Member Resources

The information provided here is intended to be a summary of our plan, effective January 1, 2017.

• Member Handbook – Combined Annual Notice of Changes (ANOC), Evidence of Coverage (EOC) (English)
  
• Member Handbook – Combined Annual Notice of Changes (ANOC), Evidence of Coverage (EOC) (Spanish)
  
• Member Handbook – Combined Annual Notice of Changes (ANOC), Evidence of Coverage (EOC) (Arabic)
  
• Member Handbook – Combined Annual Notice of Changes (ANOC), Evidence of Coverage (EOC) (Vietnamese)
  
• Member Handbook – Combined Annual Notice of Changes (ANOC), Evidence of Coverage (EOC) (Tagalog)
  
• Pharmacy/Provider Directory Notice (English)
  
• Pharmacy/Provider Directory Notice (Spanish)
  
• Pharmacy/Provider Directory Notice (Arabic)
  
• Pharmacy/Provider Directory Notice (Vietnamese)
  
• Pharmacy/Provider Directory Notice (Tagalog)
  
• Combined Pharmacy-Provider Directory-English
  
• Combined Pharmacy-Provider Directory-Spanish
  
• Combined Pharm-Provider Directory-Arabic
  
• Combined Pharmacy-Provider Directory-Vietnamese
  
• Combined Pharmacy-Provider Directory-Tagalog
  
• List of Covered Drugs (Formulary) (English)
  
• List of Covered Drugs (Formulary) (Spanish)
  
• List of Covered Drugs (Formulary) (Arabic)
  
• List of Covered Drugs (Formulary) (Vietnamese)
  
• List of Covered Drugs (Formulary) (Tagalog)
  
• Pharmacy Prior Authorization Criteria
  
• Pharmacy Step Therapy Criteria
  
• Summary of Benefits (English)
  
• Summary of Benefits (Spanish)
  
• Summary of Benefits (Arabic)
  
• Summary of Benefits (Vietnamese)
  
• Summary of Benefits (Tagalog)
  
• Drug Transition Policy
  
• Multi-language Interpreter Services (PDF)
  
• Member ID Card

Forms

• Appointment of Representative Form (English) (PDF)
• Appointment of Representative Form (Spanish) (PDF)
• CMS Part D Coverage Redetermination Request Form (PDF)
• CMS Part D Coverage Determination Request Form (PDF)
• MedImpact Part D Coverage Determination Form

Additional Member Resources

Please click on the following link to access Centers for Medicare & Medicaid Services website:
www.cms.hhs.gov

Please click on the following link to access the Medicare and You Handbook:

Medicare and You Handbook

Please click on the following link to obtain information on help with prescription drug costs:

www.ssa.gov/prescriptionhelp

Disclaimers

CommuniCare Advantage Cal MediConnect Plan is a health plan that contracts with both Medicare and Medi-Cal to provide benefits of both programs to enrollees. Enrollment in CommuniCare Advantage Cal MediConnect Plan depends on contract renewal.

This is not a complete list. The benefit information is a brief summary, not a complete description of benefits. For more information contact the plan or read the Member Handbook.

Limitations, copays and restrictions may apply. For more information, call CommuniCare Advantage Cal MediConnect Customer Service or read the CommuniCare Advantage Cal MediConnect Member Handbook. Benefits, List of Covered Drugs, pharmacy and provider networks and/or copayments may change on January 1 of each year.

Copays for prescription drugs may vary based on the level of Extra Help you receive. Please contact the plan for more details.

English

ATTENTION: If you speak another language, language assistance services, free of charge, are available to you. Call: Medi-Cal: 1-800-224-7766, Cal MediConnect: 1-888-244-4430 (TTY: 1-855-266-4584).

Español (Spanish)

ATENCIÓN: Si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al: Medi-Cal: 1-800-224-7766, Cal MediConnect: 1-888-244-4430 (TTY: 1-855-266-4584).

Tiếng Việt (Vietnamese)

CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số: Medi-Cal: 1-800-224-7766, Cal MediConnect: 1-888-244-4430 (TTY: 1-855-266-4584).

Tagalog (Tagalog - Filipino)

PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa: Medi-Cal: 1-800-224-7766, Cal MediConnect: 1-888-244-4430 (TTY: 1-855-266-4584).

العربیة (Arabic)

ملحوظة: اذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة  اللغوية تتوافر لك بالمجان. اتصل برقم

Medi-Cal: 1-800-224-7766, Cal MediConnect: 1-888-244-4430 (TTY: 1-855-266-4584)

Last update 01/18/2018

H5172_Website2017 Approved 1/17/17