Select Advantage is being rolled over to MediBlue. This is an HISTORICAL Page.
Here’s our Blue Cross Affiliate Website.
Select advantage is a much richer benefited plan with a larger provider selection than Senior Secure Email dated 10.1.2014
- Anthem Select Advantage (HMO) Summary of Benefits The Summary of Benefits document contains a benefit comparison chart showing premiums, cost shares, and additional benefit information. Also includes the Star Ratings and Multi-language Interpreter Services documents.
- Anthem Select Advantage (HMO) Star Rating
- Anthem Select Advantage (HMO) Evidence of Coverage
- Anthem Select Advantage (HMO) 2015 Comprehensive Formulary
♦ Paper Enrollment Form Be sure to return to us.
Some Anthem Medicare Advantage Plans are not being renewed. Please read the letter that you will get from Anthem carefully and then fax or email to us for review. We can help you select a new plan with Anthem or another company.
Information for Los Angeles ONLY – Go into the Blue Cross Affliate Website to verify relevant documents for your situation!
Anthem Select Advantage (HMO) Documents
Using the Plan:
- Service Area
- Prescription Drug Claim Form
- Low Income Subsidy (LIS) Premium Summary Table For more information about receiving extra help to pay for your prescription drug coverage: In certain cases, CMS systems do not reflect a beneficiary’s correct low-income subsidy (LIS) status at a particular point in time. As a result, the most up-to-date and accurate subsidy information has not been communicated to the Part D plan. In order to address these special situations, CMS has created the Best Available Evidence (BAE) policy. This policy requires Part D plans to establish the appropriate cost-sharing for low-income beneficiaries when presented with evidence that the beneficiary’s information is not accurate. For more information, review the CMS policy.
- Appointment of Representative Form An appointed representative is a relative, friend, advocate, doctor or other person authorized to act on your behalf in obtaining a grievance, coverage determination or appeal. Those not authorized under state law to act for you will need to sign an Appointment of Representative Form and mail or fax it to Customer Service.
- Prior Authorization Criteria (includes the Part B vs. Part D coverage determination information)
- Quantity Limits (Refer to the Comprehensive Formulary for more information)
- Formulary Transition Notice
- Step Therapy Criteria
- Request for Medicare Prescription Drug Coverage Determination Form Need to request an exception to the formulary? This form contains the coverage determination (including exceptions) request form.You or your physician can send a request for a prescription coverage determination or an appeal for a Medicare plan via email by sending the request to the following address: [email protected] Express Scripts, Inc. is a separate company that provides pharmacy services and pharmacy benefit management services on behalf of health plan members.
- Request for Redetermination (Appeal) of Medicare Prescription Drug Denial This form provides basic information to enrollees and prescribers on how to ask for a redetermination from a Medicare drug plan.
- Part D Conditions and Limitations By law, certain types of drugs or categories of drugs are not covered by Medicare Prescription Drug Plans. These drugs or categories of drugs are called “exclusions”.
- Out of Network Prescription Drug Coverage Review the procedures for filling prescriptions outside of the network.
- Quality Assurance (for plans with prescription drug benefits)
- Medication Therapy Management Program (MTMP) Information Please note that this program is not considered a benefit.
- Personal Medication List and Medication Action Plan The Medication Therapy Management Program (MTMP) helps you understand your medications and use them safely. The action plan has steps you should take to help you get the best results from your medications. The medication list will help you keep track of your medications and how to use them the right way.
- Partcipating Medicare Part D Pharmacy Locator
- Anthem Select Advantage (HMO) Prescription Drug Formulary
- Contact Us
Forms for Physicians:
- Medicare Part D Coverage Determination and Prior Authorization Request Form (for use by physicians): This form is used by physicians to provide a supporting statement for an exceptions request or to submit a prior authorization request. A physician can send a request for a prescription coverage determination or an appeal for a Medicare plan via email by sending the request to the following address: [email protected] Express Scripts, Inc. is a separate company that provides pharmacy services and pharmacy benefit management services on behalf of health plan members.
If you are already a member, you can change from your current plan to a new plan, or disenroll from your current plan, by selecting the appropriate form:
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