A Healthy CollaborationSM

Forms and Documentation

Review the Summary of Benefits and the Evidence of Coverage to find more detailed information about your plan.

Summary of Benefits

Download Summary of Benefits for your region:

Evidence of Coverage

Appeals and Grievances

If we deny all or part of your coverage determination request, you or your appointed representative may ask us to reconsider our decision. This is called an appeal or re-determination.

A grievance is different from an appeal because usually it will not involve complaints regarding coverage or payment for prescription drugs included in Medicare prescription drug coverage benefits.

S5803_08P0434_v6 (01/2009) Last Updated: 01/01/2022

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