Plan Material and Forms

At Community Health Choice, we’re always here to help you make smart decisions about your health—including finding the right health plan to best suit your needs and information to help you navigate your policy.

On this page, you will find downloadable documents for this year’s Community Health Choice (HMO D-SNP) plan.

Questions?

Call 1.833.276.8306
(TTY users should call 711)

October 1 to March 31, 8:00 am to 8:00 pm, 7 days a week and April 1 through September 30, Monday through Friday, 8:00 am to 8:00 pm.

On certain holidays your call will be handled by our automated phone system.

Pre-enrollment Checklist

In this Medicare checklist, we outline the seven steps you’ll want to check off your to-do list before deciding what best fits your Medicare needs and how to properly become a Medicare beneficiary.

Summary of Benefits

The Summary of Benefits outlines your plan benefits for the current calendar year.

Please click on the links below download a PDF copy.

Please call Member Services if you would like a hard copy of the Summary of Benefits mailed to you.

Evidence of Coverage

The Evidence of Coverage (EOC), along with your enrollment form, is Community’s contract with you. These documents explain your rights, benefits, and responsibilities as a Member of Community Health Choice (HMO D-SNP).

Please click on the links below download a PDF copy.

Please call Member Services if you would like a hard copy of the EOC mailed to you.

Provider Directory

The Provider Directory outlines your plan’s network of primary care physicians, specialists, hospitals, skilled nursing facilities, outpatient mental health Providers, DMEs, dental, and vision Provider contacts.

Please click on the links below download a PDF copy.

Please call Member Services if you would like a hard copy of the directory mailed to you.

How to Cancel or Leave the Plan

You can change health plans only at certain times during the year. From October 15 – December 7, you can join, switch or drop a Medicare health or drug plan for the following year.

How to Cancel or Leave the Plan

Pharmacy Directory

The Pharmacy Directory provides a list of your plan’s network pharmacies.

Please click on the links below download a PDF copy.

Please call Member Services if you would like a hard copy of the directory mailed to you.

Community Health Choice (HMO D-SNP)

Am I Eligible

Community Health Choice (HMO D-SNP)

Community Spotlight Blog

Frequently Asked Questions

Low Income Subsidy (LIS)

Ready to Enroll

Service Area

FInd a doctor or pharmacy

Find a Doctor or Pharmacy

Nations Hearing Benefit

Drug and Pharmacy Information

Drug List (Formulary)

Medication Therapy Management

Medicare Prescription Payment Plan (MPPP)

Over the Counter (OTC)

Prescription Drug Transition Policy

Real-Time Benefit Tool

Plan Material and Forms

Evidence of Coverage

How to Cancel or Leave the Plan

How to Appoint a Representative

Papa Pals

Pharmacy Directory

Pre-enrollment checklist

Provider Directory

Pyx Health

Summary of Benefits

Member Rights & Forms

Appeals and Grievance

CMS Appointment of Representative Form

Determination/Redetermination Forms

Direct Member Reimbursement (DMR) Form

Legal Disclaimer

Member Rights and Responsibilities

Prior Authorization Forms

Quality Assurance Policy

For Medicare Members

H9826_IT_10045_092919_M Last updated October 15, 2024

Why Choose Community?

As a local nonprofit health plan, Community Health Choice gives you plenty of reasons to join our Community. From the benefits and special programs we offer to the way our Member Services team helps you make the most of them, Community is always working life forward for you and your family.

“Community Health Choice is always there to answer my questions and help me and my family with our medical needs. I truly appreciate and value their customer support and service.”
– Cecily
Member of Community Health Choice