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Information from your health plan about COVID-19 (coronavirus disease)

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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.

    Download

  • 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

    Download

  • 2021 Ally Rx D-SNP Comprehensive Formulary

    A comprehensive list of all prescription drugs available to Ally Rx D-SNP members

    Download

  • 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

    Download

  • 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

    Download

  • 2021 Ally Rx D-SNP Enrollment form

    Use this form to request enrollment in the Ally Rx D-SNP plan

    Download

  • 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

    Download

  • 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

    Download

  • 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

    Download

  • 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

    Download

  • 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

    Download

  • 2021 Delta Dental Comprehensive Certificate

    The booklet that details what the comprehensive dental plan covers and what the member pays

    Download

  • 2021 Delta Dental Preventive Certificate

    The booklet that explains the preventive dental coverage provided at no charge to the member

    Download

  • 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

    Download

  • 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

    Download

  • 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

    Download

  • 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

    Download

  • HIPAA Authorization to Use and Disclose Protected Health Information

    Use this form to designate individuals you choose to have access to your health information

    Download

  • Medicare Complaint Form

    Used to submit a complaint or concern about your Medicare health plan directly to the Centers for Medicare & Medicaid Services

    Download

  • Other insurance information

    Form to indicate insurance coverage a potential member may have in addition to their Medicare Advantage plan from Security Health Plan

    Download

  • 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

    Download

  • 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

    Download

  • SilverSneakers Brochure

    Flyer that describes the SilverSneakers fitness benefits offered free of charge to Security Health Plan’s HMO-POS and D-SNP members

    Download

Security Health Plan and its agents are not in any way connected with the Medicare program.
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