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I have a question I would like to request a SCAN form I would like to change my contact information I would like to request a replacement Member ID card I would like to request information Click on the box indicating the form you would like: Mail Order Pharmacy Request Auto-Pay Application - For Kern, Ventura, and San Diego Signature Members Please indicate below where you would like the materials sent. Address Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware D.C. Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming City State Zip Please enter all the information that has changed. 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Click on the box indicating the material you would like: Evidence of Coverage - All counties included Summary of Benefits - Los Angeles, Orange, Riverside and San Bernardino Summary of Benefits - Kern, Ventura Summary of Benefits - San Diego County Summary of Benefits - San Diego Signature Plan Drug Formulary - Los Angeles, Orange, Riverside and San Bernardino Drug Formulary - Kern, Ventura Drug Formulary - San Diego County Drug Formulary - San Diego Signature Plan Provider Directory - Los Angeles Provider Directory - Orange Provider Directory - Riverside and San Bernardino Provider Directory - Kern, Ventura Provider Directory - San Diego County Provider Directory - San Diego Signature Plan Marque aquí si desea estos materiales en Español Please indicate below where you would like the materials sent. Address Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware D.C. 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