Medicare document library
We try to minimize paperwork. But sometimes you need a form or other information. And when you need it, you want it to be convenient. We have created a document library to give you easy access to the most requested documents.
If you’re a Security Health Plan member, simply log in to your My Security Health Plan account and view your specific plan documents, in the “Coverage and benefits” section.
-
2021 Ally Rx D-SNP Abridged Formulary
A list of the most common prescription drugs available to Ally Rx D-SNP members.
-
2021 Ally Rx D-SNP Annual Notice of Changes
A letter sent in September 2020 to inform members about plan changes effective Jan. 1, 2021
-
2021 Ally Rx D-SNP Comprehensive Formulary
A comprehensive list of all prescription drugs available to Ally Rx D-SNP members
-
2021 Ally Rx D-SNP Customer Guide
A brochure that explains the Ally Rx D-SNP plan, including the costs, benefits and coverage provided beyond Original Medicare
-
2021 Ally Rx D-SNP Drug Prior Authorization List
A list of prescription drugs available to Ally Rx D-SNP members only with prior authorization
-
2021 Ally Rx D-SNP Enrollment form
Use this form to request enrollment in the Ally Rx D-SNP plan
-
2021 Ally Rx D-SNP Evidence of Coverage
The comprehensive booklet that details what services the Ally Rx D-SNP plan covers, what the member pays, and plan rules
-
2021 Ally Rx D-SNP Pre-Enrollment Checklist
An information sheet provided in the Sales Kit to help potential members understand the benefits and rules of the Ally Rx D-SNP plan
-
2021 Ally Rx D-SNP Provider Directory
The list of health care providers in the Ally Rx D-SNP network; prior approval from Security Health Plan is needed to use other providers
-
2021 Ally Rx D-SNP Provider Directory - Addendum
Monthly updates to the list of in-network health care providers and facilities available to Ally Rx D-SNP members
-
2021 Ally Rx D-SNP Summary of Benefits
A summary document that details the services the Ally Rx D-SNP plan covers and what the member pays
-
2021 Delta Dental Comprehensive Certificate
The booklet that details what the comprehensive dental plan covers and what the member pays
-
2021 Delta Dental Preventive Certificate
The booklet that explains the preventive dental coverage provided at no charge to the member
-
2021 Medicare Advantage HMO/D-SNP Star Rating
A sheet that explains the Centers for Medicare and Medicaid Services (CMS) Star Rating achieved by Security Health Plan’s HMO-POS and D-SNP plans
-
2021 Medicare Advantage Member Handbook
“Quick start” guide that explains key benefits and other information to help members use their health plan to the fullest
-
2021 Medicare Advantage Pharmacy Directory
The detailed list of all pharmacies in the network for Security Health Plan’s HMO-POS and D-SNP plans
-
Ally Rx D-SNP Verificación de cobertura de 2021
El folleto completo que detalla lo que cubre el plan Ally Rx D-SNP, lo que paga el miembro y las reglas del plan
-
HIPAA Authorization to Use and Disclose Protected Health Information
Use this form to designate individuals you choose to have access to your health information
-
Medicare Complaint Form
Used to submit a complaint or concern about your Medicare health plan directly to the Centers for Medicare & Medicaid Services
-
Other insurance information
Form to indicate insurance coverage a potential member may have in addition to their Medicare Advantage plan from Security Health Plan
-
Part D Vaccine Reimbursement Request form
Use this form to request reimbursement for vaccines you paid for that are covered under your Part D prescription drug benefits
-
Q & A: Home-delivered meals for members with congestive heart failure
Security Health Plan provides 2 weeks of free meals to members with heart failure after discharge from a hospital or nursing home
-
SilverSneakers Brochure
Flyer that describes the SilverSneakers fitness benefits offered free of charge to Security Health Plan’s HMO-POS and D-SNP members