Medicare Reference Documents

Below are some resources 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.

Sunshine Health Medicare Advantage Plan (HMO) Summary of Benefits by County:

Sunshine Health Medicare Advantage Plan (HMO SNP) Summary of Benefits by County:

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

Sunshine Health Medicare Advantage Plan (HMO) Evidence of Coverage by County:

Sunshine Health Medicare Advantage Plan (HMO SNP) Evidence of Coverage by County:

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 Sunshine Health, this booklet will tell you about changes to your plan’s costs and benefits for the coming year.

Sunshine Health Medicare Advantage Plan (HMO SNP) Annual Notice of Change by County:

Comprehensive Formulary

This is the complete list of prescription drugs covered by Sunshine Health.

Sunshine Health Medicare Advantage Plan (HMO) Formulary by County:

Sunshine Health Medicare Advantage Plan (HMO SNP) Formulary by County:

Other Resources

  • 2017- 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.
  • 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 1-877-935-8022 (TTY: 711) for HMO SNP Members or 1-844-293-2636 (TTY: 711) for HMO members. 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.


Last Updated: 05/03/2017
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