Forms & Documents
Instructions on How to Get Covered Services During a Disaster.
Medicare Plans
MediSun Extra (HMO D-SNP) 019
- 2024 Annual Notice of Changes Plan 019 - updated 10/17/2023
- 2024 Annual Notice of Changes Plan 019 (Creole)
- 2024 Evidence of Coverage Plan 019 - updated 10/18/2023
- 2024 Evidence of Coverage Plan 019 (Creole)
- 2024 Summary of Benefits Plan 019
- 2025 Annual Notice of Changes Plan 019
- 2025 Evidence of Coverage Plan 019
- 2025 Summary of Benefits Plan 019
MediSun Plus (HMO D-SNP) 016
- 2024 Annual Notice of Changes Plan 016 - updated 10/17/2023
- 2024 Annual Notice of Changes Plan 016 (Creole)
- 2024 Evidence of Coverage Plan 016 - updated 10/18/2023
- 2024 Evidence of Coverage Plan 016 (Creole)
- 2024 Summary of Benefits Plan 016
- 2025 Annual Notice of Changes Plan 016
- 2025 Evidence of Coverage Plan 016
- 2025 Summary of Benefits Plan 016
Member Notices and Updates
Member Announcements
Plan Changes and Disenrollment Information
Plan Changes and Disenrollment
Prescription Drug Benefits
Prescription Drug Benefits
- 2024 Catalog Over-the-Counter (OTC) Items
- 2024 Part D Transition Policy
- 2024 Prescription Drug Formulary – updated 11/06/2024
- 2024 Prescription Drugs Formulary Changes – updated 11/14/2024
- 2024 Prior Authorization Criteria – updated 11/06/2024
- 2024 Step Therapy Criteria – updated 11/06/2024
- 2024 Step Therapy Criteria Part B Drugs only – effective 10/01/2024
- 2024 Therapy Management Medication (MTM) Program
- 2025 Catalog Over-the-Counter (OTC) Items
- 2025 HealthSun Prior Authorization - updated 11/22/2024
- 2025 OTC Order Form - All Plans
- 2025 Part D Transition Policy
- 2025 Prescription Drug Formulary – updated 09/23/2024
- 2025 Step Therapy Criteria - updated 10/03/2024
- 2025 Therapy Management Medication (MTM) Program
- Appointment of Representative Form
- B vs. D Coverage Determination Request Form
- CMS Medicare Prescription Drug Coverage Determination Request Form
- Lost, Damaged, or Stolen Medication Form
- Medication Sync Request Form
- Part D Reimbursement Request Form
- Personal Medication List Form
- Prescription Coverage Determination Request Form
- Vacation Supply Form