2022 Plan Materials and Resources

Plan Materials

2022 Annual Notice of Changes (ANOC)

2022 Summary of Benefits

2022 Evidence of Coverage

2022 Provider and Pharmacy Directory

Bronx: Brooklyn: Manhattan: Queens:

2022 Formulary

Prescription Drug Claim Form

Appointment of Representative Form

Part D Coverage Determination Form

Member Reimbursement Form

Prescription Drug Mail Order Form

Privacy Notice

Part D Coverage Re-Determination Form

2022 Medicare Star Ratings

2022 Extra Help Premium Summary Table

Plan Resources

Member Resources

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Page Last Updated: 01/12/2022