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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

Document Name
Drug Formulary, Pharmacy Prior Authorization and Step Therapy Information
Current 2022 Versions English  
Summary Of Benefits
Generations Classic, Generations Value, Generations Select and Generations Classic Choice (POS) Plan Year 2022 English Espanol
Generations Classic Plus, Generations Special Care (C-SNP) and Generations Special Care Savings (C-SNP) Plan Year 2022 English Espanol
Generations State of Oklahoma Group Retirees - Plan year 2022 English  
Benefit Overview
Plan Year 2022 English Espanol
Star Ratings - 2021 English Espanol
Evidence Of Coverage (EOC)
Generations Value - H3706-009 - Plan Year 2022 English Espanol
Generations Classic - H3706-001 - Plan Year 2022 English Espanol
Generations Classic Choice - H3706-021 - Plan Year 2022 English Espanol
Generations Classic Plus - H3706-022 - Plan Year 2022 English Espanol
Generations Classic Plus - H3706-023 - Plan Year 2022 English Espanol
Generations Select - H3706-018 - Plan Year 2022 English Espanol
Generations Special Care (C-SNP) - H3706-024 - Plan Year 2022 (updated 11/15/2021) English Espanol
Generations Special Care ( C-SNP) – H3706-024 – Plan Year 2022 erratum English Espanol
Generations Special Care Savings (C-SNP) - H3706-025 - Plan Year 2022 (updated 11/15/2021) English Espanol
Generations Special Care Savings (C-SNP) – H3706-025 – Plan Year 2022 erratum English Espanol
Generations State of Oklahoma Group Retirees - Plan Year 2022 (updated 11/15/2021) English Espanol
Generations State of Oklahoma Group Retirees erratum (updated 11/15/2021) English  
Member Letter - Important information regarding behavioral health telehealth visits English  
Annual Notice of Changes (ANOC)
Generations Value - 2022 English Espanol
Generations Classic - 2022 English Espanol
Generations Classic Choice (POS) - 2022 English Espanol
Generations Select (HMO) - 2022 English Espanol
Generations State of Oklahoma Group Retirees - 2022 English Espanol
Enrollment Forms (Annual Enrollment Period October 15- December 7)
All Plans - 2022 Enrollment Form for New Members English  
All Plans - 2022 Enrollment Attestation English  
All Plans - 2022 Pre-Enrollment Checklist English  
2022 OMES EGID Application for Medicare Advantage Prescription Drug (MA-PD) Plan English  
OMES EGID Application for Retiree/Vested/Non-Vested/Defer Insurance Coverage Form English  
Provider Directory
Plan Year 2022 [PDF] English Espanol
Pharmacy Directory
Plan Year 2022 English  

 

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 Catalog (Updated 05/01/2022) English Espanol
Over the Counter Benefit – Place Order English  
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  
Privacy Notice English  
Referral and Prior Authorization Guide for Members English  
Release of Information Form English  
Transition of Care Form English  
Your Rights and Responsibilities as a Member of a GlobalHealth Medicare Advantage plan English  
2022 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  

 

Member Newsletters
Member Newsletters
August 2022 Issue English  
June 2022 Issue English  
March 2022 Issue English  

 

Document Name
Drug Formulary, Pharmacy Prior Authorization and Step Therapy Information
Current 2023 Versions English  
Summary Of Benefits
Generations Classic Rewards (HMO), Generations Valor (HMO-POS), and Generations Classic Plus (HMO) - Plan Year 2023 English  
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 2023 English  
Generations State of Oklahoma Group Retirees - Plan year 2023 English  
Benefit Overview
Plan Year 2023 English  
Star Ratings - 2022 English Espanol
Evidence Of Coverage (EOC)
Generations Classic Rewards (HMO) - H3706-001 English  
Generations Valor (HMO_POS) - H3706-009 English  
Generations Classic Plus (HMO) - H3706-023 English  
Generations Chronic Care (HMO C-SNP) - H3706-024 English  
Generations Chronic Care Savings (HMO C-SNP) - H3706-025 English  
Generations Dual Support (HMO D-SNP) - H3706-028 English  
Generations Dual Premier (HMO D-SNP) - H3706-029 English  
Generations State of Oklahoma Group Retirees English  
Annual Notice of Changes (ANOC)
Generations Classic Rewards (HMO) - H3706-001 English  
Generations Valor (HMO-POS) - H3706-009 English  
Generations Classic Plus (HMO) - H3706-018 English  
Generations Classic Plus (HMO) - H3706-021 English  
Generations Classic Plus (HMO) - H3706-022 English  
Generations Classic Plus (HMO) - H3706-023 English  
Generations Chronic Care (HMO C-SNP) - H3706-024 English  
Generations Chronic Care Savings (HMO C-SNP) - H3706-025 English  
Generations State of Oklahoma Group Retirees (HMO)  English  
Enrollment Forms (Annual Enrollment Period October 15- December 7)
All Plans - 2023 Enrollment Form for New Members English  
All Plans - 2023 Pre-Enrollment Checklist English  
2022 OMES EGID Application for Medicare Advantage Prescription Drug (MA-PD) Plan English  
OMES EGID Application for Retiree/Vested/Non-Vested/Defer Insurance Coverage Form English  
Provider Directory
Plan Year 2023 [PDF] English & Espanol
Pharmacy Directory
Plan Year 2023 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 Catalog English  
Over the Counter Benefit – Place Order English  
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  
Privacy Notice English  
Referral and Prior Authorization Guide for Members English  
Release of Information Form English  
Transition of Care Form English  
Your Rights and Responsibilities as a Member of a GlobalHealth Medicare Advantage plan English  
2022 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  
Member Newsletters
Member Newsletters
August 2022 Issue English  
June 2022 Issue English  
March 2022 Issue English  

Click here for Medicare Advantage member materials prior to 2022.

Click here for State of Oklahoma Group Retiree member materials prior to 2022.