Member materials
2026 plan year materials:
- 2026 Annual Notice of Change – English (PDF)
- 2026 Annual Notice of Change – Spanish (PDF)
- 2026 Evidence of Coverage – English (PDF)
- 2026 Evidence of Coverage - Spanish (PDF)
- 2026 Summary of Benefits – English (PDF)
- 2026 Summary of Benefits – Spanish (PDF)
- 2026 Enrollment form – English (PDF)
- 2026 Enrollment form - Spanish (PDF)
2027 Plan year materials:
- 2027 Annual Notice of Change – English (PDF)
- 2027 Annual Notice of Change – Spanish (PDF)
- 2027 Evidence of Coverage – English (PDF)
- 2027 Evidence of Coverage - Spanish (PDF)
- 2027 Summary of Benefits – English (PDF)
- 2027 Summary of Benefits – Spanish (PDF)
- 2027 Enrollment form – English (PDF)
- 2027 Enrollment form - Spanish (PDF)
Privacy materials:
Printable forms
Prior authorization-related forms
- Medical Prior authorization form (PDF)
- Hospice exception form (PDF)
- Part D Coverage determination form – English (PDF)
- Part D Coverage determination form – Spanish (PDF)
Complaint and appeal-related forms
- Appointment of representative (PDF)
- Part D coverage redetermination form – English (PDF)
- Part D coverage redetermination form – Spanish (PDF)
Information and privacy-related forms
- Authorization to release protected health information (PDF)
- Request for an accounting of disclosures of protected health information (PDF)
- Member Appointment Assistance Form (PDF)
Benefits and services-related forms
Interactive forms
H6399_8910650_2027_M