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This page gives members easy access to documents and forms for our Virginia Premier Advantage Elite (HMO D-SNP) plan. If you can’t find the document or form you need on this page, contact us at 1-877-739-1370 (TTY: 711).
Plan Documents and Forms
2023
- 2023 Enrollment Form (Updated 10/15/2022)
- 2023 Annual Notices of Changes (Updated 10/1/2022)
- 2023 Evidence of Coverage (Updated 10/15/2022)
- 2023 Summary of Benefits (Updated 1/20/2023)
- 2023 Comprehensive Formulary (List Covered Drugs) (Updated 9/1/2023)
- 2023 Abridged Formulary (List Covered Drugs) (Updated 9/1/2023)
- 2023 Prior Authorization Criteria (Updated 9/1/2023)
- 2023 Step Therapy Criteria (Updated 9/1/2023)
- 2023 Provider Directory – English (10/15/2022)
General Documents and Forms
Other Plan Documents and Forms
- 2023 ANOC and EOC IRA Addendum
- Disenrollment Rights & Responsibilities
- Member Rights & Responsibilities
- Multi-Language Interpreter Services
- Network Coverage
- Prescription Drug Transition Policy
- Prior Authorization/ Pre-Certification Portal
- CMS Appointment of Representative
- CMS Complaint Form
- Part D Redetermination Request (Appeal) Form
- Virginia Premier Medicare Advantage Opioid Drug Management Program
