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Allowance amounts cannot be combined with other benefit allowances. Limitations and restrictions may apply. Allowance benefits vary by plan, insurance carrier, and geography.

Federal Contracting Statement (FCS) Disclaimer: Participating sales agencies represent Medicare Advantage HMO, PPO, PFFS, and SNP organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan’s contract renewal.

Participating sales agencies represent Medicare Advantage HMO, PPO, PFFS, and SNP organizations and stand-alone PDP prescription drug plans that are contracted with Medicare. Enrollment depends on the plan’s contract renewal.

TPMO Disclaimer: We do not offer every plan available in your area. Currently we represent [insert number of organizations] organizations which offer [insert number of plans] products in your area. Please contact Medicare.gov or 1–800–MEDICARE to get information on all of your options. 1-800-MEDICARE (TTY users should call 1-877-486-2048), available 24 hours a day/7 days a week.

Year Round: Enrollment in a plan may be limited to certain times of the year unless you qualify for a Special Enrollment Period or you are in your Medicare Initial Enrollment Period.

Submitting this form does NOT affect your current enrollment, nor will it enroll you in a Medicare Advantage Dual-Eligible Special Needs Plan, Medicare Prescription Drug plan, Medicare Supplement Plan, or any other Medicare plan. Quote Source is independent of the Medicare program and is neither associated with nor endorsed by The Centers for Medicare & Medicaid Services (CMS) or any other governmental agency.

If you are paying Medicare Part B premium, you must continue to pay it to maintain coverage.

Allowance amounts cannot be combined with other benefit allowances. Limitations and restrictions may apply. Allowance benefits vary by plan, insurance carrier, and geography.

Not all plans offer all of these benefits. Benefits may vary by carrier and location. Limitations and exclusions may apply.

This information is not a complete description of benefits. Contact the plan for more information.

Limitations, copayments, and restrictions may apply.

Benefits, premiums and/or copayments/coinsurance may change on January 1 of each year.

For [Humana], [UnitedHealthcare®], [Aetna], [HealthSpring℠], [Anthem Blue Cross and Blue Shield], [Devoted], and [Zing]. *Benefit(s) [This spending allowance] is a special program for members with specific health conditions. Qualifying conditions include: Diabetes mellitus, Cardiovascular disorders, Chronic and disabling mental health conditions, Chronic lung disorders, Chronic heart failure, chronic high blood pressure, chronic high cholesterol, Hypertension, Hyperlipidemia, Cancer, and/or among others. In some plans, Transportation benefit may be for health related trips only. This is not a complete list of qualifying conditions. Some plans require at least two conditions and other requirements apply. See the plan's Evidence of Coverage for details. Having a qualifying condition alone does not mean you will receive the benefit(s). Other requirements may apply. [If you use this program for rent or utilities, Housing and Urban Development (HUD) requires it to be reported as income if you seek assistance. Contact your local HUD office if you have questions.]. Contact us to confirm your eligibility for these benefits.

For [Wellcare]: Benefits mentioned are a part of Special Supplemental Benefits for the Chronically Ill. Not all members will qualify. In addition to being high-risk, you must have one or more of the following chronic conditions: cancer, cardiovascular disorders, chronic and disabling mental health conditions, chronic lung disorders, diabetes. There are other eligible conditions not listed. Eligibility for this benefit cannot be guaranteed based solely on your condition. All applicable eligibility requirements must be met before the benefit is provided. For details, please contact us or see the plan’s Evidence of Coverage/Member Handbook.

*[This spending allowance] [Extra Debit] [Chronic Condition Care Assistance] [Music Therapy] is a special program for members with specific health conditions. Qualifying conditions include diabetes mellitus, cardiovascular disorders, chronic and disabling mental health conditions, chronic lung disorders, or chronic heart failure, among others. Some plans require at least two conditions and other requirements apply. See the plan's Evidence of Coverage for details. [If you use this program for rent or utilities, Housing and Urban Development (HUD) requires it to be reported as income if you seek assistance. Contact your local HUD office if you have questions.] 

*[This spending allowance] is a special supplemental benefit for members with specific chronic conditions who require intensive care coordination and are at a high risk for hospitalization or other adverse health outcomes. Qualifying conditions may include diabetes mellitus, cardiovascular disorders, chronic and disabling mental health conditions, chronic lung disorders, or chronic heart failure, among others. Some plans require at least two conditions. [See the plan's Evidence of Coverage/Member Handbook for details.] [If you use this program for rent or utilities, Housing and Urban Development (HUD) requires it to be reported as income. Contact your local HUD office with questions.]

The Food & Home Card is a special supplemental benefit offered on certain plans, and available only to chronically ill members with conditions like diabetes, chronic heart failure, cardiac arrhythmias, coronary artery disease, or peripheral vascular disease; qualifying conditions vary by plan. All applicable plan coverage criteria must be met and other conditions are eligible. Not all members qualify.

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* Not connected with or endorsed by the United States government or the federal Medicare program.

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