form
Coverage of a Non-Formulary Drug
Request for Quantity Limit Exception
Request for Step Therapy Exception
Lower Co-pay (Tiering Exception)
Medicare Prescription Drug Coverage Determination form
Initiate a coverage determination online (by clicking on this link you will be leaving our website)
Medicare Prescription Drug Appeal (Redetermination) form
Initiate a redetermination online (by clicking on this link you will be leaving our website)
Part D Coverage Determinations, Exceptions, Appeals and Grievances
Find a pharmacy
A comprehensive formulary is a list of covered drugs selected by this plan. The formulary may change during the year. We may periodically add, remove, or make changes to coverage limitations on certain drugs or change how much you pay for a drug. If we make any formulary changes that limit our members' ability to fill their prescriptions, we will notify the affected members before the change is made. Read about formulary information and any restrictions to the formulary.
Comprehensive Formulary - Updated August 2017
Formulario - Updated August 2017
Formulary Addendum - Updated October 2018
Apéndice del Formulario - Updated October 2018
Upcoming Formulary Changes
We will notify you of a formulary change at least 60 days before the date that the change becomes effective. However, if the Food and Drug Administration (FDA) deems a drug on our formulary to be unsafe, or if the drug's manufacturer removes the drug from the market, we will immediately remove the drug from the formulary.
Formulary Change - Updated March 2018
Cambios de Formulario - Updated March 2018
Medication Therapy Management Program
Medication Therapy Management (MTM)
Personal Medication List
Prior Authorization and Step Therapy Criteria
Prior Authorization Criteria
Step Therapy Criteria
Read about the Transition Policy
View a sample Transition Letter
Transition Letter - Español
Low Income Subsidy Premium Table
The Low Income Subsidy Premium Table shows what you might expect to pay for your plan premium if you qualify for 100%, 75%, 50% or 25% Extra Help as a member. Note: the premiums listed in the chart are for both medical services and prescription drug benefits.
Notices and Policies
How to disenroll
Part C Organization Determinations, Appeals and Grievances
Enrollment disclaimer information:
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, premium and/or copayments/co-insurance may change on January 1 of each year. The Formulary, pharmacy network, and/or provider network may change at any time. You will receive notice when necessary. Medicare evaluates plans based on a 5-Star rating system. Star ratings are calculated each year and may change from one year to the next.