Member Materials

Materials for All Plan Types

Grievances and Appeals

Use these forms to file an appeal about coverage or payment decisions or to file a grievance if you have concerns about your plan, providers or quality of care.

• Member Claim Form
• How to File a Claim?
• Member Appeal Form
• Member Appeal Form (Spanish)
• Member Grievance Form
• Member Grievance Form (Spanish)
• Discrimination Grievance Form
• Discrimination Grievance Form (Spanish)

Your Rights

You'll find notices and forms in this section that help you understand your rights and responsibilities and make requests related to those rights.

• Appointment of Representative Form
• Appointment of Representative Form (Spanish)
• HIPAA Form
• HIPAA Form (Spanish)
• Personal Representative Request Form
• Personal Representative Request Form (Spanish)
• Notice of Privacy Practices
• Confidential Communication Request Form
• Confidential Communication Request Form (Spanish)
• Disclosure Accounting Form
• Disclosure Accounting Form (Spanish)
• Access Request Form
• Access Request Form (Spanish)
• Restriction Request Form
• Restriction Request Form (Spanish)
• Request to Amend Records Form
• Request to Amend Records Form (Spanish)
• Privacy Complaint Form

Materials for Mississippi‑Shared Health Dual Plus (HMO D‑SNP)^SM and Shared Health Dual Freedom (PPO D‑SNP)^SM Plans

Enrollment

• Mississippi Plan Non-Renewal Notice

Benefits and Coverage

These documents contain information about your benefits, network and coverage.

• 2025 Low Income Subsidy (LIS) Premium Summary Chart (Dual Plus (HMO D-SNP)SM)
• 2025 Low Income Subsidy (LIS) Premium Summary Chart (Dual Freedom (PPO D-SNP)SM)
• 2025 Summary of Benefits (Updated: 10/1/2024)
• 2025 Dual Plus (HMO D-SNP)SM Evidence of Coverage (EOC) (Updated: 10/1/2024)
• 2025 Dual Freedom (PPO D-SNP)SM Evidence of Coverage (EOC) (Updated: 10/1/2024)
• 2025 Dental Benefits Guide
• OTC and Utility Reimbursement Form
• 2025 Plan Rating (HMO D-SNP)
• 2025 Plan Rating (PPO D-SNP)
• Star Rating Letter (HMO D-SNP)

Pharmacies and Prescriptions

These documents offer information about your covered drug benefits.

• 2025 Dual Plus Covered Drug List (Formulary) (Updated: 12/1/2025)
• 2025 Dual Freedom Covered Drug List (Formulary) (Updated: 12/1/2025)
• Over-the-Counter Catalog
• Part D Prescription Drug Claim Form
• Request for Medicare Prescription Drug Coverage Determination Form (Updated: 12/1/2023)
• Request for Redetermination of Medicare Prescription Drug Denial Form (Updated: 12/1/2023)
• 2025 Medicare Part D Prior Authorization Criteria (Updated: 12/1/2025)
• Medicare Part B Step Therapy Guide (Updated: 12/1/2025)
• Provider-Administered Specialty Medication List (Updated: 12/2/2025)
• Provider-Administered Medication Authorization Form
• Medicare Part B Prior Authorization Criteria

Materials for Texas Shared Health Dual Freedom (PPO D‑SNP)^SM Plan

Enrollment

• Texas Plan Non-Renewal Notice

Benefits and Coverage

These documents contain information about your benefits, network and coverage.

• 2025 Low Income Subsidy (LIS) Premium Summary Chart
• 2025 Low Income Subsidy (LIS) Premium Summary Chart (Spanish)
• 2025 Summary of Benefits (Updated: 10/01/2024)
• 2025 Summary of Benefits (Spanish) (Updated: 10/01/2024)
• 2025 Evidence of Coverage (EOC) (Updated: 10/01/2024)
• 2025 Evidence of Coverage (EOC) (Spanish) (Updated: 10/01/2024)
• 2025 Dental Benefits Guide
• 2025 Plan Rating (PPO D-SNP)
• 2025 Plan Rating (PPO D-SNP) (Spanish)
• OTC and Utility Reimbursement Form

Pharmacies and Prescriptions

These documents offer information about your covered drug benefits.

• 2025 Dual Freedom Covered Drug List (Formulary) (Updated: 12/2/2025)
• 2025 Dual Freedom Covered Drug List (Formulary) (Spanish) (Updated: 12/2/2025)
• Over-the-Counter Catalog
• Part D Prescription Drug Claim Form
• Request for Medicare Prescription Drug Coverage Determination Form (Updated: 12/1/2023)
• Request for Redetermination of Medicare Prescription Drug Denial Form (Updated: 12/1/2023)
• Medicare Part B Prior Authorization Criteria
• Medicare Part B Step Therapy Guide (Updated: 12/2/2025)
• 2025 Medicare Part D Prior Authorization Criteria (Updated: 9/1/2025)
• Provider-Administered Specialty Medication List (Updated: 12/2/2025)
• Provider-Administered Medication Authorization Form