2015 Benefits & Resources

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Summary of Benefits
Annual Notice of Change
Evidence of Coverage
Formulary
Medication Management Therapy Program
Part D Clinical Prior Approval Drug List
* Medicare Part D Quantity Limits
Step Therapy Protocols
Medicare Part D Transition Policy
Plan Ratings
Personal Medication List
* Medicaid Member Hand Book
Formulary Changes
* Helping Medicare Part D Members with Medication Safety
* Pharmacy Quality Assurance Policies and Procedures
* Grievance, Exceptions, Coverage Determinations and Appeals
Low Income Subsidy (LIS) Premium Summary Chart
Privacy Notice
* National Coverage Determinations (NCD)
Mail Order
Multi-Language Interpreter Services
Provider and Pharmacy Directory (Bronx 2015, Brooklyn 2015, Manhattan 2015, Queens 2015, Suffolk 2015, Nassau 2015)
* Dental Directory
* Locate a Provider
Part D Coverage Determinations

Forms

Enrollment
Medicare Advantage Enrollment
Medicaid Advantage Plus Enrollment

How to Appoint a Representative
New York State Health Care Proxy
Appointment of Representative Form – CMS 1696

Medicare Advantage Prescription Drug Request
Medicare Coverage Part D Coverage Determination Request Form – For Members & Providers
Request for Medicare Prescription Drug Coverage Determination
Request for Redetermination of Medicare Prescription Drug Denial
Prescription Claim Reimbursement Form

Provider Materials
Fraud, Waste and Abuse Training for Providers
Model of Care CMS Training
GuildNet Gold Model of Care
Emblem Provider Manual
GuildNet Provider Manual
Provider Portal Instructions

Personal Medication List

Links

CMS Best Available Evidence Policy
Medicare Complaint Form

H6864_GN110b_Web15_Website_Pending
Last Updated: 1/1/2015