2022 Lycoming Tioga 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 Premier Rx (HMO)  $22 - HMO Deductible Rx (HMO)  $38 - HMO Rx Choice (HMO)  $81 - HMO Rx (HMO)  $302 - HMO Rx Enhanced (HMO)  $0 - PPO Flex Rx (PPO) 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 133 1010101010101010101010 1100100001001000011001 1000100100001001000000 1010000100100001111111 1010010000100100001000 1000010010000000101011 1001000001010101101000 1001001000010101101101 1100001010101000110000 1100100001111011111011 1000100101110010101110 1010000101100110011101 1010010000001111000000 1000000001011011101011 1001011000100010011000 1001000100111110101101 1100001110111010101000 1100101010000010000011 1000100101011100110010 1010110100101011000001 1100011000100100001000 1111111111111111111111