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Y0020_WCM_178064E_M
Last Updated On: 11/10/2025
This document includes any changes in coverage, costs or service area between your previous and current plan year.
This document provides some of the features of this plan. For a complete list of benefits, see your Evidence of Coverage.
This document includes a legal, detailed description of your benefits and costs as a member.
Use this form to enroll in a Prescription Drug Plan.
Star Ratings judge how well Medicare health and drug plans perform in different categories. They are distributed by Medicare. Medicare evaluates plans based on a 5-Star rating system. Star Ratings are calculated each year and may change from one year to the next.
If you speak a language other than English, free language assistance services are available to you. Appropriate auxiliary aids and services to provide information in accessible formats are also available free of charge. Call 1-877-374-4056 (TTY: 711).
This document includes information about multi-language interpreter services for speakers of Arabic, Chinese Cantonese, Chinese Mandarin, French Creole, French, German, Hindi, Italian, Japanese, Korean, Polish, Portuguese, Russian, Spanish, Tagalog, and Vietnamese.
Each member requesting to be disenrolled must complete their own form.