Healthy Advantage (HMO) Medicare -
Enrollment Form & Instructions

Healthy Advantage (HMO) is a Medicare Advantage Prescription Drug Special Needs Plan (MAPD-SNP) offered by University Health Plans, in partnership with Molina Healthcare, who has a Medicare contract. All Medicare beneficiaries enrolled in Medicare Part A and Part B and enrolled in full Medicaid may apply. You may enroll at any time during the year.

Please click here* to download a printable copy of the enrollment form. Please follow the instructions on the form to apply. We encourage you to read the Summary of Benefits before completing an enrollment form.

If you need help enrolling, please call us at 1-866-472-9479 (TTY/TDD 1-800-346-4128) from 8:00 a.m. to 8:00 p.m. (local time)
Monday - Sunday

To be eligible for Healthy Advantage (HMO) Medicare you must meet the following requirements:

  • You must live in Davis, Salt Lake, Utah or Weber County.
  • You must be enrolled in Medicare Part A (hospital insurance) and enrolled in Medicare Part B (medical insurance), and continue to pay your Medicare Part B premium (and Part A if applicable), if not paid for by another third party.
  • Not have end-stage renal disease (ESRD) unless you are currently a member with Healthy Advantage (HMO) Medicare or if your previous Medicare Advantage Plan was terminated. An individual who receives a kidney transplant and no longer requires a regular course of dialysis to maintain life is not medically determined to have ESRD.
  • You must also be a state Medicaid recipient receiving full Medicaid benefits.

Once you know you are eligible for Healthy Advantage (HMO) Medicare please Contact a plan representative by calling
1-866-472-9479 (TDD/TTY: 1-800-665-0898) Monday through Sunday, 8 am to 8 pm (local time), to set up an appointment for a representative to visit you in your home or make a reservation to attend a seminar in your area.


Members must receive all routine care from Healthy Advantage (HMO) plan providers. The Healthy Advantage (HMO) Medicare Prescription Drug Benefit is only available to members of the plan and you must receive your drug benefit through Healthy Advantage (HMO), not another organization. Healthy Advantage’s contract with CMS is renewed annually and availability of coverage beyond the end of the current contract year is not guaranteed.

You may qualify for financial assistance to help with the payment of your prescription drug premiums and costs. To see if you qualify for getting extra help, call:

Medicare:
1-800-MEDICARE 1-800-633-4227 TDD/TTY users should call 1-877-486-2048, 24 hours a day/7days a week.

Social Security Administration:
1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTD/TTY users should call 1-800-325-0778.

Or, the Utah State Medicaid Office:
1-801-538-6155 (Salt Lake City area)
1-800-662-9651 (other parts of the state),
(TTY/TDD: not available)
Monday - Wednesday, 7 a.m. - noon and 1 - 6 p.m. and
Thursday 11 a.m. - 2 p.m.
www.health.utah.gov/medicaid

Paper copies of information posted on our web site are available upon request.

Healthy Advantage (HMO) is a Medicare Advantage Prescription Drug Special Needs Plan (MAPD-SNP) offered by University Health Plans, in partnership with Molina Healthcare, who has a Medicare contract.

*Adobe Acrobat Reader is required to view the file(s) above. Downdload a free version.