Forms, guides and other resources

2025

Plan information

• Drug list (formulary) Jan. 1, 2025
  • English | Spanish
• Provider & Pharmacy Directory Jan. 1, 2025
  • English | Spanish
• Behavioral Health Provider Directory Jan. 1, 2025
  • English | Spanish
• Dental insert
  • English | Spanish
• Dental Schedule - VIP Plan and Platinum Card members
  • English | Spanish (coming soon)
• Dental Schedule - Gold Card members and Former Sharp HealthCare employees
  • English | Spanish (coming soon)
• Dental Schedule - Delta Dental Medicare Advantage PPO^™
  • English | Spanish (coming soon)

Drug list information

• Prior authorization requirements Jan. 1, 2025
• Step therapy requirementsJan. 1, 2025
• Future formulary change file Jan. 1, 2025

Forms

Ask for a coverage determination

• Coverage determination form
  • View PDF | Fill out online

• Request for redetermination form
  • View PDF | Fill out online

Ask for prior authorization

• Prior authorization request

• Continuity of care form

For new members

• Bank withdrawal pre-authorization form

• View PDF | Fill out online

Request a refund

• Part C member reimbursement request
• Part D prescription reimbursement claim
• Part D late enrollment penalty (LEP) reconsideration request

Share information with loved ones

• Appointment of representative
• Authorization for use or disclosure of protected health information (PHI)