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Helpful Information & Forms
Helpful Information & Forms
2013 Member Resources
Evidence of Coverage (PDF) (English)
Evidence of Coverage (PDF) (Spanish)
Evidence of Coverage (PDF) (Chinese)
Summary of Benefits (PDF) (English)
Summary of Benefits (PDF) (Spanish)
Summary of Benefits (PDF) (Chinese)
Dental Benefits & Directory (PDF) (English/Spanish)
Dental Benefits & Directory (PDF) (Chinese)
Annual Notice of Changes (ANOC) (PDF) (English)
Annual Notice of Changes (ANOC) (PDF) (Spanish)
Annual Notice of Changes (ANOC) (PDF) (Chinese)
Medicare Plan Star Ratings (PDF) (English)
Medicare Plan Star Ratings (PDF) (Spanish)
Medicare Plan Star Ratings (PDF) (Chinese)
Member Rights & Responsibilities (PDF) (English)
Member Rights & Responsibilities (PDF) (Spanish)
Membership ID Card Sample (PDF)
Notice of Privacy Practices (PDF) (English)
Notice of Privacy Practices (PDF) (Spanish)
Notice of Privacy Practices (PDF) (Chinese)
Multi-language Insert (PDF) (English/Spanish/Chinese)
Formulary (PDF) (English/Spanish)
Provider Directory (PDF) (English/Spanish)
Pharmacy Directory (PDF) (English/Spanish)
Drug Transition Policy (PDF) (English)
Drug Transition Policy (PDF) (Spanish)
Drugs Requiring Prior Authorization (PDF)
Drugs Requiring Step Therapy (PDF)
Low Income Subsidy Premium Table (PDF) (English)
Low Income Subsidy Premium Table (PDF) (Spanish)
Low Income Subsidy Premium Table (PDF) (Chinese)
Low Income Subsidy Premium Table (PDF) (Korean)
Prescription Drug Mail Order Information (PDF) (English)
Prescription Drug Mail Order Form (PDF) (English)
Prescription Drug Mail Order Form (PDF) (Spanish)
Disease Management Program Information
L.A. Cares About Asthma and L.A. Cares About Diabetes are programs that help people with asthma and diabetes stay healthy. These free programs are staffed by a team of doctors, nurses and other health care team members. We want members and their families to be part of the health care team, too. As part of these programs you will get:
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- Information on what causes asthma or diabetes and how you can stay healthy
- Tips on how to control your asthma or diabetes
- A chance to talk to a nurse or educator. We can talk about ways to get you the best care.
Members are signed up for these programs when our records show that you have asthma or diabetes. If you want to be taken out of the program, call us at the phone numbers below, 24 hours per day, 7 days per week.
- Call (888) 200-3094 (TTY/TDD 1-888-448-6894), if you have questions about asthma, want to self refer, or enroll/disenroll yourself into L.A. Cares About Asthma.
- Call (866) 756-2048 (TTY/TDD 1-866-782-7237), if you have questions about diabetes, want to self refer, or enroll/disenroll yourself into L.A. Cares About Diabetes.
2013 Forms
Enrollment Form (PDF) (English)
Enrollment Form (PDF) (Spanish)
Appointment of Representative Form (PDF)
L.A. Care Health Plan Request for Medicare Prescription Drug Coverage Determination (PDF)
L.A. Care Health Plan Request for Redetermination of Medicare Prescription Drug Denial (PDF)
American Sign Language (ASL)
Interpreters are available by calling our Member Services Department at 1-888-522-1298 (TTY/TDD 1-866-522-2731). L.A. Care Health Plan representatives are available 24 hours a day, 7 days a week including holidays. Click on the following links for a video in ASL on how to get an interpreter.
Why it's Important to Use an Interpreter (Video 3:34 min)
Rights and Responsibilities (Video 2:08 min)
How To Get Interpreter Services (Video 4:31 min)
H2643_4006_LA2013A CMS Approved 01302013
Updated 5/1/2013
