Plan Materials and Forms

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

This booklet gives you a summary of costs and coverage in your plan. Please select the document for your plan and county:

Florida - Sacred Heart and St. Vincent's

Plan Name	CMS #	County	Summary of Benefits
Ascension Complete St. Vincent's Reward (HMO)	H8225 - 001	Baker, Clay, Duval & Nassau	Summary of Benefits, H8225-001 - English (PDF) Summary of Benefits, H8225-001 - Spanish (PDF)
Ascension Complete Sacred Heart Reward (HMO)	H8225 - 002	Escambia and Santa Rosa	Summary of Benefits, H8225-002 - English (PDF) Summary of Benefits, H8225-002 - Spanish (PDF)
Ascension Complete St. Vincent's Secure (HMO)	H8225 -003	Baker, Clay, Duval & Nassau	Summary of Benefits, H8225-003 - English (PDF) Summary of Benefits, H8225- 003 - Spanish (PDF)
Ascension Complete Sacred Heart Secure (HMO)	H8225 - 004	Escambia and Santa Rosa	Summary of Benefits, H8225-004 - English (PDF) Summary of Benefits, H8225-004 - Spanish (PDF)

Illinois - AMITA

Plan Name	CMS#	County	Summary of Benefits
Ascension Complete Illinois Reward (HMO)	H7399-001	Cook, DuPage, Kane and Will counties	Summary of Benefits, H7399-001 - English (PDF) Summary of Benefits, H7399-001 - Spanish (PDF)
Ascension Complete Illinois Secure (HMO)	H7399-002	Cook, DuPage, Kane and Will counties	Summary of Benefits, H7399-002 - English (PDF) Summary of Benefits, H7399-002 - Spanish (PDF)

Kansas - Via Christi

Plan Name	CMS#	County	Summary of Benefits
Ascension Complete Via Christi Reward (HMO)	H5398-001	Butler, Harvey and Sedgwick counties	Summary of Benefits, H5398-001 (PDF)
Ascension Complete Via Christi Secure (HMO)	H5398-002	Butler, Harvey and Sedgwick counties	Summary of Benefits, H5398-002 (PDF)

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:

Florida - Sacred Heart and St. Vincent's

Plan Name	CMS #	County	Evidence of Coverage (EOC)
Ascension Complete St. Vincent's Reward (HMO)	H8225 - 001	Baker, Clay, Duval & Nassau	Evidence of Coverage, H8225-001 - English (PDF)
Ascension Complete Sacred Heart Reward (HMO)	H8225 - 002	Escambia and Santa Rosa	Evidence of Coverage, H8225-002 - English (PDF)
Ascension Complete St. Vincent's Secure (HMO)	H8225 -003	Baker, Clay, Duval & Nassau	Evidence of Coverage, H8225-003 - English (PDF)
Ascension Complete Sacred Heart Secure (HMO)	H8225 - 004	Escambia and Santa Rosa	Evidence of Coverage, H8225-004 - English (PDF)

Illinois - AMITA

Plan Name	CMS #	County	Evidence of Coverage (EOC)
Ascension Complete Illinois Reward (HMO)	H7399 - 001	Cook, DuPage, Kane and Will counties	Evidence of Coverage, H7399-001 - English (PDF)
Ascension Complete Illinois Secure (HMO)	H7399 - 002	Cook, DuPage, Kane and Will counties	Evidence of Coverage, H7399-002 - English (PDF)

Kansas - Via Christi

Plan Name	CMS #	County	Evidence of Coverage (EOC)
Ascension Complete Via Christi Reward (HMO)	H5398 - 001	Butler, Harvey and Sedgwick counties	Evidence of Coverage, H5398-001 - English (PDF)
Ascension Complete Via ChristiSecure (HMO)	H5398 - 002	Butler, Harvey and Sedgwick counties	Evidence of Coverage, H5398-002 - English (PDF)

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:

Florida - Sacred Heart and St. Vincent's

Plan Name	CMS #	County	Annual Notice of Changes (ANOC)
Ascension Complete St. Vincent's Reward (HMO)	H8225 - 001	Baker, Clay, Duval & Nassau	Annual Notice of Changes, H8225-001 - English (PDF)
Ascension Complete Sacred Heart Reward (HMO)	H8225 - 002	Escambia and Santa Rosa	Annual Notice of Changes, H8225-002 - English (PDF)
Ascension Complete St. Vincent's Secure (HMO)	H8225 -003	Baker, Clay, Duval & Nassau	Annual Notice of Changes, H8225-003 - English (PDF)
Ascension Complete Sacred Heart Secure (HMO)	H8225 - 004	Escambia and Santa Rosa	Annual Notice of Changes, H8225-004 - English (PDF)

Illinois - AMITA

Plan Name	CMS#	County	Annual Notice of Changes (ANOC)
Ascension Complete Illinois Reward (HMO)	H7399-001	Cook, DuPage, Kane and Will counties	Annual Notice of Changes, H7399-001 - English (PDF) Annual Notice of Changes, H7399-001 - Spanish (PDF)
Ascension Complete Illinois Secure (HMO)	H7399-002	Cook, DuPage, Kane and Will counties	Annual Notice of Changes, H7399-002 - English (PDF) Annual Notice of Changes, H7399-002 - Spanish (PDF)

Kansas - Via Christi

Plan Name	CMS#	County	Annual Notice of Changes (ANOC)
Ascension Complete Via Christi Reward (HMO)	H5398-001	Butler, Harvey and Sedgwick counties	Annual Notice of Changes, H5398-001 (PDF)
Ascension Complete Via Christi Secure (HMO)	H5398-002	Butler, Harvey and Sedgwick counties	Annual Notice of Changes, H5398-002 (PDF)

Your current plan may have an over-the-counter benefit that allows you to purchase over-the-counter (OTC) health and wellness products. This catalog includes a list of over-the-counter items that you can order to be directly mailed to your home. Check the catalog for item limits.

Ordering is easy! Just follow the steps listed on your plan's catalog.

Over-the-Counter Catalog - English / Spanish (PDF)

Plan Benefit Materials | Ascension Complete

Plan Materials and Forms

Plan Benefit Materials

Plan Benefit Materials | Ascension Complete

Plan Materials and Forms

Summary of Benefits

Evidence Of Coverage (EOC)

Annual Notice of Changes (ANOC)

Optional Benefit Individual Enrollment Form

Optional Supplemental Benefits Flyer

Over-the-Counter Benefits

Plan Benefit Materials