Publications and Forms

The following publications and forms are for plan members. All publications below are applicable to the plan year indicated. If you need a publication or form that is not listed below, please contact Member Services. If you would like a printed copy of any of the documents below, please contact Member Services.

2021 Plan Publications

2021 Summary of Benefits
2021 Quality and Performance Ratings (Every year, Medicare evaluates plans based on a 5-star rating system.)
2021 Annual Notice of Changes (ANOC)
2021 Evidence of Coverage
2021 Comprehensive Formulary (effective April 1, 2021; last updated March 23, 2021)
2021 Prescription Drug Prior Authorization Criteria (effective April 1, 2021)
2021 Prescription Drug Step Therapy Criteria (effective April 1, 2021)

Provider and Pharmacy Directories

Search online using our Network Provider/Facility/Pharmacy Search application
Provider and Part B Pharmacy Directory (last updated April 1, 2021)
Part D Pharmacy Directory (last updated April 1, 2021)

To report any errors in the PHP provider or pharmacy, please send an email to [email protected], or send a message using our web form. You may also report directory errors by calling Member Services at (800) 263-0067, Option 2 (TTY 711). Agents are available 8:00 am to 8:00 pm, seven days a week.

Other Publications and Forms

Appointment of a Representative Form and Information
Notice of Privacy Practices
Health and Wellness Benefit Option Election
Over-the-Counter Pharmacy Order Form (effective April 13, 2020)
Enrollee Demographics Questionnaire

You will need the Adobe Acrobat Reader program to view the above forms. To download this free program click here or use the link above – the link will open a new window and take you to the Adobe website.

H5852_4006 101520_2021

PHP, California