Forms you may need

Use these resources to help you enroll in a plan.

Enrollment Form

These documents contain information about your benefits, network and coverage.

Low Income Subsidy (LIS) Premium Summary Chart

Summary of Benefits

Evidence of Coverage (EOC)

These documents offer information about your pharmacy and prescription benefits.

Prescription Drug List (Formulary)

Over-the-Counter Catalog

Part D Prescription Drug Claim Form

Request for Medicare Prescription Drug Coverage Determination Form

Request for Redetermination of Medicare Prescription Drug Denial Form

Part D Prescription Home Delivery Form

Part D Out of Network Coverage

Part D Prior Authorization Criteria

Part D Quality Assurance Policy

Part D Transition Supply Policy

One Touch® Free Blood Glucose Monitor Voucher

Ascensia® Contour Free Blood Glucose Monitor Voucher

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.

Appointment of Representative Form

HIPPA Form

Personal Representative Request Form

Notice of Privacy Practices

Request Confidential Communication

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.

Member Appeal Form

Member Grievance Form

Discrimination Grievance Form

Aging Well: Making Your Home Fall-Proof

High Blood Pressure