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GLOBALHEALTH MEDICARE ADVANTAGE PLANS, 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.

Member Newsletters

 

Materials for all 2022 Plan Options

Document Name Language Action
Drug Formulary, Pharmacy Prior Authorization and Step Therapy Information
Current 2022 Versions English View
Summary Of Benefits
Global Classic (HMO)
Plan Year 2022
English View
Global Special Care (HMO C-SNP) and Global Special Care Savings (HMO C-SNP)
Plan Year 2022
English View
Benefit Overview
Plan Year 2022 (Updated 10/01/2021) English View
Evidence Of Coverage (EOC)
H6062-001 Global Classic (HMO) English View
H6062-001 Global Classic (HMO) Espanol View
H6062-003 Global Classic (HMO) English View
H6062-003 Global Classic (HMO) Espanol View
H6062-005 Global Special Care (HMO C-SNP) English View
H6062-005 Global Special Care (HMO C-SNP) Espanol View
H6062-006 Global Special Care Savings (HMO C-SNP) English View
H6062-006 Global Special Care Savings (HMO C-SNP) Espanol View
Enrollment Forms (Annual Enrollment Period October 15- December 7)
2022 Enrollment Form (All Plan Options - New Members) English View
2022 Enrollment Attestation English View
2022 Pre-Enrollment Checklist English View
Provider Directory
Plan Year 2022 (Current Listing) English View
Pharmacy Directory
Plan Year 2022 (Current Listing) English View

 

Important Links Language Action
Pharmacy
Medicare Part D Prescription Claim Form English View
2022 Pharmacy Search Tool English View
Prescription Drug Mail Order Form English View
Prescription Drug Mail Order Form Spanish View
Prescription Drug Transition Policy English View
Medication Therapy Management (MTM) Program Information English View
Utilization Management Program English View
Request for Medicare Prescription Drug Coverage Determination Form English View
Request for Medicare Prescription Drug Appeal (Redetermination) Form English View
Request for Prescription Drug Prior Authorization Exception English View
Request for Prescription Drug Quantity Limits English View
Request for Prescription Drug Step Therapy Exception English View
Request for Prescription Drug Reimbursements English View
Over the Counter Benefit – Place Order English View
Over the Counter Benefit Catalog (Updated 10/01/2021) English View

 

Additional Documents Language Action
Advance Directive Information English View
Appointment of Representative Form English View
Assistance During a Disaster English View
CMS Website's Best Available Evidence (BAE) Page English View
Dental Benefits English View
Direct Member Reimbursement Form English View
Disenrollment Rights and Responsibilities English View
Fitness Benefits English View
Get information about Extra Help to pay your plan premium or prescriptions (LIS) English View
National Coverage Determinations (NCD) and Local Coverage Determinations (LCD) English View
Non-Discrimination Notice English View
Physician Treatment Request Form (Medical Prior Authorization) English View
Privacy Notice English View
Quality Improvement Program English View
Release of Information Form English View
Tobacco Cessation English View
Transportation Benefits English View
Transition of Care Form English View
Value-Added Items and Services English View
Your Rights and Responsibilities as a Member of a GlobalHealth Medicare Advantage plan English View