2018 Benefits & Resources


Summary of Benefits
Annual Notice of Change

Evidence of Coverage
Over-the-Counter Benefit
Medicare Star Ratings
Grievances Appeals Organization and Coverage Determinations
Formulary Changes 
Low Income Subsidy (LIS) Premium Summary Chart
Medicare Part D Transition Policy
Pharmacy Quality Assurance
Medication Safety
Personal Medication List
Medication Therapy Management Program
Part D Prior Authorization Criteria
Part D Step Therapy Criteria
Pharmacy Directory
Provider Directory: New York Queens Richmond Kings Bronx
Provider Directory Addendum
Locate a Dental Provider
Locate a Provider
Locate a Pharmacy
Request Provider/Pharmacy Directory or List of Covered Drugs (Formulary) by Mail
Privacy Notice
Non-Discrimination Notice

Enrollment Forms
Medicare Advantage Enrollment
Medicaid Advantage Plus Enrollment Form

Medicare Advantage Prescription Drug Request
Request for Medicare Prescription Drug Coverage Determination
Request for Redetermination of Medicare Prescription Drug Denial

Prescription Drug Claim Form
Prescription Drug Mail Order Form
Part D Authorization Portal

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

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
Provider Portal Instructions

H6864_GN655_2018 Website­_Approved
Last Updated: 3/19/18