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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

June 2022 Issue

Materials for all 2022 Plan Options

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

Document Name
Drug Formulary, Pharmacy Prior Authorization and Step Therapy Information
Current 2022 Versions English  
Summary Of Benefits
Global Classic - Plan Year 2022 English  
Global Special Care (C-SNP) and Global Special Care Savings (C-SNP) - Plan Year 2022 English  
Benefit Overview
Plan Year 2022 (Updated 10/01/2021) English Espanol
Evidence Of Coverage (EOC)
Global Classic - H6062-001 (updated 11/15/2021) English Espanol
Global Classic - H6062-003 (updated 11/15/2021) English Espanol
Global Special Care (C-SNP) - H6062-005 (updated 11/15/2021) English Espanol
Global Special Care Savings (C-SNP) - H6062-006 (updated 11/15/2021) English Espanol
Enrollment Forms (Annual Enrollment Period October 15- December 7)
All Plans - 2022 Enrollment Forms for New Members English  
All Plans - Enrollment Attestation English  
All Plans - 2022 Pre-Enrollment Checklist English  
Provider Directory
Plan Year 2022 English  
Plan Year 2022 [PDF] English Espanol
Pharmacy Directory
Plan Year 2022 English  

 

Important Links
Pharmacy
Medicare Part D Prescription Claim Form English  
2022 Pharmacy Search Tool 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  
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  
Additional Benefits
Dental Benefits English  
Fitness Benefits English  
Transportation Benefits 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  
Tobacco Cessation English  
Value-Added Items and Services English