Skip Ribbon Commands
Skip to main content
Materials and Forms 2027

2027 Materials and Forms

In order to help you find all materials needed to learn about our products, we designed this exclusive section. For full information of each form, please refer to their individual sections.

Evidence of Coverage

Summary of Benefits

Annual Notice of Change​

Durable Medical Equipment Formulary

Providers Directory

Providers Search tool
Providers and Pharmacies Directory
Authorization for use and/or disclosure of protected health information
Request for access to your protected health information
Request for accounting of disclosures
Request to amend protected health information
Request for Confidential Communications
Privacy complaint form
Request for the restriction of use and/or disclosure of protected health information
Request to revoke my authorization for use and or Disclosure of protected health information
Request for termination of a restriction for use and or Disclosure of protected health information
Automatic Discount Request Form (ACH)
Grievances Submission Form
Appeals Request Form
Appointment of Representative Form
Preauthorization Request Formulary
Direct Member Reimbursement Form - Pharmacy
Medical Expenses Reimbursement form
Reimbursement form for over the counter items (OTC) form
Request for Determination of Medicare Prescription Drug
Request for Hospice Information for Medicare Part D Form
Part D late enrollment penalty reconsideration request
Request for Reconsideration of Medicare Prescription Drug Denial form
Request for Redetermination of Medicare Prescription Drug Denial
Registration and Prescription Mail Order Form
Notice of Availability of Language Assistance Services and Auxiliary Aids and Services

​
Social