Forms, authorizations and resources

2020

Forms

• Enrollment form for 2020
• Enrollment form for 2020, in Spanish
   
• Plan change form
• Disenrollment form (coming soon)

Plan information

• Enrollment Guide, including Summary of Benefits, effective 1-1-20
• Summary of Benefits, effective 1-1-20
• Comprehensive Drug List, effective 1-1-20
• Provider and Pharmacy Directory, effective Jan. 1, 2020
• Low-Income Subsidy (LIS) Premium Summary Chart
• Medicare star ratings flyer

en español / In Spanish

• Enrollment Guide, Including Summary of Benefits, effective 1-1-20
• Summary of Benefits, effective 1-1-20
• Comprehensive Drug List, effective 1-1-20
• Provider and Pharmacy Directory, effective Jan. 1, 2020
• Medicare star ratings flyer

Benefit information

• Dental insert, effective 1-1-20
• Delta Dental Plan (included for Platinum Card members), effective 1-1-20
• Delta Dental Plan (for Gold Card members, Basic members or Premium members who add the plan), effective 1-1-20
• Vision benefits summary (included for Platinum Card members), effective 1-1-20
• Vision benefits summary (included for Gold Card members), effective 1-1-20

Annual Notice of Changes

• Sharp Direct Advantage Gold Card, effective 1-1-20
• Sharp Direct Advantage Platinum Card, effective 1-1-20

en español / In Spanish

• Sharp Direct Advantage Gold Card, effective 1-1-20
• Sharp Direct Advantage Platinum Card, effective 1-1-20

Evidence of Coverage (EOC)

• Sharp Direct Advantage Gold Card, effective 1-1-20
• Sharp Direct Advantage Platinum Card, effective 1-1-20

en español / In Spanish

• Sharp Direct Advantage Gold Card, effective 1-1-20
• Sharp Direct Advantage Platinum Card, effective 1-1-20

2019

• Enrollment form for 2019
• Enrollment form for 2019, in Spanish
   
• Plan change form
• Disenrollment form

Plan information

• Enrollment Guide, including Summary of Benefits, effective 1-1-19
• Summary of Benefits, effective 1-1-19
• Comprehensive Drug List, effective Dec. 1, 2019
• Provider and Pharmacy Directory, effective Sept. 1, 2019
• Provider and Pharmacy Directory addendum, effective Nov. 1, 2019
• Low-income Subsidy (LIS) Premium Summary Chart
• Star ratings flyer

en español / In Spanish

• Enrollment Guide, including Summary of Benefits, effective 1-1-19
• Comprehensive Drug List, effective Dec. 1, 2019
• Provider and Pharmacy Directory, effective Sept. 1, 2019
• Provider and Pharmacy Directory addendum, effective Nov. 1, 2019
• Star ratings flyer

Benefit information

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

Annual Notice of Changes

• Sharp Direct Advantage Gold Card, effective 1-1-19
• Sharp Direct Advantage Platinum Card, effective 1-1-19

en español / In Spanish

• Sharp Direct Advantage Gold Card, effective 1-1-19
• Sharp Direct Advantage Platinum Card, effective 1-1-19

Evidence of Coverage (EOC)

• Sharp Direct Advantage Gold Card, effective 1-1-19
• Sharp Direct Advantage Platinum Card, effective 1-1-19

en español / In Spanish

• Sharp Direct Advantage Gold Card, effective 1-1-19
• Sharp Direct Advantage Platinum Card, effective 1-1-19