PHP, California

Rachel Sakai
AHF Provider

Publications and Forms

If you need a publication or form that is not available here, please contact Provider Relations.

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 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)

Provider Publications and Documents

• Delegated Roster Template
• Quick Reference Guide
• Improving HEDIS Scores
• Homeless Provider Communication
• NPI Tax ID Flyer
• Waiver of Liability Statement
• Prescription Drug Authorization Request
• Direct Referral Authorization Form
• Authorization Request Form
• Claims Dispute Submission Form
• Provider Grievance Form
• Injectable Drugs Requiring Pre-Service Approval (last updated May 1, 2013)
• California Pre-Service Injectable Drug Authorization Request
• 2018 Model of Care Summary
• 2014 Cultural & Linguistics Program
• PHP Provider Manual

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