2025 Plan Information
The information provided here is intended to be a summary of our plan, effective January 1, 2025.
Annual Notice of Changes (ANOC)
- 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)
- Annual Notice of Changes (ANOC) (Chinese)
- Annual Notice of Changes (ANOC) (Farsi)
Member Handbook - Evidence of Coverage (EOC)
- 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)
- Member Handbook - Evidence of Coverage (EOC) (Chinese)
- Member Handbook - Evidence of Coverage (EOC) (Farsi)
Combined Pharmacy/Provider Directory
- 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)
- Combined Pharmacy/Provider Directory (Chinese)
- Combined Pharmacy/Provider Directory (Farsi)
List of Covered Drugs (Formulary)
- 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)
- List of Covered Drugs (Formulary) (Chinese)
- List of Covered Drugs (Formulary) (Farsi)
- Pharmacy Prior Authorization Criteria
- Pharmacy Step Therapy Criteria
Summary of Benefits
- Summary of Benefits (English)
- Summary of Benefits (Spanish)
- Summary of Benefits (Arabic)
- Summary of Benefits (Vietnamese)
- Summary of Benefits (Tagalog)
- Summary of Benefits (Chinese)
- Summary of Benefits (Farsi)
- Drug Transition Policy 2025
Over-the Counter (OTC) Benefit
- Over-the-Counter Benefit Catalog
- Over-the-Counter Benefit Catalog (Spanish)
- Over-the-Counter Benefit Catalog (Vietnamese)
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 (HMOD-SNP) is an HMO D-SNP health plan with a Medicare contract and a contract with the Medi-Cal program. Enrollment in CommuniCare Advantage depends on contract renewal.
ATTENTION: If you speak another language, language assistance services, free of charge, are available to you. Call 1-888-244-4430 , TTY users should call 1-855-266-4584, 24 hours a day, 7 days a week. The call is free.
ATENCIÓN: Si habla español, hay servicios de asistencia de idiomas disponibles sin cargo. Llame al 1-888-244-4430 (TTY: 1-855-266-4584). Las llamadas a estos números son gratuitas.
请注意:如果您说简体中文,可免费获得语言援助服务。请致电 1-888-244-4430 (听障专线:1-855-266-4584)。通话免费。
PANSININ: Kung nagsasalita kayo ng ibang wika, may mga paglingkod na pagtulong sa wika na maabot ninyo, na libre. Tawagan ang 1-888-244-4430 (TTY: 1-855-266-4584). Liber ang tawag na ito.
請注意:如果您說繁體中文,可免費獲得語言援助服務。請致電 1-888-244-4430 (聽障專線:1-855-266-4584)。通話免費。
CHÚ Ý: Nếu bạn nói tiếng Việt, các dịch vụ hỗ trợ ngôn ngữ, miễn phí, sẽ có sẵn cho bạn. Gọi số 1-888-244-4430 (TTY: 1-855-266-4584). Cuộc gọi được miễn phí.
1-888-244-4430 تنبيه: إذا كنت تتحدث اللغة العربية ، فأن خدمات المساعدة اللغوية متاحة لك بدون اي مقابل. إتصل بالرقم :
1-855-266-4584او الهاتف النصي :
كلا الرقمين متوفرين ٢٤ ساعة باليوم ٧ أيام بالاسبوع.
توجه: اگر به زبان فارسی صحبت میکنید، خدمات کمک زبانی، به صورت رایگان، در اختیار شماست. با3313-232-800-1 (پیامنگار: 4584-266-855-1) تماس بگیرید. تماس با این شمارهها رایگان است.
Last Website Update 9/30/2024
H4733_Website2025