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)
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)
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 (English)
Summary of Benefits (Spanish)
Annual Notice of Changes
2019 HMO Annual Notice of Changes - English
2019 HMO 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: (855) 645-8448 (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: (855) 645-8448 (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: (855) 645-8448 (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: (855) 645-8448 (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
2019 Abridged Formulary - HMO - English
2019 Abridged Formulary - HMO - Spanish
2019 Comprehensive Formulary - HMO - English
2019 Comprehensive Formulary - HMO - Spanish
Formulary Addendum - HMO - English
Formulary Addendum - HMO - 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 Reimbursement Drug Claim Form
Low-Income Subsidy (LIS) Premium Summary Chart — HMO
See what the monthly plan premiums are for those who qualify for Extra Help.
Member Reimbursement Form
Our plan allows for reimbursements of certain claims. Please download the form below, complete it and follow the submission directions.
Member Reimbursement Medical Claim Form
Member Reimbursement Drug Claim Form
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.
2019 Medicare Star Ratings - English
2019 Medicare Star Ratings - Spanish
Other Forms and Documents
Appeal Request Form
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
Member Reimbursement Form
Multilanguage Insert — HMO
Prior Authorization Form - Part C
Privacy Policy