Member Documents

• Annual Notice of Change
• Appointment of Representative Form (pdf)
• Appointment of Representative Instructions (pdf)
• Coverage Criteria and Utilization Management
• Coverage Determination Request Form (pdf)
• Drug Formulary
• Electronic Material Notice (pdf)
• Enrollment Application (pdf)
• Evidence of Coverage (EOC)
• Nascentia Health Plus Frequently Asked Questions (pdf)
• Grievances & Appeals
• HIPAA Release of Information
• LIS Premium Summary Chart (pdf), updated 10/01/2024
• Medication Therapy Management (MTM) Letter and Personal Medication List (pdf)
• Medication Therapy Management (MTM) Program Requirements
• Medicare Complaint Form
• Medicare Enrollment Help
• Medicare Plan Finder
• Medicare Star Rating (pdf)
• Member Rights & Responsibilities
• Nondiscrimination Notice (pdf)
• Pharmacy Directory
• Pharmacy Transition Process (pdf)
• Prior Authorization Requirements (pdf), updated 10/1/2024
• Prior Authorization Request Form (pdf)
• Privacy Policy
• Provider Directory
• Redetermination Request Form (pdf)
• Summary of Benefits – Nascentia Dual Advantage (D-SNP) (pdf), updated 10/01/2024
• Summary of Benefits – Nascentia Skilled Nursing Facility (I-SNP) (pdf), updated 10/01/2024

Last Updated on February 13, 2025