ذكذكتسئµ
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Plan Material and Forms

Plan Material and Forms

At ذكذكتسئµ, we’re always here to help you make smart decisions about your health—including finding the right health plan to best suit your needs and information to help you navigate your policy.

On this page, you will find downloadable documents for this year’s ذكذكتسئµ (HMO D-SNP) plan.

Questions?

Call 1.833.276.8306
(TTY users should call 711)

October 1 to March 31, 8:00 am to 8:00 pm, 7 days a week andآ April 1 through September 30, Monday through Friday, 8:00 am to 8:00 pm.

On certain holidays your call will be handled by our automated phone system.

Pre-enrollment Checklist

In this Medicare checklist, we outline the seven steps you’ll want to check off your to-do list before deciding what best fits your Medicare needs and how to properly become a Medicare beneficiary.

Summary of Benefits

The Summary of Benefits outlines your plan benefits for the current calendar year.

Please click on the links below download a PDF copy.

Please call Member Services if you would like a hard copy of the Summary of Benefits mailed to you.

Evidence of Coverage

The Evidence of Coverage (EOC), along with your enrollment form, isآ ذكذكتسئµ’s contract with you. These documents explain your rights, benefits, and responsibilities as a Member of a ذكذكتسئµ Medicare Advantage plan.

Please click on the links below download a PDF copy.

Please call Member Services if you would like a hard copy of the EOC mailed to you.

Provider Directory

The Provider Directory outlines your plan’s network of primary care physicians, specialists, hospitals, skilled nursing facilities, outpatient mental health Providers,آ DMEs, dental, andآ vision Provider contacts.

Please click on the links below download a PDF copy.

Please call Member Services if you would like a hard copy of the directory mailed to you.

How to Cancel or Leave the Plan

You can change health plans only at certain times during the year. From October 15 – December 7, you can join, switch or drop a Medicare health or drug plan for the following year.

How to Cancel or Leave the Plan

Pharmacy Directory

The Pharmacy Directory provides a list of your plan’s network pharmacies.

Please click on the links below download a PDF copy.

Please call Member Services if you would like a hard copy of the directory mailed to you.

H9826_IT_10045_092919_M Last updated October 14, 2025

Why Choose ذكذكتسئµ?

As a local nonprofit health plan, ذكذكتسئµ gives you plenty of reasons to join our ذكذكتسئµ. From the benefits and special programs we offer to the way our Member Services team helps you make the most of them, ذكذكتسئµ is always working life forward for you and your family.

“ذكذكتسئµ is always there to answer my questions and help me and my family with our medical needs. I truly appreciate and value their customer support and service.â€‌

– Cecily
Member of ذكذكتسئµ

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