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(TTY for hearing impaired 711)

8:00 a.m to 8:00 p.m in your local time zone, 7 days a week. Members, please call the number on the back of your Member ID card

2015 SNP Medicare Advantage Plans

TRIBUTE HMO SNP

older woman sitting with healthcare provider

Tribute HMO SNP

Medicare Advantage Special Needs Plans (SNPs) are types of Medicare Advantage Plans designed for people:

  • with certain chronic diseases and conditions or,
  • who have special needs (such as people with both Medicare and Medicaid) or,
  • who live in certain institutions

Medicare Advantage SNPs provide members with all Medicare Part A (Hospital Insurance), Medicare Part B (Medical Insurance) services, and Medicare Prescription Drug coverage (Part D). 

Tribute is a Medicare-approved, $0 premium Special Needs Plan (SNP) offered through SelectCare of Oklahoma and designed to meet the needs of people living in skilled/long-term care facilities in certain counties in South Central Oklahoma. The plan helps to create a nursing facility-based medical program that provides members more care, more often, right where they live. 

Each Tribute member receives routine evaluations and treatment from a Personal Care Team including a Primary Care Physician, and Nurse Practitioner or Physician's Assistant.

Enrollment in a Tribute plan may be taken through an agent, by mail or phone.  Download the application, found below, and follow the instructions to submit your application.  To enroll in Tribute by phone, please speak with a Tribute representative by calling 1-800-817-3515, 8:00 a.m. to 8:00 p.m. in your local time zone (TTY users call 711) 7 days a week.

Medicare beneficiaries may also enroll in Tribute® HMO SNP through the Centers for Medicare & Medicaid Services Online Enrollment Center, located at www.Medicare.gov (by clicking on this link you will be leaving our website). Tribute is offered in Carter, Cleveland, Garvin, Jefferson, Johnston, Love, McClain, Murray, Oklahoma and Stephens counties in Oklahoma.

 

Summary of Benefits pdf icon
Evidence of Coverage pdf icon
Enrollment Form pdf icon
Medical Prior Authorization Request Form pdf icon

Medicare beneficiaries may also enroll in this plan through the CMS Medicare Online Enrollment Center, located at
www.Medicare.gov (by clicking on this link you will be leaving our website)

Provider Directories Provider Directorypdf icon

Medicare Plan Ratings
H3708: Tribute Medicare Plan Ratingspdf icon
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.

Translation Service
Multi-language informationpdf icon

Appointment of Representative form
Once the form is filled out in its entirety, fax it to us at 1-877-907-2982 or call us at 1-866-568-8921 for more information on submitting this formpdf icon to us.

Medicare Complaint Form (by clicking on this link you will be leaving our website)

This plan covers part or all of prescription drugs covered under Medicare Part B; see the Summary of Benefits for specific details. For drugs covered under Medicare Part D, this plan uses a formulary (a list of covered drugs). We have formed a network of pharmacies. To receive plan prescription drug benefits, you must use a network pharmacy, except in non-routine circumstances, and quantity limitations and restrictions may apply.
For the most recent list of drugs please call the number or visit the website listed on the back of your Member ID card.

Part D Prescription Drug Coverage Forms
Medicare Part D Prescription Claim Form pdf icon
Request for Coverage of a Non-Formulary Drug pdf icon
Request for Quantity Limit Exception pdf icon
Request for Step Therapy Exception pdf icon
Request for Lower Co-pay (Tiering Exception) pdf icon
Request for a Medicare Prescription Drug Coverage Determination form pdf icon
To initiate a coverage determination online, please click here (by clicking on this link you will be leaving our website) Request for Medicare Prescription Drug Appeal (Redetermination) form pdf icon
To initiate a redetermination online, please click here (by clicking on this link you will be leaving our website)

Part D Appeals, Grievances, Coverage Decisions and Appeals pdf icon

Pharmacy Directory
Pharmacy Directory pdf icon
We also list pharmacies that are in our network but are outside our coverage area.

Formulary Information
A comprehensive formulary is a list of covered drugs selected by this plan. The formulary may change during the year. We may periodically add, remove, or make changes to coverage limitations on certain drugs or change how much you pay for a drug. If we make any formulary changes that limit our members' ability to fill their prescriptions, we will notify the affected members before the change is made. Read about formulary information pdf icon and any restrictions to the formulary.

Comprehensive Formulary - No changes made since August 2014 pdf icon
Formulary Addendum - Updated August 2014 pdf icon
Apéndice del Formulario - Updated August 2014 pdf icon

Upcoming Formulary Changes
We will notify you of a formulary change at least 60 days before the date that the change becomes effective. However, if the Food and Drug Administration (FDA) deems a drug on our formulary to be unsafe, or if the drug's manufacturer removes the drug from the market, we will immediately remove the drug from the formulary.

Medication Therapy Management Program
Medication Therapy Management (MTM) Programs pdf icon

Prior Authorization and Step Criteria
Prior Authorization Criteriapdf icon
Step Therapy Criteria pdf icon

Transition Policy
Transition Policy pdf icon
View a sample Transition Letter pdf icon

Low Income Subsidy Premium Table
This chart pdf icon shows what you might expect to pay for your plan premium if you qualify for 100%, 75%, 50% or 25% Extra Help as a member. Note: the premiums listed in the chart are for both medical services and prescription drug benefits.


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Enrollment disclaimer information:
You must continue to pay your Medicare Part B premium. The benefit information provided is a brief summary, not a complete description of benefits. For more information contact the plan. Limitations, copayments, and restrictions may apply. Benefits, formulary, pharmacy network, provider network, premium and/or co-payments/co-insurance may change on January 1 of each year. This plan is available to anyone with Medicare who meets the Skilled Nursing Facility (SNF) level of care and resides in a nursing home.