Below is a listing of plan forms, brochures and documents to help you manage and understand your benefits.

Member Forms & Documents

Title Download
2022 – Official Plan Brochure PDF
2022 – Summary of Benefits PDF
2022 – Medicare Plan Brochure PDF
2022 – Medicare Summary of Benefits Guide PDF
Medicare Rewards Program – Medicare Advantage PDF
2022 New Member Guide PDF
2022 Making the Most Out of Your Plan PDF
2021 – Official Plan Brochure PDF
2021 Know Where to Go Guide PDF
Prescription Drug Guide/Formulary PDF
Prescription Drug Guide – Specialty Drugs PDF
Prescription Drug Guide – All Other Drugs PDF
Specialty Quantity Limit Program – Drug List PDF
Performance Drug List PDF
Performance Drug List Change Summary PDF
Claim Form – Medical PDF
Claim Form – Mail Order Prescription PDF
Claim Form – Prescription, Retail Pharmacy PDF
Authorization for Release of Protected Health Information (PHI) PDF