Member Materials - Medicare Advantage
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 |
| Plan Year 2022 (Updated 10/01/2021) | Espanol | View |
| Evidence Of Coverage (EOC) | ||
| Global Classic (HMO) - H6062-001 (updated 11/15/2021) | English | View |
| Global Classic (HMO) - H6062-001 (updated 11/15/2021) | Espanol | View |
| Global Classic (HMO) - H6062-003 (updated 11/15/2021) | English | View |
| Global Classic (HMO) - H6062-003 (updated 11/15/2021) | Espanol | View |
| Global Special Care (HMO C-SNP) - H6062-005 (updated 11/15/2021) | English | View |
| Global Special Care (HMO C-SNP) - H6062-005 (updated 11/15/2021) | Espanol | View |
| Global Special Care Savings (HMO C-SNP) - H6062-006 (updated 11/15/2021) | English | View |
| Global Special Care Savings (HMO C-SNP) - H6062-006 (updated 11/15/2021) | 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 |
| Plan Year 2022 [PDF] | English | View |
| Plan Year 2022 [PDF] | Espanol | 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 | Espanol | 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 |