Forms & Documents

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Medicare Plans

2022 Annual Notice of Changes Plan 001
2022 Evidence of Coverage Plan 001
2022 Summary of Benefits Plan 001
2023 Annual Notice of Changes Plan 001
2023 Evidence of Coverage Plan 001
2023 Summary of Benefits Plan 001

2022 Annual Notice of Changes Plan 012
2022 Evidence of Coverage Plan 012
2022 Summary of Benefits Plan 012
2023 Annual Notice of Changes Plan 012
2023 Evidence of Coverage Plan 012
2023 Summary of Benefits Plan 012

2022 Annual Notice of Changes Plan 013
2022 Evidence of Coverage Plan 013
2022 Summary of Benefits Plan 013
2023 Annual Notice of Changes Plan 013
2023 Evidence of Coverage Plan 013
2023 Summary of Benefits Plan 013

2022 Evidence of Coverage Plan 017
2022 Summary of Benefits Plan 017
2023 Annual Notice of Changes Plan 017
2023 Evidence of Coverage Plan 017
2023 Summary of Benefits Plan 017

2022 Evidence of Coverage Plan 018
2022 Summary of Benefits Plan 018
2023 Annual Notice of Changes Plan 018
2023 Evidence of Coverage Plan 018
2023 Summary of Benefits Plan 018

2023 Evidence of Coverage Plan 020
2023 Summary of Benefits Plan 020

2022 Annual Notice of Changes Plan 006
2022 Evidence of Coverage Plan 006
2022 Summary of Benefits Plan 006
2023 Annual Notice of Changes Plan 006
2023 Evidence of Coverage Plan 006
2023 Summary of Benefits Plan 006

2022 Evidence of Coverage Plan 019
2022 Summary of Benefits Plan 019
2023 Annual Notice of Changes Plan 019
2023 Annual Notice of Changes Plan 019 (015 crosswalk)
2023 Evidence of Coverage Plan 019
2023 Summary of Benefits Plan 019

2022 Annual Notice of Changes Plan 016
2022 Annual Notice of Changes Plan 016 for 2021 Plan 014 members
2022 Evidence of Coverage Plan 016
2022 Summary of Benefits Plan 016
2023 Annual Notice of Changes Plan 016
2023 Evidence of Coverage Plan 016
2023 Summary of Benefits Plan 016

2022 Annual Notice of Changes Plan 015
2022 Annual Notice of Changes Plan 015 for 2021 Plan 006 members
2022 Evidence of Coverage Plan 015
2022 Summary of Benefits Plan 015
2023 Annual Notice of Changes Plan 019 (015 crosswalk)

Help Fight Medicare Fraud

Plan Changes and Disenrollment Information

2022 Plan Change Form
2023 Plan Change Form
Change of Address Form
Disenrollment Form
Member's Right and Responsibilities Upon Disenrollment

Prescription Drug Benefits

2022 D-SNP Prescription Drug Formulary – updated 11/11/2022
2022 Medication Therapy Management (MTM) Program
2022 Non-D-SNP Prescription Drug Formulary – updated 11/11/2022
2022 OTC Order Form - Plan 001 HealthAdvantage (HMO)
2022 OTC Order Form - Plan 006 MediMax (HMO)
2022 OTC Order Form - Plan 012 HealthAdvantage (HMO)
2022 OTC Order Form - Plan 013 HealthAdvantage (HMO)
2022 OTC Order Form - Plan 015 MediSun Plus (HMO D-SNP)
2022 OTC Order Form - Plan 016 MediSun Plus (HMO D-SNP)
2022 OTC Order Form - Plan 017 HealthAdvantage Plus (HMO)
2022 OTC Order Form - Plan 018 HealthAdvantage Plus (HMO)
2022 OTC Order Form - Plan 019 MediSun Extra (HMO D-SNP)
2022 Over The Counter (OTC) Catalog
2022 Part D Transition Policy
2022 Personal Medication List Form
2022 Prescription Drug Formulary Changes (HMO – HMO D-NSP) – updated 11/17/2022
2022 Prior Authorization Criteria – updated 11/11/2022
2022 Step Therapy Criteria – updated 11/11/2022
2022 Step Therapy Criteria Part B Drugs only – effective 12/01/2022
2023 Drug Prescription Formulary - updated 09/26/2022
2023 Medication Therapy Management (MTM) Program
2023 Over-the-Counter (OTC) Catalog
2023 Part D Transition Policy
2023 Personal Medication List Form
2023 Prior Authorization Criteria – updated 11/14/2022
2023 Step Therapy Criteria – updated 09/29/2022
Appointment of Representative Form
B vs. D Coverage Determination Request Form
CMS Medicare Prescription Drug Coverage Determination Request Form
Grievances/Appeal Form
Hospice PA and Plan of Care Form
Lost, Damaged, or Stolen Medication Form
Medication Sync Request Form
Part D Reimbursement Request Form
Prescription Coverage Determination Request Form
Redetermination of Medicare Prescription Drug Denial Request Form
Vacation Supply Form

Health & Wellness

Am I at Risk for Type 2 Diabetes?
Diabetes Medicines
Eating and Diabetes
Keep Your Diabetes Under Control
Kidney Disease & Medicines
Medicare Diabetes Prevention Program

Protecting Against Medicare Fraud

Help Fight Medicare Fraud

Getting Extra Help with Medicare Costs

2022 LIS Premium Summary (Extra Help)
2023 LIS Premium Subsidy Summary (Extra Help)

Reimbursement and Grievances

CMS Appointment of Representation Form
Grievance Appeals Form
Member Reimbursement Form

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No results found.

Medicare Plans

HealthAdvantage (HMO) Plan 001

HealthAdvantage (HMO) Plan 012

HealthAdvantage (HMO) Plan 013

HealthAdvantage Plus (HMO) 017

HealthAdvantage Plus (HMO) 018

HealthAdvantage Plus (HMO) 020

MediMax (HMO) Plan 006

MediSun Extra (HMO D-SNP) 019

MediSun Plus (HMO D-SNP) Plan 016

MediSun Plus (HMO D-SNP) Plan 015

Help Fight Medicare Fraud

Plan Changes and Disenrollment Information

Plan Changes and Disenrollment

Prescription Drug Benefits

Prescription Drug Benefits

Health & Wellness

Health & Wellness

Protecting Against Medicare Fraud

Help Fight Medicare Fraud

Getting Extra Help with Medicare Costs

Extra Help

Reimbursement and Grievances

Reimbursement and Grievances

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