Medicare Reference Documents

The documents and links below may be helpful at different times during your membership:

Summary of Benefits (SB)

This booklet gives you a summary of costs and coverage in your plan. The complete list of services, limitations and exclusions is included in the Evidence of Coverage.

Superior HealthPlan Medicare Advantage (HMO) Summary of Benefits by County:

Superior HealthPlan Medicare Advantage (HMO SNP) Summary of Benefits:

Evidence of Coverage (EOC)

  • Out-of-Network Coverage Rules: Chapter 3
  • Exclusions & Limitations: Chapter 4, Section 3
  • Prior Authorization: Chapter 3 (medical) and Chapter 5 (prescription drug)
  • Appeals & Grievances: Chapter 9
  • Disenrollment: Chapter 10

Superior HealthPlan Medicare Advantage (HMO) Evidence of Coverage by County:

Superior HealthPlan Medicare Advantage (HMO SNP) Evidence of Coverage:

Prescription Drug Mail Order Form

Use this order form to enroll and receive prescription drugs by mail.

Annual Notice of Change (ANOC)

If you are already a member of Superior HealthPlan, this booklet will tell you about changes to your plan’s costs and benefits for the coming year.

Superior HealthPlan Medicare Advantage (HMO SNP) Annual Notice of Change:

Comprehensive Formulary

This is the complete list of prescription drugs covered by Superior HealthPlan.

Superior HealthPlan Medicare Advantage (HMO) Formulary by County:

Superior HealthPlan Medicare Advantage (HMO SNP) Formulary:

Other Resources

  • Best Available Evidence (BAE)
    • This is a CMS policy that allows for changes to cost-sharing for low-income beneficiaries when there is evidence that information from a beneficiary is not up-to-date or accurate.

Call Member Services at 1-844-796-6811 (for HMO) or 1-877-935-8023 (for HMO SNP) (TTY: 711) help if you have questions. October 1 – February 14, 7 days a week, 8 a.m. to 8 p.m.; February 15 – September 30, Monday – Friday, 8 a.m. to 8 p.m. On weekends and holidays, an automated system will handle your call.


Last Updated: 05/03/2017
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