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.
2024 Plan Publications
- 2024 Summary of Benefits
- 2024 Quality and Performance Ratings (Every year, Medicare evaluates plans based on a 5-star rating system.)
- 2024 Annual Notice of Changes (ANOC)
- 2024 Evidence of Coverage
- 2024 Comprehensive Formulary (effective August 1, 2024; last updated July 25, 2024)
- 2024 Prescription Drug Prior Authorization Criteria (effective August 1, 2024; last updated July 25, 2024)
- 2024 Prescription Drug Step Therapy Criteria (effective August 1, 2024; last updated July 25, 2024)
Provider and Pharmacy Directories
- Search online using our Network Provider/Facility/Pharmacy Search application
- Provider and Part B Pharmacy Directory (last updated July 01, 2024)
- Part D Pharmacy Directory (last updated July 01, 2024)
| 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
- Fitness Benefit Election Form
- Over-the-Counter Pharmacy Order Form (effective December 20, 2023)
- 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.
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Page Updated: August 7, 2024 @ 6:30pm