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2018 Golden State Medicare Gold (HMO) Plan Documents

The following information is for the plan year effective January 1, 2018. Click on the PDF links for details.

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Annual Notice of Change / Evidence of Coverage (LA/OC/Riv/Stan)
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Annual Notice of Change / Evidence of Coverage (San Luis Obispo)
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Annual Notice of Change / Evidence of Coverage (Contra Costa)
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Summary of Benefits (LA/OC/Riv/Stan)
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Summary of Benefits (San Luis Obispo)
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Summary of Benefits (Contra Costa)
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Enrollment Form & Instructions (LA/OC/Riv/Stan/SLO)
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Enrollment Form & Instructions (Contra Costa)
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Provider & Pharmacy Directory (LA/OC)
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Provider & Pharmacy Directory (Riverside)
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Provider & Pharmacy Directory (Stanislaus)
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Provider & Pharmacy Directory (San Luis Obispo)
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Pharmacy & Provider Directory (Contra Costa)
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Grievance Process
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Organization Determination
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Privacy Notice
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Appeals Process
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Multi-Language Insert
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Plan Ratings (English)
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Request for Reconsideration of Medicare Prescription Drug Denial
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Ending Your Membership in the Plan
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Part D Late Enrollment Penalty Reconsideration Notice

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Please refer to the Evidence of Coverage document for detailed information on the following topics: Description of Part D Drug coverage, Exceptions to our network coverage, Mail-Order service, Long-term supply of drugs, Cost sharing tiers, Restrictions, Coverage changes, Formulary updates, Drug safety, Drugs not covered by the plan, Drug payment stages, Explanation of Benefits, Drug Costs, Coverage Gap, Catastrophic Coverage, Vaccine Coverage, Late Enrollment Penalty, Grievance, Coverage Determinations and Appeals, Medication Therapy Management (MTM) program, Contract termination, Member rights and responsiblities. This information is available for free in other languages. Please contact our customer service number at (877) 541-4111 or TTY at (877) 551-4111 from 8 am to 8 pm Monday through Friday and daily during the enrollment period. This information is available for free in other languages. Please contact our customer service number at (877) 541-4111 or TTY at (877) 551-4111 from 8 am to 8 pm Monday through Friday, and every day during the registration period. This document may be available in an alternate format such as Braille, larger print or audio.


CMS Links

Medicare and You 2018
Best Available Evidence (BAE) / Low Income Subsidy (LIS)
Please click to go to the CMS forms webpage for the following documents:

Appointment of Representative Form CMS -1696 (English)

If a beneficiary would like to appoint a person to file, request a coverage determination or exception, or request an appeal on his or her behalf, the beneficiary and the person accepting the appointment must fill out this form (or a written equivalent) and submit it with the request. (See the link in "Related Links" section).

Part D Late Enrollment Penalty Reconsideration Request Form
Medicare Part D Appeals