Medicare Reference Documents

Listed below are some documents that may be helpful at different times during your membership.  

Can't find what you need?  Call Member Services.  We are here to help!

This booklet gives you a summary of costs and coverage in your plan. 

Please select the document for your plan and county:

For HMO SNP Members:  

County  Summary of Benefits

Lane county

  • English- Summary of Benefits
  • Espanol- Summary of Benefits    

This booklet gives you a complete list of services, limitations and exclusions for your plan coverage.

Please select the document for your plan and county:

For HMO SNP Members:  

County  Evidence of Coverage

Lane county

  • English- Evidence of Coverage
  • Espanol- Evidence of Coverage

HMO Reconsideration Form 

HMO SNP Redetermination Form 

HMO SNP Redetermination Form 

HMO Reconsideration Form 

If you were enrolled in Trillium Medicare Advantage last year, this booklet will tell you about changes to your plan’s costs and benefits for the coming year.

Please select the document for your plan and county:

For HMO SNP Members:  

County  ANOC

Lane county

  • English- ANOC
  • Espanol- ANOC



This is the complete list of prescription drugs covered by Trillium Medicare Advantage.

Please select the document for your plan and county:

For HMO SNP Members:  

County  Formulary

Lane county

  • English- Formulary
  • Espanol- Formulary

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 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.

  1. Click on any of the forms listed below
  2. Print out the form you need
  3. Fill in the answers before your appointment
  4. 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:

  • Asthma
  • Coronary Artery Disease
  • Diabetes
  • High Blood Pressure
  • High Cholesterol
  • Weight Management

Use this form to enroll and receive prescription drugs by mail.

Please select the form for your plan. 

  • English HMO SNP Form Ɩ Espanol HMO SNP Formulario

This is an introduction to the provider and pharmacy directory, including an explanation of the provider symbols found in the directory.

Visit our Find a Doctor page to learn more. 

  • 2018 - PHI Authorization Form
    • Use this form when you want to allow Allwell to share your health information with a person or group.
  • 2018- PHI Revocation Form
    • Use this form when you want Allwell to cancel or revoke your previous permission to share health information with a person or group.
  • 2018 - Appointing a Representative
    • Use this form to name a person to act as your representative. Must be completed by you and accepted by the person you appoint.
  • 2018 - Multi-language Interpreter Services
    • We have free interpreters to answer questions in multiple languages. Call Member Services.
  • 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.

Take a look at the below Beginner's Guide to Medicare booklet.  Our Medicare guide will give you a solid foundation for understanding the basics of Medicare and available options you have as a new Medicare beneficiary.

If you have any questions or need assistance, call us.  We are here to help!

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Last Updated: 05/04/2017
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