Documents and forms

Summary of Benefits

A Summary of Benefits is a document that lists plan benefits and cost-sharing. 

Plan comparisons

This brochure outlines our benefits and cost information in an easy-to-read chart so that you can compare your options.

Evidence of Coverage

An Evidence of Coverage is a booklet that is part of your contract with us. It describes your complete benefits as well as how to use the plan.

You can find information about our grievance, coverage determination and appeal (and exceptions for Part D if the plan includes Part D) processes in your Evidence of Coverage. Please refer to the chapter called "What to do if you have a problem or complaint (coverage decisions, appeals, complaints)."

You can also find information about your rights and responsibilities as a member of our plan in your Evidence of Coverage. Please refer to the chapter called "Your rights and responsibilities."

Provider directories

These directories provide lists of network providers, including physicians, specialists, hospitals and other providers.


Annual Notice of Changes (ANOC)

An ANOC is a document which explains any changes in your coverage, costs, or service area that will be effective on January 1.


You can also request a printed formulary or directory.

Other benefit documents and forms

Benefit Bank forms

Medicare plan ratings

Enrollment and member change forms



Privacy forms

Call us toll-free at 1-888-340-5504 (TRS 711), 8 a.m.–8 p.m., seven days a week.
(Apr.–Sept., we are available 8 a.m.–8 p.m., Mon.–Fri.)

H9001_240093_C | The information on this page was last updated on 10/1/2023.

Every year, Medicare evaluates plans based on a 5-star rating system.