Summary of Benefits
This booklet gives you a summary of what we cover and what you pay. It doesn’t list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, call us and ask for the Evidence of Coverage.
Evidence of Coverage
This booklet gives you the details about your Medicare health care and prescription drug coverage from January 1 – December 31, 2020. It explains how to get coverage for the health care services and prescription drugs you need. This is an important document, so keep a link to it handy.
Prior Authorization Request Form
Appointment of Representation Form
Usually, there should not be a PA needed. But in rare cases, here is the form to request a prior authorization.
Prescription Drug Coverage Determination Request Form
Use this form when you want to ask for a coverage determination about a prescription drug.