Forms & Documents
Now Available
Instructions on How to Get Covered Services During a Disaster.
Medical Plans
HealthAdvantage (HMO) Plan 001
HealthAdvantage (HMO) Plan 012
HealthAdvantage (HMO) Plan 013
There are no documents in this section
MediSun Plus (HMO D-SNP) Plan 015
HealthAdvantage Plus (HMO) 017
HealthAdvantage Plus (HMO) 018
MediSun Extra (HMO D-SNP) 019
Plan Changes and Disenrollment Information
Plan Changes and Disenrollment
Prescription Drug Benefits
Prescription Drug Benefits
- 2022 D-SNP Prescription Drug Formulary – updated 09/24/2021
- 2022 Medication Therapy Management (MTM) Program
- 2022 Non-SNP Prescription Drug Formulary – updated 09/24/2021
- 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 HealthSun MediSun Extra (HMO D-SNP)
- 2022 Over The Counter (OTC) Catalog
- 2022 Part D Transition Policy
- 2022 Personal Medication List Form
- 2022 Prior Authorization Criteria – updated 12/28/2021
- 2022 Step Therapy Criteria – updated 12/03/2021
- 2022 Step Therapy Criteria Part B Drugs only – effective 01/01/2022
- 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
