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

Prescription Drug Mail Order Form

Use this order form to enroll and receive prescription drugs by mail.

Comprehensive Formulary

This is the complete list of prescription drugs covered by Magnolia Health Plan Medicare Advantage.

Other Resources

  • 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.
  • 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