Member Forms & Resources

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We have provided free forms and resources to help answer any questions you may have. You may download and save this documentation to your computer or device for future reference.

• ANOC - Important Information
  • 2019
    • English
      • AllCare Preferred Plan (HMO)
      • CalPlus Plan (HMO)
      • Heart & Diabetes (HMO SNP)
      • My Choice Plan (HMO) - LA,OC, Riv and SB
      • My Choice Plan (HMO) - Santa Clara
      • My Choice Plan (HMO) - Stanislaus and San Joaquin
      • Platinum Plan (HMO)
      • smartHMO (HMO)
    • Spanish
      • AllCare Preferred Plan (HMO)
      • CalPlus Plan (HMO)
      • Heart & Diabetes (HMO SNP)
      • My Choice Plan (HMO) - LA,OC, Riv and SB
      • My Choice Plan (HMO) - Santa Clara
      • My Choice Plan (HMO) - Stanislaus and San Joaquin
      • Platinum Plan (HMO)
      • smartHMO (HMO)

• Appointment of a Representative

  English

  Spanish

• Best Available Evidence

  Best Available Evidence

• CMS Fraud Awareness Tools

  Identity Theft Prevention Tips

  Consejos para la prevención del robo de identidad

  Protecting Medicare for Future Generations

  Protegiendo Medicare para futuras generaciones

• Dental Benefit Information
  • 2019
    • Dental Benefits - All Other Plans - English
    • Dental Benefits - smartHMO - English
    • Dental Directory - All Plans - English and Spanish

• Drug Formulary
  • 2019
    • English and Spanish - All Plans

  *PDFs last updated September 01, 2019

  Click here to request a printed Drug Formulary

• Enrollment Forms
  • 2019
    • English
      • Enrollment Application - (All Other Plans)
      • Enrollment Application - (Heart & Diabetes Plan)
      • Pre Qualification Form - (Heart & Diabetes Plan)
    • Spanish
      • Enrollment Application - (All Other Plans)
      • Enrollment Application - (Heart & Diabetes Plan)
      • Pre Qualification Form - (Heart & Diabetes Plan)

• Evidence of Coverage
  • 2019
    • English
      • AllCare Preferred Plan (HMO)
      • CalPlus Plan (HMO)
      • Heart & Diabetes (HMO SNP)
      • My Choice Plan (HMO) - LA,OC, Riv and SB
      • My Choice Plan (HMO) - Santa Clara
      • My Choice Plan (HMO) - Stanislaus and San Joaquin
      • Platinum Plan (HMO) - Los Angeles and Orange
      • Platinum Plan (HMO) - Riverside and San Bernardino
      • Platinum Plan (HMO) - San Diego
      • smartHMO (HMO)
    • Spanish
      • AllCare Preferred Plan (HMO)
      • CalPlus Plan (HMO)
      • Heart & Diabetes (HMO SNP)
      • My Choice Plan (HMO) - LA,OC, Riv and SB
      • My Choice Plan (HMO) - Santa Clara
      • My Choice Plan (HMO) - Stanislaus and San Joaquin
      • Platinum Plan (HMO) - Los Angeles and Orange
      • Platinum Plan (HMO) - Riverside and San Bernardino
      • Platinum Plan (HMO) - San Diego
      • smartHMO (HMO)

  Click here to request a printed Evidence of Coverage booklet

• Grievance & Appeals Form

  English

  Spanish

• Healthy Rewards Catalog
  • 2019
    • English
      • CalPlus & My Choice Plans
      • Other Plans
    • Spanish
      • CalPlus & My Choice Plans
      • Otros Planes

• Low Income Subsidy (LIS) Levels
  • 2019
    • English
    • Spanish

• Multi-language Interpreter Services

  Multi-language

• Notices
  • English
    • Non-Discrimination Notice
    • How to Get Care During a Disaster
  • Spanish
    • Non-Discrimination Notice
    • How to Get Care During a Disaster

• Over-the-Counter Brochure
  • 2019
    • English
      • Cal Plus Plan
      • Other Plans
    • Spanish
      • Cal Plus Plan
      • Otros Planes

• Pharmacy Directory
  • 2019
    • Pharmacy Directory - All Other Plans - English & Spanish
    • Pharmacy Directory - CalPlus (HMO) - English & Spanish

  Click here to request a printed Pharmacy Directory

• Plan Star Ratings
  • 2019
    • English
    • Spanish
    • Tiếng Việt
    • 中文
    • 한국어

• Pre-Enrollment Kits
  • 2019
    • English
      • AllCare Preferred Plan (HMO)
      • CalPlus Plan (HMO)
      • Heart & Diabetes (HMO SNP)
      • My Choice Plan (HMO) - LA, OC, RS & SB
      • My Choice Plan (HMO) - Stanislaus, San Joaquin & Santa Clara
      • Platinum Plan (HMO) - Los Angeles and Orange
      • Platinum Plan (HMO) - Riverside and San Bernardino
      • Platinum Plan (HMO) - San Diego
      • smartHMO (HMO)
    • Spanish
      • AllCare Preferred Plan (HMO)
      • CalPlus Plan (HMO)
      • Heart & Diabetes (HMO SNP)
      • My Choice Plan (HMO) - LA, OC, RS & SB
      • My Choice Plan (HMO) - Stanislaus, San Joaquin & Santa Clara - Spanish - 2019
      • Platinum Plan (HMO) - Los Angeles and Orange
      • Platinum Plan (HMO) - Riverside and San Bernardino
      • Platinum Plan (HMO) - San Diego
      • smartHMO (HMO)

• Prior Authorization Criteria
  • 2019
    • English
    • Spanish

• Provider Directory

  For an up-to-date, real time online provider search, please click here

  Download PDF* for selected coverage area:

  • 2019
    • AllCare Preferred (HMO) - Stanislaus - English and Spanish
    • Los Angeles - English and Spanish
    • Orange - English and Spanish
    • Riverside and San Bernardino - English and Spanish
    • San Diego - English and Spanish
    • San Joaquin, Stanislaus and Santa Clara - English and Spanish

  *PDFs last updated Sept. 1, 2019

  Click here to request a printed Provider Directory

• Special Enrollment Period

  SEP Attestation Form - English

  SEP Attestation Form - Spanish (Español)

• Step Therapy Protocol
  • 2019
    • English
    • Spanish

• Summary of Benefits
  • 2019
    • English
      • AllCare Preferred Plan (HMO)
      • CalPlus Plan (HMO)
      • Heart & Diabetes (HMO SNP)
      • My Choice Plan (HMO) - LA,OC, Riv and SB
      • My Choice Plan (HMO) - Santa Clara
      • My Choice Plan (HMO) - Stanislaus and San Joaquin
      • Platinum Plan (HMO) - Los Angeles and Orange
      • Platinum Plan (HMO) - Riverside and San Bernardino
      • Platinum Plan (HMO) - San Diego
      • smartHMO (HMO)
    • Spanish
      • AllCare Preferred Plan (HMO)
      • CalPlus Plan (HMO)
      • Heart & Diabetes (HMO SNP)
      • My Choice Plan (HMO) - LA,OC, Riv and SB
      • My Choice Plan (HMO) - Santa Clara
      • My Choice Plan (HMO) - Stanislaus and San Joaquin
      • Platinum Plan (HMO) - Los Angeles and Orange
      • Platinum Plan (HMO) - Riverside and San Bernardino
      • Platinum Plan (HMO) - San Diego
      • smartHMO (HMO)