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

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 2021 — 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 2021 — HMO (English) / (Spanish)
Evidence of Coverage 2021 — Plus HMO (English) / (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 (EOC).

Summary of Benefits 2021 — HMO (English) / (Spanish)
Summary of Benefits 2021 — Plus HMO (English) / (Spanish)

Annual Notice of Changes

2021 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.

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 aquí.

2021 Pharmacy Directory

Formulary

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

Costco Mail Order Information and Forms

If you take a "long-term" medication, consider enrolling in Costco Mail Order Pharmacy services. There are two options available to you: traditional mail order or online enrollment. For more information on home delivery (mail order) information, please visit the Costco Mail Order section of the Pharmacy FAQ page.

To enroll in traditional mail order services, please see the forms below.

Mail-Order Form (English) Mail-Order Form (Spanish)

For more information, please reach out to directly to Costco Mail Order Pharmacy at (800) 607-6861 or click here.

For instructions on how to enroll for prescriptions online with Costco Mail Order, click here.

Navitus Member Portal

This private, secure website is designed just for you. All of your pharmacy plan information is available and kept up-to-date in real time.

Easy access allows you to:

  • Manage all your prescriptions on a single dashboard
  • Compare prices at local pharmacies
  • Find your lowest prescription cost
  • Locate your pharmacy and get driving directions
  • Keep track of your health history
  • Learn more about your drugs
  • Take it all with you through the mobile app
  • And much more.

Visit https://members.navitus.com/ and use your member ID number to register. Questions? Call Navitus Customer Service at (866) 270-3877. (Please note that by clicking on this link, you will be leaving Memorial Hermann website).

Navitus Mobile App

The mobile app provides easy, on-the-go access to your personalized health information. Once you have your member ID number, download the app to take advantage of the benefits your pharmacy plan offers. Managing your prescription medications is a key part of managing your health. Take your medication information with you wherever you are with the mobile app. Download now for iOS and Android devices. (Please note that by clicking on this link, you will be leaving Memorial Hermann website).

For Mobile App Account Assistance Contact Customer Care, please call customer service at (844) 268-9789.

Navitus QR Code

Contact Us

For more information on your pharmacy benefits, contact Navitus Customer Service at (855) 645-8448.

Dental Benefit Information

Dental benefits under the Memorial Hermann Medicare Advantage plans are provided by Delta Dental. Please review your plan’s Evidence of Coverage (EOC) to ensure you fully understand the dental benefits offered with your specific plan. Contact Delta Dental directly at (888) 845-6023 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 Delta Dental.
(Please note that by clicking on this link, you will be leaving Memorial Hermann Advantage website.)

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 the Request for Coverage Determination Form.

HMO   Plus HMO

HMO   Plus HMO

Low-Income Subsidy (LIS) Premium Summary Chart 2021 — HMO

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 2021
Member Reimbursement Drug Claim Form 2021

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 2021 - HMO (English) / (Spanish)

Other Forms and Documents

Appointment of Representative (AOR) Form
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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