Resources / Materials

• Annual Notice of Changes - English (PDF) 
• Annual Notice of Changes - Spanish (PDF) 

• Member Handbook - English (PDF)
• Member Handbook - Spanish (PDF)

• How to request a Member Handbook by Mail - English (PDF)
• How to request a Member Handbook by Mail - Spanish (PDF)

• 2024 Summary of Benefits - English (PDF)
• 2024 Resumen de Beneficios - Spanish (PDF)

• Prescription Drug Claim Form-English (PDF)
• Prescription Drug Claim Form-Spanish (PDF)

• Express Scripts Mail Order Form-English (PDF)
• Express Scripts Mail Order Form-Spanish (PDF)

• List of Drugs (Formulary)

• List of Drugs Change Notice

• Drug Coverage Determination
• Drug Redeterminations (Appeals)

• Part D Prior Authorization Criteria Form

• Part D Step Therapy Criteria Form

• Appointment of Representative Form-English (PDF)Oct 1, 2023
• Appointment of Representative Form Spanish (PDF)Oct 1, 2023

Your current health plan offers an over-the-counter (OTC) benefit that lets you buy OTC health and wellness products. The catalog includes a list of OTC items that you can order and have mailed directly to your home.

There are three ways to order—in store, online, or by phone.  You can also download the new OTC Health Solutions App. The app is an easy and quick way to scan items in store, view your benefit information and items offered, process an order, review past orders, and look up account information. Ordering is easy. Just follow the steps in your plan's catalog.

Click on the OTC Catalog link below for all of your benefit details:

• Over-the-Counter Catalog - English (PDF)
• Over-the-Counter Catalog - Spanish (PDF)

You can also connect to CVS® OTC Health Solutions to review products and store information.

• Covered Diabetes Testing Supplies (PDF)

• PCP Change Request Form - English (PDF)  - coming soon
• PCP Change Request Form - Spanish (PDF)  - coming soon

• Part B Step Therapy - English (PDF)
• Part B Step Therapy - Spanish (PDF)

• Annual Notice of Changes - English (PDF)
• Annual Notice of Changes - Spanish (PDF)

• Member Handbook - English (PDF)
• Member Handbook - Spanish (PDF)

• Summary of Benefits - English (PDF)
• Summary of Benefits - Spanish (PDF)

• Prescription Drug Claim Form - English (PDF)
• Prescription Drug Claim Form - Spanish (PDF)

Your current health plan offers an over-the-counter (OTC) benefit that lets you buy OTC health and wellness products. The catalog includes a list of approved OTC items that you can order and have mailed directly to your home or pick up at a local CVS community pharmacy.

There are three ways to place an order—in store, online, or by phone.  You can also download the OTC Health Solutions App from the App Store (iOS) or Google Play (Android). The app  will allow you to process an order, view past orders, view account information, and more!

Ordering is easy. Just follow the steps in your plan's catalog.

Click on the OTC Catalog link below for all of your benefit details:

• Over-the-Counter Catalog - English (PDF)
• Over-the-Counter Catalog - Spanish (PDF)

You can also connect to CVS® OTC Health Solutions to review products and store information.

• Covered Diabetes Testing Supplies (PDF)

Express Scripts® Pharmacy Forms:

• Express Scripts Pharmacy Mail Order Form - English (PDF)
• Formulario de pedidos por correo de Express Scripts Pharmacy – Español (PDF)

• PCP Change Request Form - English (PDF)
• PCP Change Request Form - Spanish (PDF)

• Part B Step Therapy (PDF)