2021 Plan Information
The information provided here is intended to be a summary of our plan, effective January 1, 2021.
- Annual Notice of Changes (ANOC) ERRATA
- Annual Notice of Changes (ANOC) (English)
- Annual Notice of Changes (ANOC) (Spanish)
- Annual Notice of Changes (ANOC) (Arabic)
- Annual Notice of Changes (ANOC) (Vietnamese)
- Annual Notice of Changes (ANOC) (Tagalog)
- Member Handbook - Evidence of Coverage (EOC) (English)
- Member Handbook - Evidence of Coverage (EOC) (Spanish)
- Member Handbook - Evidence of Coverage (EOC) (Arabic)
- Member Handbook - Evidence of Coverage (EOC) (Vietnamese)
- Member Handbook - Evidence of Coverage (EOC) (Tagalog)
- Combined Pharmacy/Provider Directory-English
- Combined Pharmacy/Provider Directory (Spanish)
- Combined Pharmacy/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 (English)
- Summary of Benefits (English)
- Summary of Benefits (Spanish)
- Summary of Benefits (Arabic)
- Summary of Benefits (Vietnamese)
- Summary of Benefits (Tagalog)
- Drug Transition Policy
Forms
- Appointment of Representative Form (English)
- Appointment of Representative Form (Spanish)
- CMS Part D Coverage Determination Request Form (English)
- CMS Part D Coverage Redetermination Request Form (English)
- MedImpact Part D Coverage Determination Form
Additional Member Resources
Please click on the following link to access Centers for Medicare & Medicaid Services website:
Please click on the following link to access the Medicare and You Handbook:
Please click on the following link to obtain information on help with prescription drug costs:
https://www.ssa.gov/benefits/medicare/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.
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).
简体中文 (Mandarin)
请注意：如果您使用简体中文，可为您免费提供语言协助服务。请致电：加州医疗补助计划 Medi-Cal: 1-800-224-7766, Cal MediConnect: 1-888-244-4430 残障专线：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).
فارسی (Farsi)
توجه: اگر به زبان فارسی صحبت میکنید، خدمات کمک زبانی، بدون پرداخت هزینه، در اختیار شماست. با این مراکز تماس بگیرید:
Medi-Cal: 1-800-224-7766, Cal MediConnect: 1-888-244-4430 (TTY: 1-855-266-4584).
Last Website Update 12/13/2021
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