Below is a listing of plan forms, brochures and documents to help you manage and understand your benefits.
Member Forms & Documents
Title | Download |
---|---|
2023 – Summary of Benefits | |
2023 – Official Plan Brochure | |
2023 – Medicare Plan Brochure | |
2023 Medicare – 2023 Evidence of Coverage – Medicare Advantage | |
2023 Medicare – 2023 Schedule of Cost Sharing – Medicare Advantage | |
2023 Medicare Summary of Benefits Guide | |
2023 New Member Guide | |
2023 Making the Most Out of Your Plan | |
2022 – Official Plan Brochure | |
2022 – Summary of Benefits | |
2022 – Medicare Plan Brochure | |
2022 – Medicare Summary of Benefits Guide | |
Medicare Rewards Program – Medicare Advantage | |
Know Where to Go Guide | |
Contraceptive Management Exception Form | |
2023 Prescription Drug Guide/Formulary | |
2023 Prescription Drug Guide – Specialty Drugs | |
2023 Prescription Drug Guide – All Other Drugs | |
2022 Prescription Drug Guide/Formulary | |
2022 Prescription Drug Guide – Specialty Drugs | |
2022 Prescription Drug Guide – All Other Drugs | |
Specialty Quantity Limit Program – Drug List | |
Performance Drug List | |
Performance Drug List Change Summary | |
Claim Form – Medical | |
Claim Form – Mail Order Prescription | |
Claim Form – Prescription, Retail Pharmacy | |
Authorization for Release of Protected Health Information (PHI) |