Forms and Translated Materials


Appointment of Representative
Authorization to Disclose Protected Health Information
Automated Premium Payment (ACH) Form
Prescription Drug Mail-Order Form
Prescription Drug Claim Form
Prior Authorization
Request for Medicare Prescription Drug Coverage Determination Form
Request for Redetermination of Medicare Prescription Drug Denial Form
Physician Fax Form
File a Grievance (Please select your health plan and health plan type for information about filing a grievance.)
Step Therapy Form

en Español

Alternate formats for these materials, including Spanish translations, may be available. Please contact our Product Specialists for additional information.

Este material está disponible en otros formatos, incluida la traducción al Español. Contacte nuestro numero de Servicio al Cliente para obtener información adicional.

Materials in English Materiales en Español
Summary of Benefits
Y0096_BEN_NM_DSNPSB14b Accepted 02052014
Summary of Benefits en Español 
Y0096_BEN_NM_DSNPSB14bSPA Accepted 02052014
Drug List  
Y0096_MRK_TMP_MAFRMLRY14 Accepted 10012013
Drug list en Español  
Y0096_MRK_TMP_MAFRMLRY14SPA_NM DSNP Accepted 10012013
Pharmacy Directory  
Y0096_BEN_TMP_MAPHAR14 Accepted 10012013
Pharmacy Directory en Español  
Y0096_BEN_TMP_MAPHAR14SPA Accepted 10012013
Provider Directory  
Y0096_BEN_TMP_MAPRDIRCVR14a Approved 08132013
Provider Directory en Español  
Y0096_BEN_NM_DSNPPRDR14aSPA Accepted 10272013
Evidence of Coverage
Y0096_BEN_TMP_MAEOCCVR14 Approved 08222013
Evidence of Coverage en Español
Y0096_BEN_NM_HMOSNPEOC_2014aSPA Accepted 10312013.pdf