Documents and forms
- Annual Notice of Change (for Medicaid and Medicare) (updated 10/1/24)
- Annual Notice of Change (for Medicaid only) (updated 10/1/24)
- Summary of Benefits (for Medicaid and Medicare) (updated 10/1/24)
- Summary of Benefits (for Medicaid only) (updated 10/1/24)
- Evidence of Coverage (for Medicaid and Medicare) (updated 10/1/24)
- Evidence of Coverage (for Medicaid only) (updated 10/1/24)
- LIS Premium Summary Chart (updated 10/1/24)
- List of Covered Drugs (updated 4/30/25)
- Provider and Pharmacy Directory (SNP) (updated 4/30/25)
- Provider and Pharmacy Directory (SCO) (updated 4/30/25)
- Part D Star Rating (updated 10/30/24)
2025 Materiales en Español para Miembros
- Aviso Anual de Cambios (para Medicaid y Medicare) (updated 10/1/24)
- Aviso Anual de Cambios (solo para Medicaid) (updated 10/1/24)
- Resumen de Beneficios (para Medicaid y Medicare) (updated 10/1/24)
- Resumen de Beneficios (solo para Medicaid) (updated 10/1/24)
- Evidencia de Cobertura (para Medicaid y Medicare) (updated 2/5/25)
- Evidencia de Cobertura (solo para Medicaid) (updated 2/5/25)
- Gráfico de Resumen para LIS Premium (updated 10/1/24)
- Lista de Medicamentos (updated 4/30/25)
- Directorio de Proveedores y Farmacias (SNP) (updated 4/30/25)
- Directorio de Proveedores y Farmacias (SCO) (updated 4/30/25)
- Calificación 2024 de Medicare con Estrellas (updated 10/30/24)
- Appointment of Representative Form
- Appointment of Representative Form (large print) (updated 7/14/23)
- Appointment of Representative Form (Spanish) (updated 8/3/23)
- Assign or Revoke a Personal Representative form (updated 7/15/24)
Name someone you know and trust to communicate with our plan on your behalf.- Formulario para designar un representante personal (updated 7/15/24)
- Formulário de Indicação de Representante Pessoal (updated 7/15/24)
- Fòm pou Deziyen yon Reprezantan Pèsonèl (updated 7/15/24)
- Disenrollment form (updated 2/28/24)
- Solicita la desafiliación formulario (updated 2/29/24)
- Model Drug Coverage Determination Form (Medicaid Only) (updated 3/4/25)
Request approval of a prescription drug that is not covered or has restrictions. - Model Drug Coverage Determination Form (Medicaid + Medicare) (updated 3/4/25)
Request approval of a prescription drug that is not covered or has restrictions. - Request for Redetermination of Medicare Prescription Drug Denial Form (updated 3/16/23)
Appeal a decision about drug coverage that you do not agree with. - Over-the-Counter Reimbursement Form (updated 3/16/23)
Request reimbursement for the monthly over-the-counter (OTC) card allowance. - Prescription Reimbursement Form (updated 7/26/23)
Request reimbursement for a prescription that you paid for out-of-pocket.- Formulario de reembolso de recetas (updated 5/13/24)
- Reimbursement Request Form (updated 3/16/23)
Request reimbursement for any medical expenses you may have paid for out-of-pocket.- Formulario de Solicitud de Reembolso (updated 3/16/23)
- Personal Care Attendant (PCA) UM Notification Form (updated 3/16/23)
- PCP Selection Form (updated 6/5/23)
Select or change your Primary Care Provider (PCP) - PHI Permissions for Use Form (updated 7/27/23)
Let us share your Protected Health Information (PHI) with those who need it to provide healthcare services to you.- Permisos para el uso de información protegida de salud (updated 7/27/23)
- Release of Information Form (updated 7/15/24)
Request that we share your information with a third party- Formulario de divulgación de información (updated 7/15/24)
- Formulário de Divulgação de Informações (updated 7/15/24)
- Fòm pou Pibliye Enfòmasyon (updated 7/15/24)
- Release of Reproductive Healthcare Attestation (updated 10/21/24)
- Request for Access to Information Form (updated 2/14/24)
- VSP reimbursement form (updated 1/25/25)
Use this form if you need to be reimbursed for your $325 supplemental vision allowance.
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