2024 Plan Materials and Resources

Plan Materials

2024 Summary of Benefits

2024 Evidence of Coverage

2024 Addendum to ANOC, Summary of Benefits and Evidence of Coverage

2024 Formulary

Multi-Language Insert

Language Assistance and Notice of Non-Discrimination (LANN)

Prescription Drug Claim Form

Appointment of Representative Form

Health Care Proxy Form & Information

Part D Coverage Determination Form

Part D Coverage Re-Determination Form

Member Reimbursement Form

Privacy Notice

Enrollment Form

2024 Medicare Star Ratings

2024 Extra Help Premium Summary Table

MedImpact Forms

MedImpact Direct Referral Form

MID Mail Order Form English (updated 5/2024)

MID Mail Order Form Spanish (updated 6/2024)

MID Mail Order Form Chinese (updated 6/2024)

 

Plan Resources

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