Participant Materials – 2021

List of Materials

• Evidence of Coverage/Participant and Family Handbook

• Annual Notice of Change

• Summary of Benefits

• Comprehensive Formulary

  → 2021 PHP Searchable Formulary
  → Pharmacy Locator Tool

• Provider Directories by Service Area

  To request a copy of a provider directory, please send an email with the name of the requested county and your full mailing address to directoryrequests@phpcares.org.

  Can’t find a provider? Call us at 1-855-747-5483 or TTY/TDD: 711 for the most up to date provider listing.

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• Participant Rights and Responsibilities

• Multi-Language Insert

• Medication Therapy Management Program (for eligible participants who opt in)

• Out-of-Network Coverage Rules

• CMS Appointment of Representative Form (CMS Form - 1696)

  You can ask a friend, relative, your doctor or other provider, or another person to act for you as your “representative“ if you need assistance with a coverage determination, grievance, or appeal. To give a friend, relative, doctor or other provider, or another person the right to be your representative, download and print a copy of the Appointment of Representative Form in your preferred language. The form must be signed by you and the person whom you would like to act as your representative. The completed and signed form must be provided to PHP Care Complete FIDA-IDD Plan and will be valid for 1 year.

• Prior Authorization Criteria (Part D)

• Step Therapy Criteria