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.
2023 Plan Publications
- 2023 Summary of Benefits
- 2023 Quality and Performance Ratings (Every year, Medicare evaluates plans based on a 5-star rating system.)
- 2023 Annual Notice of Changes (ANOC)
- 2023 Evidence of Coverage
- 2023 Comprehensive Formulary (effective January 1, 2023; last updated October 7, 2022)
- 2023 Prescription Drug Prior Authorization Criteria (effective January 1, 2023; last updated November 14, 2023)
- 2023 Prescription Drug Step Therapy Criteria (effective January 1, 2023; last updated November 14, 2023)
2022 Plan Publications
- 2022 Summary of Benefits
- 2022 Quality and Performance Ratings (Every year, Medicare evaluates plans based on a 5-star rating system.)
- 2022 Annual Notice of Changes (ANOC)
- 2022 Evidence of Coverage
- 2022 Comprehensive Formulary (effective December 1, 2022; last updated November 23, 2022)
- 2022 Prescription Drug Prior Authorization Criteria (effective December 1, 2022)
- 2022 Prescription Drug Step Therapy Criteria (effective December 1, 2022)
Provider and Pharmacy Directories
- Search online using our Network Provider/Facility/Pharmacy Search application
- Provider and Part B Pharmacy Directory (last updated August 1, 2022)
- Part D Pharmacy Directory (last updated August 1, 2022)
| To report any errors in the PHP provider or pharmacy, please send an email to [email protected]. 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 101422_2023
