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MEMBER MATERIALS, FORMS, RESOURCES & GUIDELINES

Learn more about your GlobalHealth Medicare Advantage Plan plan and benefits. Download the latest member materials below. All materials shown are available in printed versions. If you need a printed version, please contact Customer Care and a copy will be mailed to you.

Materials for all Plan Options

Unless otherwise stated, all plans are HMO and require referrals from your Primary Care Physician.

Materials for all plan options

2024 Plan Year Documents
Enrollment Forms
All Plans - 2024 Enrollment Request Form English  
C-SNP Plans - Pre-Enrollment Qualification Assessment Tool English  
All Plans - 2024 Pre-Enrollment Checklist English  
For OMES EGID enrollment forms, please contact the employer group    
Benefit Overview & STAR Rating
Plan Year 2024 English Espanol
Star Ratings - 2024 English Espanol
Summary Of Benefits
Generations Classic Rewards (HMO), Generations Valor (HMO-POS), and Generations Classic Plus (HMO) - Plan Year 2024 English Espanol
Generations Chronic Care (HMO C-SNP), Generations Chronic Care Savings (HMO C-SNP), Generations Dual Support (HMO D-SNP) and Generations Dual Premier (HMO D-SNP) - Plan Year 2024 English Espanol
Generations State of Oklahoma Group Retirees - Plan year 2024 English Multi-Language
Evidence Of Coverage (EOC)
Generations Classic Rewards (HMO) - H3706-001 English Espanol
Generations Valor (HMO_POS) - H3706-009 English Espanol
Generations Classic Plus (HMO) - H3706-023 English Espanol
Generations Chronic Care (HMO C-SNP) - H3706-024 English Espanol
Generations Chronic Care Savings (HMO C-SNP) - H3706-025 English Espanol
Generations Dual Support (HMO D-SNP) - H3706-028 English Espanol
Generations Dual Premier (HMO D-SNP) - H3706-029 English Espanol
Generations State of Oklahoma Group Retirees English Espanol
Annual Notice of Changes (ANOC)
Generations Classic Rewards (HMO) - H3706-001 English Espanol
Generations Valor (HMO-POS) - H3706-009 English Espanol
Generations Classic Plus (HMO) - H3706-023 English Espanol
Generations Chronic Care (HMO C-SNP) - H3706-024 English Espanol
Generations Chronic Care Savings (HMO C-SNP) - H3706-025 English Espanol
Generations Dual Support (HMO D-SNP) - H3706-028 English Espanol
Generations Dual Premier (HMO D-SNP) - H3706-029 English Espanol
Generations State of Oklahoma Group Retirees (HMO)  English Espanol
Drug Formulary, Pharmacy Prior Authorization and Step Therapy Information
Current 2024 Versions English  
Pharmacy Directory
Plan Year 2024  English & Espanol
Provider Directory
Plan Year 2024 [PDF] English & Espanol
January 2024 - Provider Directory Update English & Espanol
Multi-language Insert
Multi-language Insert English & Espanol

 

Important Links
Pharmacy
Medicare Part D Prescription Claim Form English  
Prescription Drug Mail Order Form English Espanol
Prescription Drug Transition Policy English  
Medication Therapy Management (MTM) Program Information English  
Utilization Management Program English  
Request for Medicare Prescription Drug Coverage Determination Form English  
Request for Medicare Prescription Drug Appeal (Redetermination) Form English  
Request for Prescription Drug Prior Authorization Exception English  
Request for Prescription Drug Quantity Limits English  
Request for Prescription Drug Step Therapy Exception English  
Request for Prescription Drug Reimbursements English  
Over the Counter Benefit – Place Order English  
Over the counter Catalog for Classic Rewards, Classic Plus, Valor, and State of Oklahoma Retiree Plan English Espanol
Over the counter and Grocery Product Catalog for Chronic Care, Chronic Care Savings, Dual Support, and Dual Premier Plans English Espanol
Pharmacy FAQ
What is a Coverage Gap - "Donut Hole"? English  
What is a formulary? English  
What is a late penalty for Part D? English  
All Plans - Additional Documents
Legal Documents
Advance Directive Information English  
Appointment of Representative Form English  
Disenrollment Rights and Responsibilities English  
National Coverage Determinations (NCD) and Local Coverage Determinations (LCD) English  
Non-Discrimination Notice English  
Physician Treatment Request Form (Medical Prior Authorization) English  
Notice of Privacy Practices English  
Referral and Prior Authorization Guide for Members English  
Authorization to Disclose PHI Form English  
Transition of Care Form English  
Your Rights and Responsibilities as a Member of a GlobalHealth Medicare Advantage plan English  
Creditable Coverage Notice English  
Member Reimbursement
Direct Member Reimbursement Form - Online Form - Routine Vision Exam/Eyewear English  
Direct Member Reimbursement Form - Mail In Form - Routine Vision Exam/Eyewear English  
Direct Member Reimbursement Form - Other Medical Services English  
Extra Help to pay your plan premium or prescriptions (LIS) English  
Extra Documents
Assistance During a Disaster English  
Best Available Evidence (BAE) - from CMS English  
Quality Improvement Program English  
Remember to Take Your Medication English  
2024 Health Risk Assessment (HRA) English  
Smart Wallet Approved Items English  
Member Newsletters
Member Newsletters
October 2023 Issue English  
August 2023 Issue English  
June 2023 Issue English  
March 2023 Issue English