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.
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Information about Out of Network Coverage including limits and financial responsibility: English Español
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: English Español
Appointment of Representative Form (AOR) - (CMS-1696)
How to request an exception to Citizens Choice Healthplan HMO's Drug Formulary: Non Formulary Drug Tier Exception
Medication Therapy Management Program (MTMP): English Español
Transition Process: English Español
Prior Authorization Criteria: English Spanish
Step Therapy Protocol: English
Quality Assurance Policy: English
Low Income Subsidy (LIS) Levels: English - 2013 Español - 2013 中文 - 2013
View Common Part D Questions

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

EnvisionRx 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 EnvisionRx services. EnvisionRx is the Pharmacy Benefit Manager (PBM), for Citizens Choice Healthplan HMO. EnvisionRx 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 EnvisionRx 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_12113EN CMS Approved 04292013

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