Medicare Reference Documents
Below are some resources that you may find helpful at different times during your membership:
Summary of Benefits
This booklet gives you a summary of the costs and coverage in your plan. The complete list of services, limitations and exclusions are included in the Evidence of Coverage.
Evidence of Coverage
- Out-of-Network Coverage Rules: Chapter 3
- Exclusions & Limitations: Chapter 4, Section 3
- Prior Authorization: Chapter 3 (medical) and Chapter 5 (prescription drug)
- Appeals & Grievances: Chapter 9
- Disenrollment: Chapter 10
Use this order form to enroll and receive prescription drugs by mail.
This is the complete list of prescription drugs covered by Magnolia Health Plan Medicare Advantage.
- Provider & Pharmacy Directory Information
- This is an introduction to the provider and pharmacy directory, including an explanation of the provider symbols found in the directory.
- PHI Authorization Form
- Use this form when you want to allow Magnolia Health Plan Medicare Advantage to share your health information with a person or group.
- PHI Revocation Form
- Use this form when you want to cancel, or revoke, your previous permission to share health information with a person or group.
- Appointing a Representative
- Use this form to name a person to act as your representative. Must be completed by you and accepted by the person you appoint.
- 2017 Multi-language Interpreter Services
- We have free interpreters to answer questions in multiple languages
By clicking on the links below, you will be leaving the Magnolia Health Plan Medicare Advantage website.
- File a complaint directly with CMS
- Submit feedback about your Medicare plan directly to Medicare.gov.
- Stop Medicare Fraud, Waste and Abuse
- Learn how to identify, prevent and report Medicare fraud, waste or abuse.
- Office for Civil Rights
- The OCR protects your health information privacy rights and right to nondiscrimination.
- The Office of the Medicare Ombudsman (OMO)
- The Medicare Beneficiary Ombudsman helps you with Medicare-related complaints, grievances, and information requests.
- Best Available Evidence (BAE)
- This is a CMS policy that allows for changes to cost-sharing for low-income beneficiaries when there is evidence that information from a beneficiary is not up-to-date or accurate.
Call Member Services at 1-844-786-7711 (TTY: 711) for help if you have questions. From October 1 to February 14, you can call us 7 days a week from 8 a.m. to 8 p.m. From February 15 to September 30, you can call us Monday through Friday from 8 a.m. to 8 p.m On weekends and holidays, an automated system will handle your call.
Last Updated: 05/03/2017