Part D Resources & Links

Plan Premiums, Deductibles, and Cost Sharing

To find out more about our benefits please click here to review our Summary of Benefits. The document highlights applicable premiums, co-payments, co-insurance, and deductibles. Please refer to the Evidence of Coverage for a complete explanation of our benefits.

Find a Pharmacy
Find a Drug
Information about out of network coverage including limits and financial responsibility
Instructions for requesting a Grievance, Coverage Determination or Appeal: English Español
File a Medicare Prescription Drug Coverage Determination Form Here: English Español
File a Redetermination Request Form Here: English Español
Download a Medicare Part D Coverage Determination Request Form
How to request an exception to Citizens Choice Healthplan HMO's Drug Formulary
Appointment of Representative Form (AOR) - (CMS-1696)
Prior Authorization Criteria
Step Therapy Protocol
Quality Assurance Policy
Low Income Subsidy (LIS) Levels: English Español
View Common Part D Questions

For more information on Medicare prescription drug coverage, visit www.medicare.gov

CVS Caremark is proud to offer Citizens Choice Healthplan HMO members a specific section of information on their website. The purpose of this section is to provide information on CVS Caremark services. CVS Caremark is the Pharmacy Benefit Manager (PBM), for Citizens Choice Healthplan HMO. CVS Caremark has approximately 6,000 pharmacies statewide for you to choose from, including the large chain retail pharmacies as well as local community pharmacies. If you would like more information on CVS Caremark click below.

If you would like to order a 90 day supply of your prescription drug(s), click here for our mail order forms.

H3815_11148EN CMS Approved 10242011
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