Member Materials and Forms

Here you can find important documents about your Senior Whole Health plan. Click the links below to download each document.


Summary of Benefits:
a summary of what we cover and what you pay. For a complete list of covered services and exclusions, refer to your Evidence of Coverage below.

download arrow 2022 Summary of Benefits - Senior Whole Health Medicare Complete Care (HMO D-SNP)


Evidence of Coverage (EOC):
your Medicare health benefits and services and prescription drug coverage as a member of Senior Whole Health Medicare Complete Care (HMO D-SNP).

download arrow 2022 Evidence of Coverage (EOC) - Senior Whole Health Medicare Complete Care (HMO D-SNP)


Formulary:
a list of the drugs covered in this plan. To see what’s covered, visit our Pharmacy and Prescription Drugs page.


Low Income Subsidy (LIS) Premium Summary Chart: If you qualify for extra help, Low Income Subsidy (LIS), to pay for your prescription drug costs, Medicare could also pay 75% or more of your Plan Premium, annual deductibles and co-insurance (if applicable). To qualify in 2021, your yearly income is limited to $7,970 for an individual or $11,960 for a married couple living together.

download arrow 2022 LIS Chart - Senior Whole Health Medicare Complete Care (HMO D-SNP)


Mail Order Prescription Service Notice:
we’d like to offer you a way to save time and money with Senior Whole Health’s mail order prescription service.

download arrow 2022 Mail Order Prescription Service Notice


Provider/Pharmacy Directory:
a list of your plan’s current network providers and pharmacies.

download arrow 2022 Provider/Pharmacy Directory - Senior Whole Health Medicare Complete Care (HMO D-SNP)

Find a provider or pharmacy online here.

download arrow View 2022 Provider/Pharmacy Directory Information:

  • Senior Whole Health Medicare Complete Care (HMO D-SNP)

If you would like to request a printed copy of this directory, please call Member Services or email us at CentralizedOps.Medicare@MolinaHealthcare.com.


Medicare Quick Start Guide:
A simple tool for new members to explain what you need to know, things you should do now and what to expect to get the most from your health plan.

download arrow 2022 Medicare Quick Start Guide - Senior Whole Health Medicare Complete Care (HMO D-SNP) (Coming Soon)


Member ID Card

You will receive your Member ID Card after your enrollment is confirmed

While you are a member, you must use your membership card whenever you get any services covered by this plan. It is also to be used for prescription drugs you get at network pharmacies.

If your plan membership card is damaged, lost, or stolen, you can request for a new card on your My Senior Whole Health portal.

ID Card Sample

 

Member Forms

Click on the links below to access important member forms.

Appointment of Representative Form (CMS-1696) – An appointed representative is a relative, friend, advocate, doctor or other person authorized to act on your behalf in obtaining a grievance, coverage determination or appeal.

download arrow Appointment of Representative Form (CMS-1696)

If you would like to appoint a representative, you and your appointed representative must complete this form and mail it to Senior Whole Health at:

Senior Whole Health
7050 Union Park Center, Suite 200
Midvale, UT 84047


Coverage Determination Request Form
 – Use this form to request coverage for a drug that is not on the formulary (a formulary exception), an exception to a quantity limit, a lower copayment for a drug on the formulary (a tiering exception) or reimbursement for a covered drug that you purchased at an out-of-network pharmacy.

download arrow Senior Whole Health

Complete this form and mail or fax to:

Mail:     Senior Whole Health
7050 Union Park Center, Suite 200
Midvale, Utah 84047

Fax:       (866) 290-1309 

You may also submit your Coverage determination request form online here.


How to Request a Redetermination 
- Please read this document to understand what you need to do to request an appeal

download arrow Senior Whole Health


Redetermination Form
 - Use this form to request a redetermination (appeal).

download arrow Senior Whole Health

Complete this form and mail or fax to:

Mail:     Senior Whole Health
7050 Union Park Center, Suite 200
Midvale, Utah 84047

Fax:       (866) 290-1309

You may also submit your Redetermination request form online here.


Direct Member Reimbursement Form 
- Use this form to request a reimbursement for something you have paid out of pocket but believe should have been covered by your plan.

download arrow Senior Whole Health

 

Grievance and Appeal forms

Medicare.gov Complaint Form


Advance Directives Information Sheet:
provides insight on Advance Directives.

download arrow Advance Directives Information Sheet (Coming Soon)

 

Member Newsletters

Created especially for Senior Whole Health members. This important health news can help keep you and your family healthy.

Coming Soon

 

For more information or if you have questions, please call Member Services.

*Printed copies of information posted on our website are available upon request.