2022 Erie Mercer Venango MA Kit

2022 Enrollment Recap Fill out this worksheet and keep it with your important health care coverage papers. My Plan My new plan is (check one):  $0 - HMO No Rx (HMO) (does not include Part D prescription drug coverage)  $0 - HMO Salute (HMO) (does not include Part D prescription drug coverage)  $0 - HMO Premier Rx (HMO)  $22 - HMO Deductible Rx (HMO)  $38 - HMO Rx Choice (HMO)  $81 - HMO Rx (HMO)  $302 - HMO Rx Enhanced (HMO) My preferred plan e ective date is: __ __ /__ __ /__ __ __ __ My plan will provide:  my Medicare health coverage  my Medicare health and Part D prescription drug coverage My plan can change each year. My current plan is e ective from ________ to _________. I can enroll in a di erent plan each year during the Annual Election Period (Oct. 15 – Dec. 7). If I have any questions about my plan or want to make a change, I can call my UPMC for Life Medicare Advisor at ___________________. My Network Check which plan type applies to you:  HMO plan —I must get my care and services from in-network providers. If I get care from out-of-network providers, I may have to pay the full cost unless it is for emergency care, urgent care, or out-of-area dialysis.  PPO plan —I can also use out-of-network providers, but my cost sharing (coinsurance, copays, and deductible) may be higher. My plan is for the area where I live. If I move out of the area, I need to notify the plan so I can disenroll and find a new plan in my new area. My primary care provider, ________________, is currently in the plan’s network. My specialists (listed below) are currently in my plan’s network: ______________________ _______________________ _______________________ Enrollment 125 1010101010101010101010 1100100001001000011001 1000100100001001000000 1010000100100001111111 1010010000100100001000 1000010010000000101011 1001000001010101101000 1001001000010101101101 1100001010101000110000 1100100001111011111011 1000100101110010101110 1010000101100110011101 1010010000001111000000 1000000001011011101011 1001011000100010011000 1001000100111110101101 1100001110111010101000 1100101010000010000011 1000100101011100110010 1010110100101011000001 1100011000100100001000 1111111111111111111111