Enrolling in Priority Health Medicare Advantage plans

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Enrollment materials

Summary of Benefits (642KB PDF)*
Form number: H2320_1001_1012_18 CMS-approved 09142011
Summary of covered services, including copays

Primary Care Provider list (771KB PDF)*
Form numbers: Y0056_9000_9000_19 CMS 09132011
Primary care doctors who are in the Priority Health Medicare network

2012 Medicare Formulary (979MB PDF)
Form number: Y0056_5000_5003_14 File and Use 08122011
An index by drug name begins on page 67.

Enrollment form, instructions and checklist (282KB PDF)*
Form numbers: Y0056_2000_2001_27 CMS-approved 09142011; Y0056_1009_1009_63 File and Use 080820110
You can also enroll online on this website or by phone at 888 389-6676, from 8 a.m. to 8 p.m., 7 days a week. TTY users should call 711.

Automatic Bill Payment set-up form (72KB PDF)
Use this form to sign up to have your premiums automatically deducted from your bank account by electronic funds transfer (EFT).
You can also sign up online when you use the online enrollment form. (coming soon)

Appeals and Grievances flyer (97KB PDF)*
Form number: Y0056_1009_1009_52 File and Use 09272010

Notice of Privacy Practices (91KB PDF)*

Centers for Medicare and Medicaid (CMS) Plan ratings (63KB PDF)*
Form numbers: H2320_9000_9004_4 File and Use 10182011; H4875_9000_9004_5 File and Use 10182011

Enhanced Dental option documents

Summary of Benefits (130KB PDF)
Form number: Y0056_1009_1009_83 File and Use 10032011

Enhanced Dental plan enrollment form (227KB PDF)
Form number: Y0056_2000_2001_29 CMS approved 09202011
You can also enroll online.

Three ways to enroll

• By phone - speak to one of our Medicare experts at 888 389-6676, from 8 a.m to 8 p.m., 7 days a week. TTY users should call 711.
• Online - by going to "Compare plans" and choosing the plan you want.
• Mail - print and fill out the paper enrollment form above and mail it to: Priority Health, MS 1175, 1231 E. Beltline, Grand Rapids, MI 49525.

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