Plan Documents


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The following documents can help you get more information about this Medicare Prescription Drug plan, enroll in a plan and more.


General Plan Information 
Annual Notice of Change Basic (PDP) English PDF Document 
en Espanol PDF Document
Annual Notice of Change Value (PDP) English PDF Document 
en Espanol PDF Document
Annual Notice of Change Plus (PDP) English PDF Document 
en Espanol PDF Document
Evidence of Coverage Basic (PDP) English PDF Document 
en Espanol PDF Document
Evidence of Coverage Value (PDP) English PDF Document 
en Espanol PDF Document
Evidence of Coverage Plus (PDP) English PDF Document 
en Espanol PDF Document
Summary of Benefits (PDP) English PDF Document 
en Espanol PDF Document
Prescription Drug Forms
Mail- Order Physician New Prescription Fax Form PDF Document
Pharmacy Mail-Order Form PDF Document
Prescription Drug Claim Form PDF Document 
Medicare Part B vs. Part D Form PDF Document 
Additional Resources
Authorization to Disclose Protected Health Information (PHI) Form PDF Document 
Automated Premium Payment (ACH) Form PDF Document 
CMS Appointment of Representative Form PDF Document
Direct Member Reimbursement Form PDF Document
Multi-language Interpreter Services PDF Document
Notice of Privacy Practices PDF Document