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Medicare Advantage 2017

Memorial Hermann Advantage Resource Center

Thank you for choosing Memorial Hermann Advantage. On this page, you will be able to quickly find member materials, forms, flyers and brochures.

Plan Information and Materials

Enrollment Forms

Here you'll find our enrollment form that you can print out, complete and mail to Memorial Hermann Advantage. Mail your completed form to:

Memorial Hermann Advantage Enrollment
929 Gessner Road
Suite 1500
Houston, TX
77024

Enrollment Form — HMO (English)

Enrollment Form — HMO (Spanish)

Enrollment Form — PPO (English)
Enrollment Form — PPO (Spanish)

Evidence of Coverage

This document includes a detailed legal description of your benefits and costs as a member. All Evidence of Coverage documents are organized by plan name.

Evidence of Coverage — HMO (English)
Evidence of Coverage — HMO (Spanish)

Evidence of Coverage — PPO (English)
Evidence of Coverage — PPO Spanish

Summary of Benefits

The Summary of Benefits provides some of the features of our plans. These documents are organized by plan name. For a complete list of benefits, see your Evidence of Coverage.

Summary of Benefits — HMO (English)
Summary of Benefits — HMO (Spanish)

Summary of Benefits — PPO (English)
Summary of Benefits — PPO (Spanish)

Annual Notice of Changes

2017 HMO Annual Notice of Changes - English

2017 HMO Annual Notice of Change - Spanish

2017 PPO Annual Notice of Changes - English

2017 PPO Annual Notice of Change - Spanish

Provider Directories

Here at Memorial Hermann Advantage we strive to provide our members with the most accurate Provider Directories. If you need help finding a network provider, please call customer service:

HMO: (844) 550-6886 (TTY 711)
PPO: (844) 550-6896 (TTY 711)

or click here to access our online searchable directory. If you would like a Provider Directory mailed to you, you may call the number above, or request one here.

Aquí en Memorial Hermann Advantage nos esforzamos por ofrecer a nuestros miembros los Directorios de Proveedores más precisos. Si necesitas ayuda para encontrar un proveedor dentro de la red, llama al:

HMO: (844) 550-6886 (TTY 711)
PPO: (844) 550-6896 (TTY 711)

o visita aquí para acceder a nuestro directorio de búsqueda online. Si deseas recibir por correo un Directorio de Proveedores, puedes llamar al número indicado más arriba o solicitar uno en el sitio web a aquí.

Pharmacy Directories

Here at Memorial Hermann Advantage we strive to provide our members with the most accurate Pharmacy Directories. If you need help finding a network provider, please call customer service:

HMO: (844) 550-6886 (TTY 711)
PPO: (844) 550-6896 (TTY 711)

or click here to access our online searchable directory. If you would like a Pharmacy Directory mailed to you, you may call the number above, or request one here.

Aquí en Memorial Hermann Advantage nos esforzamos por ofrecer a nuestros miembros los Directorios de Farmacias más precisos. Si necesitas ayuda para encontrar un farmacia dentro de la red, llama al:

HMO: (844) 550-6886 (TTY 711)
PPO: (844) 550-6896 (TTY 711)

o visita aquí para acceder a nuestro directorio de búsqueda online. Si deseas recibir por correo un Directorio de Farmacias, puedes llamar al número indicado más arriba o solicitar uno en el sitio web a aquí.

Formulary

Abridged Formulary — HMO & PPO

Abridged Formulary — HMO & PPO Spanish

Comprehensive Formulary — HMO & PPO

Comprehensive Formulary - HMO & PPO Spanish

Formulary Addendum - HMO & PPO

Formulary Addendum - HMO & PPO Spanish

This document shows you what drugs are covered in a specific plan.

The Formulary may change at any time during the year. You will receive notice when necessary.

Part D Materials

Part D Transition Policy
This transition policy applies to Part D medications and ensures a smooth transition for new Memorial Hermann Advantage members.

To request coverage for a non-formulary drug, a quantity limit exception, a step therapy exception or drugs requiring prior authorization, please download this form.

Drugs that Require Prior Authorization

Drugs that Require Step Therapy

Drugs that have Quantity Limits

Member Self-Pay Reimbursement Form

Low-Income Subsidy (LIS) Premium Summary Chart — HMO
See what the monthly plan premiums are for those who qualify for Extra Help.

Low-Income Subsidy (LIS) Premium Summary Chart — PPO
See what the monthly plan premiums are for those who qualify for Extra Help.

Medicare Star Ratings

The Medicare Program rates all health and prescription drug plans each year, based on a plan's quality and performance. Medicare Star Ratings help you know how good a job our plan is doing. You can use these Star Ratings to compare our plan's performance to other plans.

2017 Medicare Stars Rating - HMO
2017 Medicare Stars Rating - PPO

2017 Medicare Stars Rating - HMO (Spanish)
2017 Medicare Stars Rating - PPO (Spanish)

Other Forms and Documents

Appointment of Representative (AOR)
This form confirms your request for a particular person to act as your representative in connection with a claim.

For information on how to Authorization To Disclose Protected Health Information, visit our Privacy Page.

Continuity of Care Form

Medical Power of Attorney

Disenrollment Information

Health Risk Assessment (HRA) Form

Multilanguage Insert — HMO

Multilanguage Insert — PPO

Prior Authorization Form - Part C

Privacy Policy