PHP, California

Rachel Sakai
AHF Provider

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 January 1, 2021; last updated September 3, 2020)
• 2021 Prescription Drug Prior Authorization Criteria (effective January 1, 2021)
• 2021 Prescription Drug Step Therapy Criteria (effective January 1, 2021)

2020 Plan Publications

• 2020 Summary of Benefits
• 2020 Quality and Performance Ratings (Every year, Medicare evaluates plans based on a 5-star rating system.)
• 2020 Annual Notice of Changes (ANOC)
• 2020 Evidence of Coverage
• 2020 Comprehensive Formulary (effective November 1, 2020; last updated October 23, 2020)
• 2020 Prescription Drug Prior Authorization Criteria (effective November 1, 2020)
• 2020 Prescription Drug Step Therapy Criteria (effective November 1, 2020)

Provider and Pharmacy Directories

• Search online using our Network Provider/Facility/Pharmacy Search application
• Provider and Part B Pharmacy Directory (last updated  October 1, 2020)
• Part D Pharmacy Directory (last updated October 1, 2020)

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