Participant Materials – 2019

List of Materials

• Annual Notice of Change

• Participant Rights and Responsibilities

• Nondiscrimination Notice

• Summary of Benefits

• Evidence of Coverage / Participant and Family Handbook

• Comprehensive Formulary

  2019 PHP Searchable Formulary

• Multi-language Insert

• 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.

• 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.

• Coverage Determination Form (Part D)

• Coverage Redetermination Form (Part D)

• Prior Authorization Criteria (Part D)

• Step Therapy Criteria (Part D)

• Prescription Drug Transition Policy

• Personal Medication List Form

• Information on our Provider Directory

• Mail Order Prescriptions