Plan Documents


Print

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


General Plan Information 
Austin and Surrounding Area Evidence of Coverage Basic (HMO) English PDF Document 
en Espanol PDF Document
Austin and Surrounding Area Evidence of Coverage Premier (HMO) English PDF Document 
en Espanol PDF Document
El Paso and Surrounding Area Evidence of Coverage Basic (HMO) English PDF Document 
en Espanol PDF Document
El Paso and Surrounding Area Evidence of Coverage Premier (HMO) English PDF Document 
en Espanol PDF Document
Houston and Surrounding Area Evidence of Coverage Basic (HMO) English PDF Document 
en Espanol PDF Document
Houston and Surrounding Area Evidence of Coverage Premier (HMO) English PDF Document 
en Espanol PDF Document
South Texas and Surrounding Area Evidence of Coverage Basic (HMO) English PDF Document 
en Espanol PDF Document
South Texas and Surrounding Area Evidence of Coverage Premier (HMO) English PDF Document 
en Espanol PDF Document
Austin and Surrounding Areas Evidence of Coverage Choice Plus (PPO) English PDF Document 
en Espanol PDF Document
Austin and Surrounding Areas Evidence of Coverage Choice Premier (PPO) English PDF Document 
en Espanol PDF Document
Dallas and Surrounding Areas Evidence of Coverage Choice Plus (PPO) English PDF Document 
en Espanol PDF Document
Dallas and Surrounding Areas Evidence of Coverage Choice Premier (PPO) English PDF Document 
en Espanol PDF Document
Houston and Surrounding Areas Evidence of Coverage Choice Plus (PPO) English PDF Document 
en Espanol PDF Document
Houston and Surrounding Areas Evidence of Coverage Choice Premier (PPO) English PDF Document 
en Espanol PDF Document
Austin and Surrounding Area Summary of Benefits (HMO) English PDF Document 
en Espanol PDF Document
Austin and Surrounding Area Annual Notice of Change Choice Plus (PPO) English PDF Document 
en Espanol PDF Document
Austin and Surrounding Area Annual Notice of Change Choice Premier (PPO) English PDF Document 
en Espanol PDF Document
Dallas and Surrounding Area Annual Notice of Change Choice Plus (PPO) English PDF Document 
en Espanol PDF Document
Dallas and Surrounding Area Annual Notice of Change Choice Premier (PPO) English PDF Document 
en Espanol PDF Document
El Paso and Surrounding Area Summary of Benefits (HMO) English PDF Document 
en Espanol PDF Document
Houston and Surrounding Area Summary of Benefits (HMO) English PDF Document 
en Espanol PDF Document
Houston and Surrounding Area Annual Notice of Change Basic (HMO) English PDF Document 
en Espanol PDF Document
Houston and Surrounding Area Annual Notice of Change Choice Plus (PPO) English PDF Document 
en Espanol PDF Document
Houston and Surrounding Area Annual Notice of Change Choice Premier (PPO) English PDF Document 
en Espanol PDF Document
San Antonio and Surrounding Area Evidence of Coverage Choice Plus (PPO) English PDF Document 
en Espanol PDF Document
San Antonio and Surrounding Area Evidence of Coverage Choice Premier (PPO) English PDF Document 
en Espanol PDF Document
South Texas and Surrounding Area Summary of Benefits (HMO) 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 External Link
Pharmacy Mail-Order Form External Link
Prescription Drug Claim Form (MAPD) External Link
Medicare Part B vs. Part D Form External Link
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