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Find Medicare Advantage formularies and pharmacy documents here.
Medicare Advantage plan documents
- 2021
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Annual notice of changes (ANOC)
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Evidence of coverage (EOC)
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Health plan guide
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Guía del plan de salud
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Pharmacy directory
Last updated: 11/13/2020
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Provider directory
Last updated: 1/4/2021
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Summary of benefits
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Evidence of coverage (EOC)
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Health plan guide
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Guía del plan de salud
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Over the counter (OTC) benefit catalog and order form
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Pharmacy directory
Last updated: 11/13/2020
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Provider directory
Last updated: 1/4/2021
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Summary of benefits
-
Annual notice of changes (ANOC)
-
Evidence of coverage (EOC)
-
Health plan guide
-
Guía del plan de salud
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Provider directory
Last updated: 1/4/2021
-
Summary of benefits
-
Annual notice of changes (ANOC)
-
Evidence of coverage (EOC)
-
Health plan guide
-
Guía del plan de salud
-
Pharmacy directory
Last updated: 11/13/2020
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Provider directory
Last updated: 1/4/2021
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Summary of benefits
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Annual notice of changes (ANOC)
If you live in Hartford, Litchfield, Middlesex or Tolland County
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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)
-
Health plan guide
-
Guía del plan de salud
-
Over the counter (OTC) benefit catalog and order form
-
Pharmacy directory
Last updated: 11/13/2020
-
Provider directory
Last updated: 1/4/2021
-
Summary of benefits
-
Annual notice of changes (ANOC)
-
Evidence of coverage (EOC)
-
Health plan guide
-
Guía del plan de salud
-
Pharmacy directory
Last updated: 11/13/2020
-
Provider directory
Last updated: 1/4/2021
-
Summary of benefits
-
Annual notice of changes (ANOC)
-
Evidence of coverage (EOC)
-
Health plan guide
-
Guía del plan de salud
-
Pharmacy directory
Last updated: 11/13/2020
-
Provider directory
Last updated: 1/4/2021
-
Summary of benefits
-
Annual notice of changes (ANOC)
-
Evidence of coverage (EOC)
-
Health plan guide
-
Guía del plan de salud
-
Pharmacy directory
Last updated: 11/13/2020
-
Provider directory
Last updated: 1/4/2021
-
Summary of benefits
-
Annual notice of changes (ANOC)
-
Evidence of coverage (EOC)
-
Health plan guide
-
Over the counter (OTC) benefit catalog and order form
-
Pharmacy directory
Last updated: 11/13/2020
-
Provider directory
Last updated: 1/4/2021
-
Summary of benefits
-
Evidence of coverage (EOC)
-
Health plan guide
-
Guía del plan de salud
-
Over the counter (OTC) benefit catalog and order form
-
Pharmacy directory
Last updated: 11/13/2020
-
Provider directory
Last updated: 1/4/2021
-
Summary of benefits
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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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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.
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Clinical review preauthorization request form
Last updated: 8/27/2019 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. Y0026_c1985_C
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HIPAA privacy release form
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.
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Medicare home health care authorization preauthorization request form
Last updated: 8/27/2019 If you are seeking to obtain authorization of home health care.
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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.
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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
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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. Y0026_127139_C
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Request for accounting of disclosures
A written request for ConnectiCare to share with the member any personal health information that ConnectiCare has shared for reasons other than to facilitate treatment, pay claims, or health plan operations.
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Request for confidential communication
Last updated: 8/27/2019 A written request for special handling of personal health information.
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Request for personal information
Last updated: 8/27/2019 A written request to obtain personal health information that ConnectiCare has on file about the member.
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Any information provided on this Website is for informational purposes only. It is not medical advice and should not be substituted for regular consultation with your health care provider. If you have any concerns about your health, please contact your health care provider's office. Also, this information is not intended to imply that services or treatments described in the information are covered benefits under your plan. Please refer to your Membership Agreement, Certificate of Coverage, Benefit Summary, or other plan documents for specific information about your benefits coverage.