Plan Documents


The following documents can help you get more information about this Medicare Advantage plan, enroll in a plan and more.

General Plan Information 
Oklahoma City and Surrounding Area
Annual Notice of Change Basic (HMO)
English PDF Document 
en Espanol PDF Document
Tulsa and Surrounding Area
Annual Notice of Change Basic (HMO)
English PDF Document 
en Espanol PDF Document
Oklahoma City and Surrounding Area
Annual Notice of Change Premier Plus (HMO-POS)
English PDF Document 
en Espanol PDF Document
Tulsa and Surrounding Area
Annual Notice of Change Premier Plus (HMO-POS)
English PDF Document 
en Espanol PDF Document
Oklahoma City and Surrounding Area
Annual Notice of Change Choice (PPO)
English PDF Document 
en Espanol PDF Document
Oklahoma City and Surrounding Area
Evidence of Coverage Basic (HMO)
English PDF Document 
en Espanol PDF Document
Tulsa and Surrounding Area
Evidence of Coverage Basic (HMO)
English PDF Document 
en Espanol PDF Document
Oklahoma City and Surrounding Area
Evidence of Coverage Premier Plus (HMO-POS)
English PDF Document 
en Espanol PDF Document
Tulsa and Surrounding Area
Evidence of Coverage Premier Plus (HMO-POS)
English PDF Document 
en Espanol PDF Document
Oklahoma City and Surrounding Area
Evidence of Coverage Choice (PPO)
English PDF Document 
en Espanol PDF Document
Tulsa and Surrounding Area
Evidence of Coverage Choice Plus (PPO) 
English PDF Document 
en Espanol PDF Document
Oklahoma City and Surrounding Area
Summary of Benefits (HMO/HMO-POS) 
English PDF Document 
en Espanol PDF Document
Tulsa and Surrounding Area
Summary of Benefits (HMO/HMO-POS) 
English PDF Document 
en Espanol PDF Document
Oklahoma City and Surrounding Area
Summary of Benefits (PPO)
English PDF Document 
en Espanol PDF Document
Tulsa and Surrounding Area
Summary of Benefits (PPO)
English PDF Document 
en Espanol PDF Document
Prescription Drug Forms
Oklahoma City and Surrounding Area Mail- Order Physician New Prescription Fax Form
Oklahoma City and Surrounding Area Pharmacy Mail-Order Form
Oklahoma City and Surrounding Area Prescription Drug Claim Form (HMO)  
Oklahoma City and Surrounding Area Prescription Drug Claim Form (HMO-POS)  
Oklahoma City and Surrounding Area Prescription Drug Claim Form (PPO)  
Oklahoma City and Surrounding Area Medicare Part B vs. Part D Form  
Tulsa and Surrounding Area Direct Member Reimbursement Form PDF Document 
Tulsa and Surrounding Area Mail- Order Physician New Prescription Fax Form PDF Document
Tulsa and Surrounding Area Pharmacy Mail-Order Form PDF Document
Tulsa and Surrounding Area Prescription Drug Claim Form PDF Document
Tulsa and Surrounding Area Medicare Part B vs. Part D Form PDF Document 
Additional Resources
Authorization to Disclose Protected Health Information (PHI) Form PDF Document 
Automated Premium Payment (ACH) Form PDF Document 
CMS Appointment of Representative Form PDF Document
Oklahoma City and Surrounding Area Multi-language Interpreter Services PDF Document
Tulsa and Surrounding Area Multi-language Interpreter Services PDF Document
Notice of Privacy Practices PDF Document