Summary of Benefits
(PDF)
Evidence of Coverage Option 1
(PDF)
Evidence of Coverage Option 2
(PDF)
Evidence of Coverage
(PDF)
Evidence of Coverage
(PDF)
Useful Telephone Numbers
Enrollment Guidelines
Forms
Formulary Search
Out-of-Network Pharmacy
(PDF)
Low-Income Subsidy Table Option 1
(PDF)
Low-Income Subsidy Table Option 2
(PDF)
Low-Income Subsidy Table
(PDF)
Low-Income Subsidy Table
(PDF)
Pharmacy Directory
(PDF)
Prescription Drug Plan Ratings
(PDF)
Drug Transition Policy (What if my drug is not on the formulary?)
(PDF)
Quality Assurance Policies & Procedures
(PDF)
Medication Therapy Management (MTM)
(PDF)
Can I Appoint a Representative?
Designate Someone to Speak on My Behalf
HIV Screening Notice
(PDF)
Report Fraud and Abuse
Privacy Notice
(PDF)
Disclaimers
You may qualify for
extra help
with your monthly premium and drug costs.
H4213_Adv 2011 Website Submission CMS Approved 10182010
Web Page Last Updated: 8/30/2011