Important Member Document
As a valued member of Provider Partners Health Plans in Pennsylvania, you can access your important documents at any time by clicking on the links below.
Member Materials
- 2024 Annual Notice of Change
- 2024 Summary of Benefits
(contains multi-language insert) - 2024 Evidence of Coverage
- 2024 Star Ratings
- 2024 LIS Summary
- Appointment of Representative Form CMS-1696
- Member Reimbursement Form
- Participating Providers
- Participating Pharmacies
- Appeals, Organizational Determinations, Coverage Determinations, Grievances
- Over The Counter (OTC) Catalog
Enrollment
Pharmacy Materials
Formulary 2024
- 2024 Comprehensive Formulary (Prescription Drugs)
(last updated 11/1/2024) - 2024 Prior Authorization Criteria
(last updated 11/1/2024) - 2024 Step Therapy Criteria
(last updated 11/1/2024) - 2024 Formulary (Prescription Drugs) Search Tool
Additional Pharmacy Information
- Coverage Determination, Appeals, and Grievances Information
- 2024 Request for Medicare Prescription Drug Coverage Determination Form
(last updated 10/15/2023) - 2024 Request for Medicare Prescription Drug Coverage Appeal (Redetermination) Form
(last updated 10/15/2023) - Online Medicare Prescription Drug Coverage Determination/Appeal (Redetermination)
- 2024 Medicare Prescription Drug Coverage Transition Policy
- 2024 Medication Therapy Management Program Description
Page Last Updated: 11/1/2024