Forms, authorizations and resources

2020

Plan information

• Enrollment Guide, including Summary of Benefits, effective 1-1-20
• Summary of Benefits (Coming soon)
• Comprehensive Drug List, effective 1-1-20
• Provider and Pharmacy Directory, effective 1-1-20
• Low-Income Subsidy (LIS) Premium Summary Chart
• Medicare star ratings flyer

en español / In Spanish

• Enrollment Guide, Including Summary of Benefits (Coming soon)
• Comprehensive Drug List, effective 1-1-20
• Provider and Pharmacy Directory, effective 1-1-20
• Medicare star ratings flyer

Benefit information

• Dental Insert, effective 1-1-20
• Delta Dental Plan (for Gold Card members, Basic members or Premium members who add the plan), effective 1-1-20

Annual Notice of Changes

• Sharp Direct Advantage Basic, effective 1-1-20
• Sharp Direct Advantage Premium, effective 1-1-20

en español / In Spanish

• Sharp Direct Advantage Basic, effective 1-1-20
• Sharp Direct Advantage Premium, effective 1-1-20

Evidence of Coverage (EOC)

• Sharp Direct Advantage Basic, effective 1-1-20
• Sharp Direct Advantage Premium, effective 1-1-20

en español / In Spanish

• Sharp Direct Advantage Basic, effective 1-1-20
• Sharp Direct Advantage Premium, effective 1-1-20

Forms

• Plan Change Form
• Disenrollment form (Coming soon)

2019

Plan information

• Enrollment Guide, including Summary of Benefits, effective 1-1-19
• Summary of Benefits, effective 1-1-19
• Comprehensive Drug List, effective 10-1-19
• Provider and Pharmacy Directory, effective 9-1-19
• Provider and Pharmacy Directory Addendum, effective 10-1-19
• Low-Income Subsidy (LIS) Premium Summary Chart
• Star Ratings flyer

en español / In Spanish

• Enrollment Form for 2019
• Enrollment Guide, Including Summary of Benefits, effective 1-1-19
• Comprehensive Drug List, effective 10-1-19
• Provider and Pharmacy Directory, effective 9-1-19
• Provider and Pharmacy Directory Addendum, effective 10-1-19
• Star Ratings flyer, in Spanish

Benefit information

• Dental Insert, effective 1-1-19
• Delta Dental Plan (for Gold Card members, Basic members or Premium members who add the plan), effective 1-1-19

en español / In Spanish

• Dental Insert in Spanish, effective 1-1-19
• Delta Dental Plan (for Gold Card members, Basic members or Premium members who add the plan) in Spanish, effective 1-1-19

Annual Notice of Changes

• Sharp Direct Advantage Basic, effective 1-1-19
• Sharp Direct Advantage Premium, effective 1-1-19

en español / In Spanish

• Sharp Direct Advantage Basic, effective 1-1-19
• Sharp Direct Advantage Premium, effective 1-1-19

Evidence of Coverage

• Sharp Direct Advantage Basic, effective 1-1-19
• Sharp Direct Advantage Premium, effective 1-1-19

en español / In Spanish

• Sharp Direct Advantage Basic, effective 1-1-19
• Sharp Direct Advantage Premium, effective 1-1-19

Forms

• Plan Change form
• Disenrollment form