Plan Information
Summary of Benefits
Pharmacy Directory
Provider Directory
- Provider Search Tool
Plan Ratings
Evidence of Coverage
- Quality Improvement (PDF)
- Pharmacy Services (PDF)
- Additional Forms
Part D Prescription Drugs
- Drug Search
- Formulary (List of Covered Drugs)
- Notice of Formulary Change
- Transition Policy (PDF)
- Direct to Member Reimbursement
- Extra Help (LIS)
- Best Available Evidence Policy (BAE)
- Out-of-Network Coverage (PDF)
- Pharmacy Prior Authorization Criteria
- Step Therapy Criteria (PDF)
Notices & Policies
- Potential for Contract Termination and Disenrollment Rights (PDF)
- Appeals and Grievances -
Medicare Part C (PDF) - Appeals and Grievances -
Medicare Part C (PDF en Espaņol) - Appeals and Grievances -
Medicare Part D (PDF) - Appeals and Grievances -
Medicare Part D (PDF en Espaņol) - Part D Coverage Determinations and Exceptions (PDF)
- Part D Coverage Determination Form (PDF)
- Privacy Notice (PDF)
PDF Coming Soon!
