Your Mississippi Health Plan
Whether you're looking to enroll in our plan or find information on your benefits and coverage, you can find it here.
Still have questions about our plans? Give us a call and we'll help.
CONTACT USDocuments and Forms
Shared Health Dual Plus (HMO D-SNP)SM
Enrollment
These documents contain information about your benefits, network and coverage.
Benefits and Coverage
These documents contain information about your benefits, network and coverage.
- 2024 Low Income Subsidy (LIS) Premium Summary Chart
- 2025 Low Income Subsidy (LIS) Premium Summary Chart
- 2024 Summary of Benefits (Updated: 10/1/2024)
- 2025 Summary of Benefits (Updated: 10/1/2024)
- 2024 Evidence of Coverage (EOC) (Updated: 10/1/2024)
- 2025 Evidence of Coverage (EOC) (Updated: 10/1/2024)
- 2025 Dental Benefits Guide
- Find a Doctor
- Health Incentives
- How It Works: Benefits Card Guide
- 2024 Plan Rating (HMO D-SNP)
- 2025 Plan Rating (HMO D-SNP)
Pharmacies and Prescriptions
These documents offer information about your covered drug benefits.
- 2024 Dual Plus Covered Drug List (Formulary)(Updated 11/1/2024)
- 2025 Dual Plus Covered Drug List (Formulary)(Updated: 10/1/2024)
- Pharmacy Directory
- Over-the-Counter Catalog
- Medicare Prescription Payment Plan Terms and Conditions
- Medicare Prescription Payment Plan Fact Sheet
- Medicare Prescription Payment Plan Fact Sheet(Spanish)
- Medicare Prescription Payment Plan Election Request Form
- Part D Prescription Drug Claim Form
- Request for Medicare Prescription Drug Coverage Determination Form(Updated: 12/1/2023)
- Request for Redetermination of Medicare Prescription Drug Denial Form(Updated: 12/1/2023)
- Part D Prescription Home Delivery Form
- Part D Out of Network Coverage
- 2024 Medicare Part D Prior Authorization Criteria(Updated: 11/1/2024)
- 2025 Medicare Part D Prior Authorization Criteria(Updated 10/1/2024)
- Medicare Part B Step Therapy Guide(Updated: 8/1/2024)
- Provider-Administered Specialty Medication List(Updated: 11/1/2024)
- Provider-Administered Medication Authorization Form
- Medicare Part B Prior Authorization Criteria
- Part D Quality Assurance Policy
- Part D Transition Supply Policy
- One Touch® Free Blood Glucose Monitor Voucher
- Free Contour Blood Glucose Monitor Coupon
- Blank Medication List
- Drug Disposal Information
Your Rights
You'll find notices and forms in this section that’ll help you understand your rights and responsibilities and make requests related to those rights.
Grievances and Appeals
Use these forms to file an appeal about coverage or payment decisions or to file a grievance if you have concerns about your plan, providers or quality of care.
Shared Health Dual Freedom (PPO D-SNP)SM
Enrollment
Use these resources to help you enroll in a plan.
Benefits and Coverage
These documents contain information about your benefits, network and coverage.
- 2024 Low Income Subsidy(LIS) Premium Summary Chart
- 2025 Low Income Subsidy(LIS) Premium Summary Chart
- 2024 Summary of Benefits(Updated: 10/1/2024)
- 2025 Summary of Benefits(Updated: 10/1/2024)
- 2024 Evidence of Coverage(EOC)(Updated: 10/1/2024)
- 2025 Evidence of Coverage(EOC)(Updated: 10/1/2024)
- 2025 Dental Benefits Guide
- 2025 Plan Rating (PPO D-SNP)
- Find a Doctor
- Health Incentives
- How It Works: Benefits Card Guide
Pharmacies and Prescriptions
These documents offer information about your covered drug benefits.
- 2024 Dual Freedom Covered Drug List(Formulary)(Updated: 11/1/2024)
- 2025 Dual Freedom Covered Drug List(Formulary)(Updated: 10/1/2024)
- Pharmacy Directory
- Over-the-Counter Catalog
- Medicare Prescription Payment Plan Terms and Conditions
- Medicare Prescription Payment Plan Fact Sheet
- Medicare Prescription Payment Plan Fact Sheet(Spanish)
- Medicare Prescription Payment Plan Election Request Form
- Part D Prescription Drug Claim Form
- Request for Medicare Prescription Drug Coverage Determination Form(Updated: 12/1/2023)
- Request for Redetermination of Medicare Prescription Drug Denial Form(Updated: 12/1/2023)
- Part D Prescription Home Delivery Form
- Part D Out of Network Coverage
- 2024 Medicare Part D Prior Authorization Criteria(Updated: 11/1/2024)
- 2025 Medicare Part D Prior Authorization Criteria(Updated: 10/1/2024)
- Medicare Part B Step Therapy Guide(Updated: 8/1/2024)
- Provider-Administered Specialty Medication List(Updated: 11/1/2024)
- Provider-Administered Medication Authorization Form
- Medicare Part B Prior Authorization Criteria
- Part D Quality Assurance Policy
- Part D Transition Supply Policy
- One Touch® Free Blood Glucose Monitor Voucher
- Free Contour Blood Glucose Monitor Coupon
- Blank Medication List
- Drug Disposal Information
Your Rights
You'll find notices and forms in this section that’ll help you understand your rights and responsibilities and make requests related to those rights.
Grievances and Appeals
Use these forms to file an appeal about coverage or payment decisions or to file a grievance if you have concerns about your plan, providers or quality of care.