2020 umha healthy rewards program book · earning your . reward card is easy. 1. call your doctor...

2020 Healthy Rewards Program

H8854_20_DRS_2023_OE_M DRS: 09/11/2019

Reward yourself with $15 reward cards for completing select preventive screenings and exams.

The start to a healthier and happier you.

At University of Maryland Health Advantage, we believe that preventive care plays an important role in staying healthy.

That is why we encourage you to participate in our Healthy Rewards Program for a healthier and happier you!

Earn a $15 reward card when you complete any of these screenings or exams.

• Health Risk Assessment

• Annual Wellness Visit

• Annual Flu Shot

• Post-Hospitalization Physician Visit

• Colorectal Cancer Screening

• Mammogram (Breast Cancer Screening)

• Diabetes HbA1c and Urine Protein

Screening (Microalbumin)

• Diabetic Retinal Eye Exam

A Foreign Transaction Fee of 3% of the purchase value is charged for foreign transactions. If your card is lost or stolen, a $5 Replacement Card Fee will be charged to replace your card. The OmniCard Visa Reward Card is issued by MetaBank®, Member FDIC, pursuant to a license from Visa U.S.A. Inc.

Earning your reward card is easy.

1

Call your doctor to schedule the

preventive screening, exam, or vaccination you need. If you prefer, we can assist you in scheduling your visit, just call our Member Services

number.

2

Take this booklet with you to your

appointment.

3

During your appointment, ask

the doctor or office staff to fill out, sign and date the form that relates to that

appointment.

4

Write your full name

and member identification

number (located on the front of

your member ID card) on the form.

5

Ask the office staff to fax the

completed form to University of

Maryland Health Advantage at

410-779-3957.

Your reward card will arrive in the mail within six (6) to eight (8) weeks after we receive the completed form from your doctor. Reward cards cannot be used to buy tobacco or alcohol. Reward cards cannot be converted to cash. You can only receive one (1) reward card per applicable service.

Member Services: 410-779-9932 (TTY: 711)

or toll free 1-844-386-6762 8 am - 8 pm EST | 7 days a week | October 1 - March 31

8 am - 8 pm EST | Monday - Friday | April 1 - September 30

2020 Health Risk Assessment

Health Risk Assessments (HRAs) are used to help identify any health risks that could impact your health. After you answer each question, your case manager at University of Maryland Health Advantage will use this and other health information to create a care plan personalized to your health care needs. University of Maryland Health Advantage mails the care plan to you and your Primary Care Provider (PCP). The care plan includes goals and actions for you to improve your health. University of Maryland Health Advantage encourages you to talk to your PCP about your care plan at every visit. To receive this reward, members must complete the HRA within the first 90 days of their enrollment with the plan, and/or annually there after. You complete this assessment in your own home. You do not have to go to the doctor to do it. There are two (2) ways to take the assessment:

1

Take it over the phone. Call 1-844-486-6762 (TTY: 711)

from 9 am to 8 pm, Monday through Friday.

It’s quick and confidential.

2

If you prefer to take the HRA at home, contact our Member Services team and ask for the

survey and a postage-paid envelope to be mailed to you.

All HRA results are confidential. Every HRA is offered at no charge to Medicare members. A member of our case management team will call you to discuss your HRA results and develop a personalized care plan shortly after we receive your completed HRA. The HRA must be completed prior to December 31, 2020 for you to be eligible to receive a reward card. Your reward card will arrive in the mail within six (6) to eight (8) weeks after we receive your HRA. Reward cards cannot be used to buy tobacco or alcohol. Reward cards cannot be converted to cash. You can only receive one (1) reward card per HRA.

2020 Annual Wellness Exam

University of Maryland Health Advantage encourages all members to get an annual wellness exam once every 12 months. The visit is offered to all Medicare members one (1) time each year at no cost. This visit must be completed during 2020 in order for you to be eligible for a reward card. During this visit, your doctor will check on your health. The doctor will work with you to develop a care plan made just for you. During your annual wellness exam, remember to:

• Educate yourself about the screenings you may need. • Ask questions about your health numbers (Blood Pressure/Body Mass Index). • Share information with your doctor about any pain you may have. • Inform your doctor about any physical or mental changes you are experiencing. • Engage your doctor in a talk about any over-the-counter drugs you take to check and see if they are safe to take along with any prescription medicine prescribed to you. • Reduce the risk of falls by talking about how to prevent them. • Discuss advance care planning with your doctor. Advance care planning is making decisions about the care you would want to receive if you become unable to speak for yourself.


Getting your reward card is easy.

1

Call your doctor to schedule the

preventive screening, exam, or vaccination you need. If you prefer, we can assist you in scheduling your visit, just call our Member Services

number.

2

Take this booklet with you to your

appointment.

3

During your appointment, ask

the doctor or office staff to fill out, sign and date the form that relates to that

appointment.

4

Write your full name

and member identification

number (located on the front of

your member ID card) on the form.

5

Ask the office staff to fax the

completed form to University of

Maryland Health Advantage at

410-779-3957.

Your reward card will arrive in the mail within six (6) to eight (8) weeks after we receive the completed form from your doctor and have verified the services. Reward cards cannot be used to buy tobacco or alcohol. Reward cards cannot be converted to cash. All preventive measures must

be completed during the 2020 calendar year. You can only receive one (1) reward card per form.

PROVIDER OFFICE USE: • Review the patient’s medical record and complete the form. • Make sure the form is signed and dated. By signing the form, you are attesting to the accuracy of the information. • Make sure the patient’s name and University of Maryland Health Advantage member identification number are included. • File a copy of the form in the patient’s medical records. • Fax the Annual Wellness Exam assessment form and any office visit notes to University of Maryland Health Advantage at 410-779-3957 or mail it to the following address: University of Maryland Health Advantage Attn: Quality Dept. 1966 Greenspring Drive, Suite 100 Timonium, MD 21093


Provider: This form is two sided. Please complete all fields and fax this form to University of Maryland Health Advantage at 410-779-3957 so your patient can redeem their reward card.

Name: _____________________________________________________________________

Member ID: _____________________________ Date of Birth: __________________________

Name of Provider: _____________________________ Date of Visit: ______________________

Practice Name: __________________________________ NPI: __________________________

Address: _____________________________________________________________________

Phone: __________________________________ Fax: ________________________________ Measures: Blood Pressure: ________/________ Weight: __________lbs. Height: __________ BMI: _______

Activities of Daily Living: Does the patient require assistance with any of the following? Bathing YES NO N/A Dressing YES NO N/A Eating YES NO N/A Walking YES NO N/A Using the toilet YES NO N/A Transferring (ex. getting in & out of chairs) YES NO N/A Can the patient perform all activities of daily living independently? YES NO N/APhysical Activity: Did you discuss the patient’s level of physical activity and provide advice to start, increase, or maintain levels as appropriate?

YES NO N/A

Balance/Falls: Does the patient have any trouble walking or standing? YES NO N/A Fallen in the last 12 months? YES NO N/A If yes, discuss treatment options. _______________________________________________Urine Leakage: Any urine leakage? YES NO N/A Does it interfere with sleep or daily activities? YES NO N/A If yes, discuss treatment options. ______________________________________________Smoking: Does the patient smoke? YES NO N/A Did you advise smoker to quit? YES NO N/A Did you discuss smoking cessation medication and/or strategies? YES NO N/AMedication Review: Is the patient taking medication? YES NO N/A

Please list all medications, including OTC and herbal or supplemental therapies prescribed or attach a signed and dated copy of the medication list.

TYPE MEDICATION DOSE/FREQ.Cholesterol

Diabetes

Blood Pressure

Did you assess for non-adherence (missing more than one dose/week and address any barriers)?

YES NO N/A

Has the patient been diagnosed with rheumatoid arthritis? YES NO N/A If yes, is the patient on a DMARD? YES NO N/A If no, why not? _________________________________________________________________________

Comprehensive Pain Assessment: Does the patient have pain? 0: Does not hurt 10: Hurts the most

Indicate level of pain for the head/neck Indicate level of pain for the chest Indicate level of pain for the muscles Indicate level of pain for bones/joints Indicate level of pain for other _____________ Is the pain under a pain management plan?

YES NO N/A

Annual Preventive Measures: Has the patient completed the following important screenings? Mammogram (for women 50-74 years of age) YES NO N/A Colorectal Cancer Screening (for patients 50-75 years of age) YES NO N/A Dilated Retinal Eye Exam (for diabetic patients up to 75 years of age) YES NO N/A Annual Flu Vaccine (for all patients) Date completed: ____________ YES NO N/AAdvanced Care Planning: Does the patient have evidence of advanced care planning directives in the medical record?

YES NO N/A

0 1 2 3 4 5 6 7 8 9 10 Freq. _______0 1 2 3 4 5 6 7 8 9 10 Freq. _______0 1 2 3 4 5 6 7 8 9 10 Freq. _______0 1 2 3 4 5 6 7 8 9 10 Freq. _______0 1 2 3 4 5 6 7 8 9 10 Freq. _______

Name of Office Staff Member Completing Form: ______________________________________________________

Provider’s Signature: __________________________________________________________________________

Provider Use Only: Please use the following coding guidance to document the annual wellness visit: Annual Wellness Visit: G0438 or G0439 (HCPCS Code) BMI: Z68.1, Z68.20-Z68.39, Z68.41-Z68.45, or Z68.51-Z68.54 Functional Status: 1170F Pain Assessment: 1125F, or 1126F

2020 Annual Flu Shot

Annual Flu Shot: An annual flu shot is offered at no cost to all Medicare members. It must be completed during 2020 in order for you to be eligible to receive a reward card. According to the Centers for Disease Control and Prevention, it is not possible to predict what any flu season will be like. The timing, severity, and length of the flu season usually varies from one year to the next. University of Maryland Health Advantage encourages members to get a flu shot. Human immune defenses become weaker with age. The flu can be serious for people age 65 and older or with other health risk factors. Call your doctor today to schedule your flu shot. Some pharmacies can also give members a flu shot at no cost to the member. Be sure to ask if your pharmacy can give you a shot at no cost.

Healthcare Professional: Please sign and date this form, then fax to 410-779-3957. Please note, all data fields must be completed in order for your University of Maryland Health Advantage patient to receive their reward card.

Name of Healthcare Professional:

_______________________________________________

Practice/Pharmacy Name: __________________________

Practice/Pharmacy Phone: __________________________

Practice/Pharmacy Fax: ____________________________

NPI: ___________________________________________

Location/Address: _________________________________

_______________________________________________

Today’s Date: ____________________________________

I confirm that I administered a flu shot to:

Member Name: __________________________________

Member ID: _____________________________________

Member Date of Birth: _____________________________

Please sign: _____________________________________

Provider Use Only: Please use one of these codes for influenza administration codes: 90656, 90674, 90686, or 90688

2020 Annual Flu Shot


1 Call your doctor to schedule an annual flu shot. If you prefer, we can assist you in scheduling your visit, just call our Member Services number.

2Take this booklet with you to your appointment.

3 During your appointment, ask the doctor or office staff to fill out, sign and date the form that relates to the appointment.

4Write your full name and member identification number (located on the front of your member ID card) on the form.

5 Ask the office staff to fax the completed form to University of Maryland Health Advantage at 410-779-3957 or mail to the address below.

University of Maryland Health Advantage Attn: Quality Dept. 1966 Greenspring Drive, Suite 100 Timonium, MD 21093

Your reward card will arrive in the mail within six (6) to eight (8) weeks after we receive the completed form from your doctor and have verified the services. Reward cards cannot be used to buy tobacco or alcohol. Reward cards cannot be converted to cash. You can only receive one (1) reward card for one (1) flu shot in 2020.

HEALTHCARE PROFESSIONAL USE: • Please fill in all data fields (including member name and ID). Sign and date the form. • Fax the form to University of Maryland Health Advantage at 410-779-3957.

2020 Post-Hospitalization

Physician VisitPost-Hospitalization Physician Visit: The post-hospitalization visit is offered at no cost to Medicare members who were hospitalized. If you complete your post-hospitalization visit within five (5) days of leaving the hospital, you will be eligible to receive a reward card. University of Maryland Health Advantage understands that it can be tough going home after being in the hospital. You may have left the hospital with multiple follow-up instructions. You may have many medicines to take. You may also want more medical help and support in the weeks following your hospital stay. This visit may be with a primary care provider or specialist. During this visit, your doctor will go over the instructions that you got at the hospital. Your doctor will see if you need to adjust any medication, follow-up on test results, and discuss future treatments.

Provider: Please sign and date this form, then fax to 410-779-3957. Please note, all data must be completed in order for your University of Maryland Health Advantage patient to receive their reward card.

Member Name: __________________________________

Member ID: _____________________________________


Hospital Discharge Date: ____________________________

Provider Appt. Date: _______________________________

Name of Office State Member Completing Form:

______________________________________________

Practice Name: __________________________________

Name of Provider: ________________________________

Practice NPI: ____________________________________

Address: ________________________________________

_______________________________________________

Phone: _________________________________________

Fax: ___________________________________________

Provider’s Signature: ______________________________

Today’s Date: ____________________________________

2020 Post-Hospitalization Physician Visit


1 Call your doctor to schedule your post-hospitalization visit. If you prefer, we can assist you in scheduling your visit, just call our Member Services number.


3 During your appointment, ask the doctor or office staff to fill out, sign and date the form that relates to that appointment.


5 Ask the office staff to fax the completed form to University of Maryland Health Advantage at 410-779-3957.

Your reward card will arrive in the mail within six (6) to eight (8) weeks after we receive the completed form from your doctor and have verified the services. Reward cards cannot be used to buy tobacco or alcohol. Reward cards cannot be converted to cash. You can only receive one (1) reward card for one (1) post-hospitalization visit in 2020.

PROVIDER USE: • Review the patient’s medical record and complete the form. • Make sure the form is signed and dated. By signing this form, you are attesting to the accuracy of the information. • Make sure the patient’s name and Member ID are included. • Please file a copy of the completed form in the patient’s medical records.

2020 Colorectal Cancer

Screening

Colorectal Cancer Screenings (iFOBT, Colonoscopy, or Flex Sigmoidoscopy): The colorectal cancer screening is offered at no cost to all Medicare members between the age of 50 and 75. The screening must be completed within the recommended time frame in order for you to receive a reward card. According to the Centers for Disease Control and Prevention, regular screening is key to preventing colorectal cancer. University of Maryland Health Advantage encourages you to talk with your provider about when to begin screening for colorectal cancer, what test to have, and how often to have it. Colorectal cancer screenings can detect problems before any symptoms occur. Your provider will take into account your age, medical history, family history, and general health to determine which screening is right for you. It is recommended that individuals get an iFOBT stool-based tests every 12 months, a Flexible Sigmoidoscopy every five (5) years, or a Colonoscopy every 10 years. Note: Members will only earn a reward card for completing one (1) of three (3) tests.

iFOBT, Colonoscopy, or Flexible Sigmoidoscopy

There are three (3) ways to be screened for colorectal cancer. You will only receive one (1) reward card for one (1) screening. Once completed, you are not eligible to receive another reward card through the Healthy Rewards Program for any additional colorectal cancer screenings during 2020. Please check off which ONE test you used for screening: □ iFOBT kit (test for blood in stool)

Date mailed kit to lab: _________________________

□ Colonoscopy

Date of test: __________________________________

□ Flexible Sigmoidoscopy

Date of test: __________________________________

If you complete either the Colonoscopy or Flexible Sigmoidoscopy, please have your provider complete the information below. Name: _________________________________________

Member ID: ______________ Date of Visit: ____________

Member Date of Birth: ______________________________

Name of Provider: _________________________________

Practice Name: ___________________________________

NPI: ____________________________________________

Address: ________________________________________

_______________________________________________

Phone: ___________________ Fax: __________________

2020 Colorectal Cancer Screening


Colorectal Cancer Screening (iFOBT)Complete an iFOBT colorectal cancer screening kit before December 31, 2020. Use the kit as instructed.1

2

3

4

Mail your sample to the lab to be processed. Instructions on how to do this will be included in your kit.

Fill out the form in this Healthy Rewards Program booklet.

Fax or mail the completed form to University of Maryland Health Advantage. FAX: 410-779-3957 MAIL: University of Maryland Health Advantage Attn: Quality Department 1966 Greenspring Drive, Suite 100 Timonium, MD 21093

Colorectal Cancer Screening (Colonoscopy or Flexible Sigmoidoscopy)

Talk with your provider to schedule an appointment for your colorectal cancer screening before December 31, 2020.

1

2 After you’ve completed your screening, have your provider fill out the form in this Healthy Rewards Program booklet.

3 Fax or mail the completed form to University of Maryland Health Advantage. FAX: 410-779-3957 MAIL: University of Maryland Health Advantage Attn: Quality Department 1966 Greenspring Drive, Suite 100 Timonium, MD 21093

Your reward card will arrive in the mail within six (6) to eight (8) weeks after we receive the completed form from your doctor and have verified the services. Reward cards cannot be used to buy tobacco or alcohol. Reward cards cannot be converted to cash. You can only receive one (1) reward card for one (1) colorectal cancer screening in 2020 within the recommended time frames.

2020 Mammogram

(Breast Cancer Screening)

Mammogram (Breast Cancer

Screening): Mammograms are offered at no cost to all female Medicare members between 50 and 74 years old. This screening must be completed between October 1, 2018 and December 31, 2020 in order for you to be eligible to receive a reward card. Mammograms check for breast cancer even if a woman does not have any signs or symptoms. During this screening, x-ray images are taken of each breast. The x-ray images look for lumps or tumors that cannot be felt. Mammograms can also see other problems that may indicate breast problems. Some imaging centers may require a referral. Be sure to ask when you call to make your appointment. If a referral is needed, your primary care provider will provide one for you. Talk with your provider if you have any questions.

Mammogram Screening Center: Please fill out this form, then fax to 410-779-3957. Please note, all data fields must be completed in order for your University of Maryland Health Advantage patient to receive their reward card.

Member Name: __________________________________

Member ID: _____________________________________


Date of Mammogram: _____________________________

Today’s Date: ____________________________________

Name of Mammogram Center: ________________________

_______________________________________________

Location Address: _________________________________

_______________________________________________

Location Phone: ___________________________________

Location Fax: _____________________________________

Name of Office Staff Member Completing this Form:

_______________________________________________

Mammogram Screening Center Use Only: Please use one of these codes for the mammogram: 77063, 77065, 77066, 77067

2020 Mammogram (Breast Cancer Screening)


1 Make an appointment for your mammogram breast cancer screening at a mammogram screening center. If you prefer, we can assist you in scheduling your visit, just call our Member Services number.


3 Ask a staff member at the mammogram screening center to fill out the form after you get your mammogram.



Your reward card will arrive in the mail within six (6) to eight (8) weeks after we receive the completed form from your doctor and have verified the services. Reward cards cannot be used to buy tobacco or alcohol. Reward cards cannot be converted to cash. You can only receive one (1) reward card for one (1) mammogram between October 1, 2018 and December 31, 2020.

PROVIDER USE: • Please fill in all data fields on the form. • Make sure the form is signed and dated. By signing this form, you are attesting to the accuracy of information. • Make sure the patient’s name and Member ID are included. • Please file a copy of the completed form in the patient’s medical records. • Please share a copy of the results with the patient’s PCP as appropriate.

2020 Diabetic Screenings

Diabetic Screenings: HbA1c and Urine Protein Screening (Microalbumin) are recommended for members who have a diagnosis of diabetes. These tests are offered at no cost to Medicare members who need them. These tests must be completed during 2020 in order for you to be eligible to receive a reward card. If you have kidney disease and are under the care of a nephrologist, you may not need to have the urine protein test completed. In this case, you may provide evidence of a visit with your nephrologist during 2020. Note: Members must complete both screenings to be eligible for a reward card.

Provider: Please fill out this form, then fax to 410-779-3957. Please note, both tests and all data fields, including the results, must be completed in order for you University of Maryland Health Advantage patient to receive their reward card.

Member Name: ___________________________________ Member ID: ______________________________________ Member Date of Birth: ______________________________ Date of HbA1C: __________________ Value:____________ Date of Urine Protein Screening (Microalbumin): __________ Value: ____________

Yes No Not PrescribedACE Inhibitor or ARBDiabetes Medication(s)Cholesterol Medication(s)

Today’s Date: _____________________________________

Does the patient see a nephrologist? If yes, date of last visit:

_______________________________________________

Name of Prover/Practice: ____________________________

Location/Address: _________________________________

_______________________________________________

Location Phone: ___________________________________

Location Fax: ________________NPI: _________________

Name of Office Staff Member Completing this Form:

_______________________________________________

Provider Signature: ________________________________

Provider Use Only: Please use one of these codes for diabetic tests: HbA1c 83036, 83037 (CPT Codes), 3044F, 3045F, or 3046F (CPT II) Nephropathy Screening: 3066F or 4010F (CPT II)

2020 Diabetic Screenings

Call your provider to schedule your diabetic screenings. If you prefer, we can assist you in scheduling your visit, just call our Member Services number.

Take this booklet with you to your appointment.


1

2

At your appointment, ask your provider to complete the form, sign, and date it.


3


Your reward card will arrive in the mail within six (6) to eight (8) weeks after we receive the completed form from your doctor and have verified the services. Reward cards cannot be used to buy tobacco or alcohol. Reward cards cannot be converted to cash. You can only receive one (1) reward card for the completion of both the HbA1c and Mircoalbumin in 2020.

PROVIDER USE: • Review the patient’s medical record and complete the form. • Make sure the form is signed and dated. By signing this form, you are attesting to the accuracy of information. • Make sure the patient’s name and Member ID are included. • Please file a copy of the completed form in the patient’s medical records.

2020 Diabetic Retinal

Eye Exam

Diabetic Retinal Eye Exam: It is recommended that members with diabetes have a retinal eye exam once a year. According to the National Institute of Health, between 40 and 45 percent of Americans diagnosed with diabetes have some stage of diabetic retinopathy. This eye exam is offered at no cost to Medicare members who need it. It must be completed during 2020 in order for you to be eligible to receive a reward card.

Provider: Please fill out this form, then fax to 410-779-3957. Please note, all data fields must be completed in order for your University of Maryland Health Advantage patient to receive their reward card.

Member Name: __________________________________

Member ID: _____________________________________


Date of Eye Exam: _________________________________

Result: _________________________________________

Today’s Date: ___________________________________

Name of Provider/Practice: __________________________

_____________________________________________

Location Address: _________________________________

_______________________________________________

Location Phone: ___________________________________

Location Fax: _____________________________________

Signature of Eye Care Professional:

_______________________________________________

Provider Use Only: Please use one of these codes for the Diabetic Retinal Screening: 3072F (CPTII), 67028, 67030, 67031, 67036, 67039, 67040 to 67043, 67101, 67105, 67107, 67108, 67110, 67113, 67121, 67141, 67145, 67210, 67218, 67220, 67221, 67227, 67228, 92002, 92004, 92012, 92014, 92018, 92019, 92134, 92225-28, 92230, 92235, 92240, 92250, 92260, 99203-05, or 99213-15 Screening with an eye care professional: 2022F, 2024F, or 2026F

2020 Diabetic Retinal Eye Exam


1 Call the ophthalmologist or optometrist to schedule your retinal eye exam. If you prefer, we can assist you in scheduling your visit, just call our Member Services number.


During your appointment, ask the eye care professional to complete the form, sign, and date it.


55

3

Ask the office staff to fax the completed form to University of Maryland Health Advantage at 410-779-3957.

Your reward card will arrive in the mail within six (6) to eight (8) weeks after we receive the completed form from your doctor and have verified the services. Reward cards cannot be used to buy tobacco or alcohol. Reward cards cannot be converted to cash. You can only receive one (1) reward card for one (1) eye exam visit in 2019.

PROVIDER USE: • Review the patient’s medical record and complete the form. • Make sure the form is signed and dated. By signing this form, you are attesting to the accuracy of information. • Make sure the patient’s name and Member ID are included. • Please file a copy of the completed form in the patient’s medical records. • Please share a copy of the results with the patient’s PCP.

2020 Medical Information

Name: ___________________________________ Date of Birth: ______________________________ Phone #:__________________________________

Primary Care Provider: Name: ___________________________________ Phone #:_________________________________

Emergency Contact: Name: ___________________________________ Relationship: ______________________________ Phone #:__________________________________

Allergies: _________________________________ _____________________________________________________________________________________________________________________________________________________________________________________________________________

Pharmacy: Name: ___________________________________ Phone #:_________________________________

Other Doctors: Name: ___________________________________ Specialty: ________________________________ Phone #:_________________________________ Name: ___________________________________ Specialty: ________________________________ Phone #:_________________________________

Medical Conditions: ________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________

Use this page to keep track of all medications you take. This includes prescription drugs, over-the-counter

medications, herbal supplements, and vitamins. Share this information with your provider and pharmacist during all visits. Remember to

use a pencil so you can make any changes if necessary.

You should review this record when starting or stopping a new medication, changing your dosage, or visiting with your provider.

Name of Medication

Form (pill, patch, injection, etc)

DosageHow Much and When

Use (regularly or occasionally)

Start/Stop Date (1/10/20 - 5/10/20 1/10/20 - ongoing)

Notes, Directions,

Reasons for Use

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

2020 Medication Record

2020 Notes

The Healthy Rewards Program is offered to all University of Maryland Health Advantage members at no cost. For assistance in scheduling a screening or test, or if you have questions about the program, please call a Member Services

representative for assistance.

Remember to register for University of Maryland Health Advantage’s online and secure member portal at

www.UMMedicareAdvantage.org.

University of Maryland Health Advantage is an HMO-SNP plan with a Medicare contract and a State of Maryland Medicaid contract. Enrollment in University of Maryland Health Advantage depends upon contract renewal.

Member Services: 410-779-9932 (TTY: 711)

or toll free 1-844-386-6762 8 am - 8 pm EST | 7 days a week | October 1 - March 31

8 am - 8 pm EST | Monday - Friday | April 1 - September 30

2020 umha healthy rewards program book · earning your . reward card is easy. 1. call your doctor...

Documents