Plan Documents & Materials

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View 2021 Medicare Advantage for this page

Questions? Contact Customer Service at (855) 645-8448

To view your pharmacy benefit information, see network pharmacies, check the drug lists and learn more about your prescription drug coverage visit the pharmacy benefits page.

Plan Information and Materials

Medicare Advantage HMO Enrollment Forms

Below 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 Medicare Advantage Enrollment
929 Gessner Road
Suite 1500
Houston, TX
77024

Enrollment Form 2022 — HMO (English) / (Spanish)

Evidence of Coverage

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

Evidence of Coverage 2022 — HMO (English) / (Spanish)
Evidence of Coverage 2022 — Plus HMO (English) / (Spanish)
Evidence of Coverage 2022 — Jefferson HMO (English) / (Spanish) - Coming Soon!
Evidence of Coverage 2022 — Dual Advantage HMO (D-SNP) (English) / (Spanish) - Coming Soon!

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 (EOC).

Summary of Benefits 2022 — HMO (English) / (Spanish)
Summary of Benefits 2022 — Plus HMO (English) / (Spanish)
Summary of Benefits 2022 — Jefferson HMO (English) / (Spanish)
Summary of Benefits 2022 — Dual Advantage HMO (D-SNP) (English) / (Spanish)

Annual Notice of Changes

2022 HMO Annual Notice of Changes - (English) / (Spanish)
2022 Plus HMO Annual Notice of Changes - (English) / (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 aquí.

Dental Benefit Information

Dental benefits under the Memorial Hermann Medicare Advantage plans are provided by Liberty Dental. Please review your plan’s Evidence of Coverage (EOC) to ensure you fully understand the dental benefits offered with your specific plan. Contact Liberty Dental directly at (888) 700-1246 for questions regarding your benefits or help finding an in-network provider. You may also register for online services or review your dental benefits at Liberty Dental.
(Please note that by clicking on this link, you will be leaving Memorial Hermann Advantage website.)

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

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.

Medicare Stars Rating 2022 - HMO (English) / (Spanish)

Other Forms and Documents

Appointment of Representative (AOR) Form (English) / (Spanish)
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.

Additional Resources

Continuity of Care Form
Medical Power of Attorney
Disenrollment Information
Health Risk Assessment (HRA) Form
Multilanguage Insert — HMO
Prior Authorization Form - Part C
Privacy Forms

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