Plan Materials &
Forms Library

Plan Materials:

• Abridged Formulary
• Comprehensive Formulary
• Summary of Benefits
• Evidence of Coverage

• Abridged Formulary
• Comprehensive Formulary
• Summary of Benefits
• Evidence of Coverage

Member Forms:

• Direct Member Reimbursement
• TrOOP Submission Form
• Appointment of Representative Form

Enrollment Forms:

Select State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington DC West Virginia Wisconsin Wyoming

*For plans starting Jan. 1st 2007
Please keep a copy for your records.

Additional Materials:

• Medicare Connection Newsletters
• Prescription Drug Spending Worksheet
• Pharmacy Directories
• Benefit Calculator
• Top 50 Covered Drugs
• Medicare Quick Facts
• Policies and Proceedures
• Exceptions and Appeals

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• Pharmacy Resources
• Physician Resources

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