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Forms

Material Request Form PDF Document

Community Meeting Request Form PDF Document

Paper Claim Form for Medicare members PDF Document

Paper Claim Form for Non Medicare members PDF Document

Mail Order Prescription Form for members only PDF Document

Prescription Advantage Non Medicare Fact Sheet PDF Document MS Word Document

Prescription Advantage Medicare Fact Sheet PDF Document MS Word Document

Helpful ResourcesPDF Document

Instructions for Online Application Only PDF Document

Non Medicare Prescription Value Guide PDF Document

Prescription Advantage Disability Status Documentation PDF Document

Prescription Advantage Income Documentation PDF Document


Prescription Advantage Application Material (Paper)

Application Form PDF Document

Overview and Instructions PDF Document

Prescription Advantage Rate Schedule Guide for Members Eligible for Medicare PDF Document MS Word Document

Prescription Advantage Rate Schedule Guide for Members Not Eligible for Medicare PDF DocumentMS Word Document

Representative Authorization Forms PDF Document


Please note: If you need assistance with any of these documents in any other language, please call our customer service line at 800-243-4636 for translation assistance.