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Plan Materials
Here’s where you’ll find our most up-to-date information on health plan benefits, printable provider directories, claims and enrollment forms, and more.
Please note: You may need to install Adobe Acrobat Reader to view these documents on your desktop computer. You can get it here.
Call Member Services at 1-800-559-3500 for additional information. (TTY Users: 711). Hours are 8 a.m. to 8 p.m., seven days a week from October 1 to March 31.
From April 1 to September 30 hours are 8 a.m. to 8 p.m. Monday through Friday. Messages received on holidays and outside of our business hours will be returned within one business day.
From April 1 to September 30 hours are 8 a.m. to 8 p.m. Monday through Friday. Messages received on holidays and outside of our business hours will be returned within one business day.
- Annual Notice of Change
- Benefit Highlights
- Claims and Reimbursement Request Forms
- Enrollment Forms
- Evidence of Coverage Documents
- Explanation of Benefits
- Formulary Documents
- Grievance & Appeals
- Low Income Subsidy Premium Summary Charts
- 2020 Over-the-Counter Catalog – Classic, Heart First & Balance
- 2020 Over-the-Counter Catalog – Connections – English
- 2020 Over-the-Counter Catalog – Connections – Spanish
- 2020 Over-the-Counter Catalog – Plus, Prime
- 2020 Over-the-Counter Catalog – Compass
- 2020 Over-the-Counter Catalog – VillageHealth – English
- 2020 Over-the-Counter Catalog – VillageHealth - Spanish
- Part C Organizational Determination Process
- Provider and Pharmacy Directory
- Rights and Responsibilities Upon Disenrollment
- STAR Ratings
- Summary of Benefits
