SeniorCare (Cost) HMO Plan H4564 Application for Coverage - 2012
Apply OnlineBefore proceeding, please read the Summary of Benefits and Evidence of Coverage. You can enroll in a SeniorCare medical plan and an optional SeniorCare Rx Medicare Part D prescription drug plan. You can only enroll in the SeniorCare Rx plan during certain times of the year. If you have questions, please contact Scott & White Health Plan at (1-800-782-5068, Monday - Friday, 8:00 a.m. - 5 p.m. TTY users call 1-800-735-2989).
Download Summary of Benefits
Download Evidence of Coverage
To obtain an application packet:
| Download an application packet.Before proceeding, please read the Summary of Benefits and Evidence of Coverage. You can enroll in a SeniorCare medical plan and an optional SeniorCare Rx Medicare Part D prescription drug plan. You can only enroll in the SeniorCare Rx plan during certain times of the year. If you have questions, please contact Scott & White Health Plan at (1-800-782-5068, Monday - Friday, 8:00 a.m. - 5 p.m. TTY users call 1-800-735-2989). Please print and complete the required forms and mail to a Scott & White Health Plan office near you. | Request an application packet to be mailed to you. | Call 1-800-782-5068 or TTY/TDD users call 800-735-2989 Monday - Sunday, 8 a.m. to 8 p.m. CST, or visit a Scott & White Health Plan office near you. |
After we receive your application, we will send your request for coverage to the Centers for Medicare and Medicaid Services (CMS) for final approval. The process may take six weeks or more. You will be notified in writing regarding your acceptance and starting date for SeniorCare (Cost) HMO plan. Do not cancel any other coverage until you have received confirmation in writing of your acceptance for the SeniorCare (Cost) HMO plan.
You may disenroll by mailing or faxing a signed written notice to a Scott & White Health Plan office or by calling 1-800-Medicare.
To choose a physician or provider, please see our Provider Directory (pdf) or you may select "Find a Provider" to use our interactive search function.
The above information is current as of October 2011.
Medicare-Approved HMO plan
H4564_WEB_SC_APP_2012REV2 CMS Approved 00/00/2011