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 | |
| 2022 – Official Plan Brochure | |
| 2022 – Summary of Benefits | |
| 2022 – Medicare Plan Brochure | |
| 2022 – Medicare Summary of Benefits Guide | |
| Medicare Rewards Program – Medicare Advantage | |
| 2022 New Member Guide | |
| 2022 Making the Most Out of Your Plan | |
| Know Where to Go Guide | |
| Contraceptive Management Exception Form | |
| Prescription Drug Guide/Formulary | |
| Prescription Drug Guide – Specialty Drugs | |
| 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) |