City of Houston Employer Group Plan

Plan Documents

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2017 Plan Materials and Forms

Summary of Benefits pdf icon
Evidence of Coverage pdf icon
Enrollment form pdf icon

Medicare beneficiaries may also enroll in this plan through the CMS Medicare Online Enrollment Center, located at (by clicking on this link you will be leaving our website)

Annual Notice of Change pdf icon

Provider Directories
Provider Directory / Directorio de proveedores pdf icon

Medicare Star Ratings
City of Houston Employer Group Medicare Star Ratings pdf icon

Translation Service
Multilanguage information pdf icon - Translation Services

Appointment of Representative form
Once the 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 this form pdf icon to us.

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 pdf icon
Find out more about Mail Order Benefits pdf icon
Medicare Part D Prescription Claim Form pdf icon
Coverage of a Non-Formulary Drug pdf icon
Request for Quantity Limit Exception pdf icon
Request for Step Therapy Exception pdf icon
Lower Co-pay (Tiering Exception) pdf icon
Medicare Prescription Drug Coverage Determination form pdf icon
To initiate a coverage determination online, please click here (by clicking on this link you will be leaving our website)
Medicare Prescription Drug Appeal (Redetermination) form pdf icon
To initiate a redetermination online, please click here (by clicking on this link you will be leaving our website)
Learn more about Part D Coverage Determinations, Exceptions, Appeals and Grievances pdf icon

Pharmacy Directory
Find a pharmacy

Formulary Information
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 pdf icon and any restrictions to the formulary.
Comprehensive Formulary pdf icon - Updated February 2017
Formulario pdf icon - Updated February 2017
Formulary Addendum - Updated May 2017 pdf icon
Apéndice del Formulario - Updated May 2017 pdf icon

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 2017 pdf icon
Cambios de Formulario - Updated March 2017 pdf icon

Medication Therapy Management Program
Medication Therapy Management (MTM) pdf icon
Personal Medication List pdf icon

Prior Authorization and Step Therapy Criteria
Prior Authorization Criteria pdf icon
Step Therapy Criteria pdf icon

Transition Policy
Read about the Transition Policy pdf icon
View a sample Transition Letter pdf icon
Transition Letter - Español pdf icon

Low Income Subsidy Premium Table
This chart pdf icon 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
Out-of-Network coverage pdf icon
Quality improvement pdf icon
Medicare fraud pdf icon
How to disenroll pdf icon
Learn more about Part C Organization Determinations, Appeals and Grievances pdf icon


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.

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