Helpful Information & Forms

2010 Member Resources

Evidence of Coverage (PDF) (English)
Evidence of Coverage (PDF) (Spanish)

Summary of Benefits (PDF) (English)
Summary of Benefits (PDF) (Spanish)

Benefits Highlights (PDF) (English)
Benefits Highlights (PDF) (Spanish)

Annual Notice of Changes (ANOC) (PDF) (English)
Annual Notice of Changes (ANOC) (PDF) (Spanish)

Member Rights & Responsibilities (PDF)
Membership ID Card Sample (PDF) 
Notice of Privacy Practices (PDF)

Formulary (PDF) (English/Spanish)
Provider Directory (PDF) (English/Spanish)
Pharmacy Directory (PDF) (English/Spanish)
Drug Transition Policy (PDF)

Drugs Requiring Prior Authorization (PDF)
Drugs Requiring Step Therapy (PDF)
Low Income Subsidy Premium Table (PDF)

2010 Forms

Enrollment Form (PDF) (English)
Enrollment Form (PDF) (Spanish)
Appointment of Representative Form (PDF)
L.A. Care Health Plan Medicare Part D Coverage Determination Request Form (PDF) (for Provider use)
L.A. Care Health Plan Request for Medicare Prescription Drug Coverage Determination (PDF) (for Member use)
Link to CMS Medicare Part D Coverage Determination Request Form (PDF) (for Provider use)
Link to CMS Request for Medicare Prescription Drug Coverage Determination (PDF) (for Member use)