Forms and Policies

Plan Forms and Policies

• 2019 Enrollment Form
• 2019 Low-Income Subsidy Table
• 2020 Enrollment Form
• 2020 Low-Income Subsidy Table
• Dental Reimbursement Form
• Out of Network and Emergency Care Policy

Prescription Drug Coverage Forms and Policies

• Medication Therapy Management Program
• Part D Prior Authorization
• Part D Step Therapy
• Part D Coverage Determination and Redetermiation
• 2019 Transition Period Drug Benefits
• 2020 Transition Period Drug Benefits

Payment Forms/Assistance

• Automatic Payment Withdrawal Form
• CMS Best Available Evidence Policy

Confidential and Representative Forms and Policies

• Notice of Privacy Practices
• Appointing a Representative
  

  You may choose someone to act on your behalf in filing a grievance, in requesting a coverage determination, and in requesting a redetermination. You may choose someone such as a relative, friend, sponsor, lawyer, or a doctor. A court may also appoint someone.

• Release of Protected Health Information (PHI)
  

  You may choose someone such as a family member of friend to share your Protected Health Information(PHI) with.

• Filing a Grievance or Complaint
  • Plan Specific Procedures for Filing a Grievance, Complaint, Coverage Decision or Appeal
  • Contact Information
  • How to File with the Federal Government
  • Request a Report or Have Questions
• Rights and Responsibilities When You End Your Plan

Helpful Resources

• 2019 Medicare and You
• 2019 Resource Guide
• 2020 Medicare and You
• 2020 Resource Guide for Core and Choice
• 2020 Resource Guide for Access
• Your Medicare Options
• Nondiscrimination Policy
• Translation Services