We've put together the most common documents and forms you might need for things like filing claims or reviewing your coverage.
Use these resources to help you enroll in a plan.
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)
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
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