2020 Medi-pak Rx
- Rights & responsibilities upon disenrollment - Basic [pdf]
- Rights & responsibilities upon disenrollment - Premier [pdf]
- Appointing or designating a representative
- EOC Appeals & Grievances - Basic [pdf]
- EOC Appeals & Grievances - Premier [pdf]
- Coverage determination and redetermination form - Basic
- Coverage determination and redetermination form - Premier
- CMS model electronic complaint form
- Annual Notice of Coverage - Basic [pdf]
- Annual Notice of Coverage - Premier [pdf]
- Medication therapy management
- Summary of benefits [pdf]
- Evidence of Coverage - Basic [pdf]
- Evidence of Coverage - Premier [pdf]
- Find a pharmacy - Basic
- Find a pharmacy - Premier
- Privacy notice
- Medicare Star Ratings [pdf]
- Medicare Star Ratings - Spanish Version [pdf]
- Formulary exceptions forms
- Prior authorization forms - Basic
- Prior authorization forms - Premier
- Request a pharmacy directory
- Find medicine - Basic
- Find medicine - Premier
- Low-Income Subsidy Table [pdf]
- Calculate my prescription drug costs
Y0083_MA Website
Last updated 10/01/2020