Plan Documents
Summary of Benefits: This document shows you a list of benefits covered by our plans.
- Alterwood Advantage Select (HMO): 2023 (updated 2/28/2023) | 2024
- Alterwood Advantage Choice (HMO): 2023 (updated 2/28/2023) | 2024
- Alterwood Advantage Choice Plus (HMO): 2023 (updated 2/28/2023) | 2024
- Alterwood Advantage Freedom (HMO): 2023 (updated 2/28/2023) | 2024
- Alterwood Advantage Dual Secure (HMO D-SNP): 2023 (updated 4/25/2023) | 2024
- Alterwood Advantage Dual Value (HMO D-SNP): 2024
Annual Notice of Change: This document tells you the changes to your plan year over year.
- Alterwood Advantage Select: (HMO): 2024
- Alterwood Advantage Choice (HMO): 2023 (updated: 2/28/2023) | 2024
- Alterwood Advantage Choice Plus (HMO): 2023 (updated: 2/28/2023) | 2024
- Alterwood Advantage Freedom (HMO): 2023 (updated: 2/28/2023) | 2024
- Alterwood Advantage Dual Secure (HMO D-SNP): 2023 (updated: 2/28/2023) | 2024
Evidence of Coverage: This document provides detailed plan benefit information, how much you pay, and covers your rights and responsibilities as a member of the plan.
- Alterwood Advantage Select (HMO): 2023 (updated: 2/28/2023) | 2024
- Alterwood Advantage Choice (HMO): 2023 (updated: 2/28/2023) | 2024
- Alterwood Advantage Choice Plus (HMO): 2023 (updated: 2/28/2023) | 2024
- Alterwood Advantage Freedom (HMO): 2023 (updated: 2/28/2023) | 2024
- Alterwood Advantage Dual Secure (HMO D-SNP): 2023 (updated: 2/28/2023) | 2024
- Alterwood Advantage Dual Value (HMO D-SNP): 2024
Over-the-Counter Products & Essential Food Pantry Items Catalog: Members of Alterwood Advantage have a quarterly allowance to order products and items through this catalog. 2023 | 2024
Low Income Subsidy (LIS) Premium Summary Chart: If you get extra help from Medicare, your monthly premium will be lower than what it would be if you did not get extra help from Medicare. 2023 | 2024
Provider & Pharmacy Directory: 2023 | 2024
Plan Forms
Fitness Reimbursement Form: use this form to request a reimbursement for a qualifying service or item under the plan’s fitness benefit. 2023 | 2024
Electronic Funds Transfer (EFT) Form: this allows Alterwood Advantage to withdraw your monthly plan premium from your bank account each month.
Social Security & Railroad Retirement Board Premium Deduction Authorization: use this form to have your monthly plan premium automatically deducted from your Social Security & Railroad Retirement Board check.
Alterwood Advantage Appointment of Representative Form: this forms allows you to appoint an individual to act as your representative for Coverage Decisions and/or Appeals.
CMS Appointment of Representative Form: this forms allows you to appoint an individual to act as your representative for Coverage Decisions and/or Appeals.
Waiver of Liability: this form is for providers that are not in the Alterwood Advantage provider network to complete when filing an appeal with Alterwood Advantage.
Request for Access to PHI: complete this form to request access to your PHI maintained by the plan
Request to Amend or Change PHI: complete this form to amend or change your PHI
Request to Restrict Use & Disclosure of PHI: complete this form to restrict how the plan uses and/or discloses your PHI
Request for Accounting of PHI: complete this form to request for an accounting of how the plan uses and/or discloses your PHI
Part D Forms
Personal Medication List: use this form to keep track of all the medications you take, including over-the-counter drugs, herbals, vitamins, and minerals, and to share it with you provider(s).
Prescription Drug Mail Order Form: use this form to request your maintenance prescription drugs to our mail order pharmacy program and have them conveniently shipped directly to your home. (Spanish version)
Prescription Claim Form: use this form to request a reimbursement for prescription drugs that you paid out-of-pocket. (Spanish version)
Part D Late Enrollment Penalty (LEP) Reconsideration Request Form: if Alterwood Advantage issues a notice of a LEP, you have the right to request a review or reconsideration of a decision to impose an LEP.
Request for Prescription Drug Coverage Determination: use this form to request a prior authorization, tiering exception, or to request coverage for a drug not on our formulary.
Request for Redetermination of Medicare Prescription Drug Denial: if Alterwood Advantage denied your request for coverage of a prescription drug, you have the right to ask us for a redetermination (appeal) of our decision.
Request for Review of Plan Dismissal: if Alterwood Advantage dismissed your request to appeal their initial decision to deny coverage or payment for a prescription drug, you have the right to ask for an independent review of the plan’s decision to dismiss your appeal request.
Request for Reconsideration of Medicare Prescription Drug Denial: if the plan denies your request for coverage or payment of a prescription drug and it was also denied (upheld) upon appeal, you have the right to ask for an independent review of the plan’s decision. (Alterwood Advantage Select form, Alterwood Advantage Choice form, Alterwood Advantage Choice Plus form, Alterwood Advantage Dual Secure form, Alterwood Advantage Dual Value)