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 PDF
2023 – Official Plan Brochure PDF
2023 – Medicare Plan Brochure PDF
2023 Medicare – 2023 Evidence of Coverage – Medicare Advantage PDF
2023 Medicare – 2023 Schedule of Cost Sharing – Medicare Advantage PDF
2023 Medicare Summary of Benefits Guide PDF
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
Know Where to Go Guide PDF
Contraceptive Management Exception Form 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