Medicare Reference Documents
On January 1, 2018, our plan name will change from Bridgeway Health Solutions Medicare Advantage to Allwell from Health Net.
Below are some resources that you may need specifically for Arizona. These are documents that may be helpful at different times during your membership:
Summary of Benefits (SB)
This booklet gives you a summary of costs and coverage in your plan. The complete list of services, limitations and exclusions are included in the Evidence of Coverage.
Evidence of Coverage (EOC)
- Out-of-Network Coverage Rules: Chapter 3
- Exclusions & Limitations: Chapter 4, Section 3
- Prior Authorization: Chapter 3 (medical) and Chapter 5 (prescription drug)
- Appeals & Grievances: Chapter 9
- Disenrollment: Chapter 10
Prescription Drug Mail Order Form
Use this order form to enroll and receive prescription drugs by mail.
Annual Notice of Change (ANOC)
If you are already a member of Bridgeway Health Solutions, this booklet will tell you about changes to your plan’s costs and benefits for the coming year.
This is the complete list of prescription drugs covered by Bridgeway Health Solutions.
- 2017- Provider & Pharmacy Directory Information
- This is an introduction to the provider and pharmacy directory, including an explanation of the provider symbols found in the directory.
- 2017- Personal Health Information (PHI) Authorization Form-
- Use this form when you want to allow Bridgeway Health Solutions to share your health information with a person or group.
- 2017- Personal Health Information (PHI) Revocation Form
- Use this form when you want to cancel or revoke your previous permission to share health information with a person or group.
- 2017- Appointing a Representative Form
- Use this form to name a person to act as your representative. Must be completed by you and accepted by the person you appoint.
- 2017- Multi-Language Interpreter Services
- We have free interpreters to answer questions in multiple languages: 1-877-935-8020.
- File a complaint directly with CMS
- Submit feedback about your Medicare plan directly to Medicare.gov.
- Stop Medicare Fraud, Waste and Abuse
- Learn how to identify, prevent and report Medicare fraud, waste or abuse.
- Office for Civil Rights
- The OCR protects your health information privacy rights and right to nondiscrimination.
- The Office of the Medicare Ombudsman (OMO)
- The Medicare Beneficiary Ombudsman helps you with Medicare-related complaints, grievances, and information requests.
- Best Available Evidence (BAE)
- This is a CMS policy that allows for changes to cost-sharing for low-income beneficiaries when there is evidence that information from a beneficiary is not up-to-date or accurate.
Call Member Services at 1-877-935-8020 (TTY: 711) for help if you have questions. From October 1 to February 14, you can call us 7 days a week from 8 a.m. to 8 p.m. From February 15 to September 30, you can call us Monday through Friday from 8 a.m. to 8 p.m. On weekends and holidays, an automated system will handle your call.
Doctor Visit Forms
Need help at the doctor's office?
Visiting the doctor’s office can be difficult when you are trying to remember the details of your medical needs and health concerns over a period of time. With the amount of paperwork to fill out and questions to answer, it can be hard to make sure you are able to tell your doctor exactly what the problems are.
Don’t wait until you get to the doctor’s office to start thinking of the reasons for your appointment. Try these helpful doctor visit guides from Bridgeway Health Solutions to learn what to expect and prepare to ask your own questions about your medications, treatment options, warning signs, health tips and diet needs.
These helpful guides include details about common medical issues, so you’ll be ready to talk to your doctor about your issue, find out the information you need, and better understand what to expect from your visit.
- Click on any of the forms listed below
- Print out the form you need
- Fill in the answers before your appointment
- Take it with you to the doctor
These helpful doctor visit guides can be useful when you're being seen for any of the following conditions:
Last Updated: 09/30/2017