Forms, authorizations and resources

2020

Forms

• Enrollment form for 2020
• Enrollment form, in Spanish
• Plan change form for 2020
• Disenrollment form

Plan information

• Enrollment Guide including Summary of Benefits Jan. 1, 2020
• Summary of Benefits Jan. 1, 2020
• Drug list (formulary) Oct. 1, 2020
• Provider & Pharmacy Directory June 3, 2020
  • Provider & Pharmacy Directory Addendum Oct.1, 2020
  • Dental insert
• Low-Income Subsidy (LIS) premium summary chart
• 2020 Medicare Star Ratings flyer

en español

• Enrollment Guide including Summary of Benefits Jan. 1, 2020
• Summary of Benefits Jan. 1, 2020
• Drug list (formulary) Oct. 1, 2020
• Provider & Pharmacy Directory June 3, 2020
  • Provider & Pharmacy Directory Addendum Oct.1, 2020
• Medicare Star Ratings flyer 2020

Benefit information
Jan. 1, 2020

• Delta Dental Plan (included for Platinum Card members)
• Delta Dental Plan (for Gold Card members who add the plan)
• Vision benefits summary (included for Platinum Card members)
• Vision benefits summary (included for Gold Card members)

en español

• Delta Dental Plan (included for Platinum Card members)
• Delta Dental Plan (for Gold Card members who add the plan)

Annual Notice of Changes
Jan. 1, 2020

• Sharp Direct Advantage Gold Card - ANOC
• Sharp Direct Advantage Platinum Card - ANOC

Aviso anual de cambios (en español)

• Sharp Direct Advantage Gold Card
• Sharp Direct Advantage Platinum Card

Evidence of Coverage
Jan. 1, 2020

• Sharp Direct Advantage Gold Card - EOC
• Sharp Direct Advantage Platinum Card - EOC

Evidencia de cobertura (en español)

• Sharp Direct Advantage Gold Card
• Sharp Direct Advantage Platinum Card