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
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 06/13/2022
- 2022 Medication Therapy Management (MTM) Program
- 2022 Non-D-SNP Prescription Drug Formulary – updated 06/13/2022
- 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 06/23/2022
- 2022 Prior Authorization Criteria – updated 06/13/2022
- 2022 Step Therapy Criteria – updated 06/13/2022
- 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
