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Find Medicare Advantage formularies and pharmacy documents here.
Medicare Advantage Plan Documents
- 2025
- 2024
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Annual Notice of Changes (ANOC)
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Evidence of Coverage (EOC)
Last Updated: 10/08/2024 -
Pharmacy Directory
Last Updated: 10/16/2024 -
Provider Directory
Last Updated: 11/01/2024 -
Summary of Benefits
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Annual Notice of Changes (ANOC)
-
Evidence of Coverage (EOC)
Last Updated: 10/08/2024 -
Provider Directory
Last Updated: 11/01/2024 -
Summary of Benefits
-
Annual Notice of Changes (ANOC)
-
Evidence of Coverage (EOC)
Last Updated: 10/08/2024 -
Pharmacy Directory
Last Updated: 10/16/2024 -
Provider Directory
Last Updated: 11/01/2024 -
Summary of Benefits
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Annual Notice of Changes (ANOC)
If you live in Hartford, Litchfield, Middlesex or Tolland County -
Annual Notice of Changes (ANOC)
If you live in Fairfield, New Haven, New London or Windham County
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Evidence of Coverage (EOC)
Last Updated: 10/08/2024 -
Pharmacy Directory
Last Updated: 10/16/2024 -
Provider Directory
Last Updated: 11/01/2024 -
Summary of Benefits
-
Annual Notice of Changes (ANOC)
-
Evidence of Coverage (EOC)
Last Updated: 10/08/2024 -
Pharmacy Directory
Last Updated: 10/16/2024 -
Provider Directory
Last Updated: 11/01/2024 -
Summary of Benefits
-
Annual Notice of Changes (ANOC)
-
Evidence of Coverage (EOC)
Last Updated: 10/08/2024 -
Pharmacy Directory
Last Updated: 10/16/2024 -
Provider Directory
Last Updated: 11/01/2024 -
Summary of Benefits
-
Annual Notice of Changes (ANOC)
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Annual Notice of Changes (ANOC)
Formerly known as ConnectiCare Choice Dual Vista (HMO-POS D-SNP)
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Evidence of Coverage (EOC)
Last Updated: 10/08/2024 -
Pharmacy Directory
Last Updated: 10/18/2024 -
Provider Directory
Last Updated: 11/01/2024 -
Summary of Benefits
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Evidence of Coverage (EOC)
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Plan Rating
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D-SNP Plan Rating
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LIS Premium Sheet
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Notice of Availability of Language Assistance Services and Auxiliary Aids and Services
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Annual Notice of Changes (ANOC)
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Evidence of Coverage (EOC)
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Pharmacy Directory
Last Updated: 11/19/2024 -
Provider Directory
Last Updated: 09/01/2024 -
Summary of Benefits
-
Annual Notice of Changes (ANOC)
-
Evidence of Coverage (EOC)
-
Provider Directory
Last Updated: 09/01/2024 -
Summary of Benefits
-
Annual Notice of Changes (ANOC)
-
Evidence of Coverage (EOC)
-
Pharmacy Directory
Last Updated: 11/19/2024 -
Provider Directory
Last Updated: 09/01/2024 -
Summary of Benefits
-
Annual Notice of Changes (ANOC)
If you live in Hartford, Litchfield, Middlesex or Tolland County -
Annual Notice of Changes (ANOC)
If you live in Fairfield, New Haven, New London or Windham County
-
Evidence of Coverage (EOC)
-
Pharmacy Directory
Last Updated: 11/19/2024 -
Provider Directory
Last Updated: 09/01/2024 -
Summary of Benefits
-
Annual Notice of Changes (ANOC)
-
Annual Notice of Changes (ANOC)
Formerly ConnectiCare Flex Plan 1 (HMO-POS)
-
Evidence of Coverage (EOC)
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Pharmacy Directory
Last Updated: 11/19/2024 -
Provider Directory
Last Updated: 09/01/2024 -
Summary of Benefits
-
Annual Notice of Changes (ANOC)
-
Evidence of Coverage (EOC)
-
Pharmacy Directory
Last Updated: 11/19/2024 -
Provider Directory
Last Updated: 09/01/2024 -
Summary of Benefits
-
Annual Notice of Changes (ANOC)
-
Evidence of Coverage (EOC)
-
Pharmacy Directory
Last Updated: 11/19/2024 -
Provider Directory
Last Updated: 09/01/2024 -
Summary of Benefits
-
Annual Notice of Changes (ANOC)
-
Evidence of Coverage (EOC)
-
Pharmacy Directory
Last Updated: 11/19/2024 -
Provider Directory
Last Updated: 09/01/2024 -
Summary of Benefits
-
Evidence of Coverage (EOC)
-
Plan Rating
-
D-SNP Plan Rating
-
LIS Premium Sheet
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Notice of Availability of Language Assistance Services and Auxiliary Aids and Services
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Vision, Hearing Aid Allowance and/or Over the Counter (OTC) Reimbursement Form
Use this form to file a claim for reimbursement of out of pocket costs of covered eyewear, hearing aids and/or OTC plan benefits (if applicable). Do not use this form for post-cataract eyewear reimbursement requests. Y0026_200572_C
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Dental Reimbursement Form
Use this form to send a claim for reimbursement of out-of-pocket costs for covered dental services. Y0026_203951_C
Last Updated: 11/02/2023 -
Authorization of Representative (AOR)
An enrollee may appoint any individual to act as his or her representative. To be appointed by an enrollee, both the enrollee making the appointment and the representative accepting the appointment must sign, date, and complete an authorization form. -
Clinical Review Preauthorization Request Form
Last updated: 7/06/2021 If you are seeking to obtain authorization of services or procedures included under ConnectiCare's preauthorization requirements.
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Coverage Determination Form
An exception is a type of coverage determination. You may ask for an exception if you need a drug that is not on our list of covered drugs. You may also ask for an exception to rules, such as a limit on the quantity of a drug. Y0026_201899_C
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Dental Provider Request Form
Use this form if we do not currently have your dentist listed as a participating provider.
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Authorization to Use and Disclose Protected Health Information - ConnectiCare
Last Updated: 05/24/2023
If you would like someone other than yourself to have access to your medical records, this written authorization is required for ConnectiCare to release a member's personal health information.
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Medicare IV Therapy Authorization Request Form
Last updated: 8/27/2019 If you are seeking to obtain authorization of IV therapy. -
Medicare Home Health Care Authorization Preauthorization Request Form
Last updated: 8/27/2019 If you are seeking to obtain authorization of home health care. -
Medicare Out-of-Network Clinical Review Preauthorization Request Form
Last updated: 8/27/2019 If you are seeking to obtain authorization of services or procedures by out-of-network providers. -
Out-of-Plan Reimbursement Form
Use this form when requesting reimbursement for a covered medical service that you paid out of your own pocket. Y0026_C19148_C -
Prescription Direct Reimbursement Form
Use this form to request reimbursement of drugs for which the member paid for out-of-pocket at the pharmacy. Y0026_201900_C
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Prescription Drug Redetermination Appeals Form
A written request to appeal a drug coverage decision.
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Last Update: 10/08/2024
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