Plan Materials and Forms

Summary of Benefits English Español
Evidence of Coverage English Español
Over-the-Counter Benefit English Español
Medicaid Advantage Plus Member Handbook
Medicaid Advantage Plus Member Handbook Complaints And Appeal Changes

Pharmacy

Formulary English Español
Formulary Changes
Medicare Part D Transition Policy
Pharmacy Quality Assurance
Medication Therapy Management Program
Medication Safety
Personal Medication List
Part D Prior Authorization Criteria
Part D Step Therapy Criteria
Pharmacy Directory English Español
Locate a Pharmacy

Forms

Medicare Advantage Enrollment Form English Español
Medicaid Advantage Plus Enrollment Form English Español
Request For Medicare Prescription Drug Coverage Determination
Request For Redetermination Of Medicare Prescription Drug Denial
Prescription Drug Claim Form
Prescription Drug Mail Order Form
New York State Health Care Proxy Form English Español
Appointment of Representative Form English Español

GuildNet Gold Provider Directory

Provider Directory: New York English Español Queens English Español Richmond English Español Kings English Español Bronx English Español
Provider Directory Addendum
Locate a Dental Provider
Locate a Provider
Request Provider, Pharmacy Directory or List of Covered Drugs (Formulary) by Mail

Important Links and Resources

Medicare Star Ratings English Español
Grievances Appeals Organization and Coverage Determinations English Español
Low Income Subsidy (LIS) Premium Summary Chart English Español
CMS Best Available Evidence Policy
Medicare Complaint Form
Passport To Good Health Rewards Program

Provider Materials

Fraud, Waste and Abuse Training for Providers
GuildNet Gold Model Of Care
Gold Model Of Care Training
Emblem Provider Manual
GuildNet Provider Manual
GuildNet Provider Portal Instructions
Part D Authorization Portal

Policy

Policy Notice
Non-Discrimination Notice

H6864_GN655_2018 Website­_Approved
Last Updated: 10/10/18