2021 Member Materials

You can get this information for free in other languages. Call 1-888-522-1298 (TTY: 711). The call is free. You can also ask for this information in other formats, such as audio CD, Braille or large print.

Annual Notice of Change

Below are our Annual Notice of Change documents in eleven languages.
(Updated 10/07/2020)

Annual Notice of Change – English (pdf)
Annual Notice of Change – Spanish (pdf)
Annual Notice of Change – Chinese (pdf)
Annual Notice of Change – Korean (pdf)
Annual Notice of Change – Armenian (pdf)
Annual Notice of Change – Russian (pdf)
Annual Notice of Change – Tagalog (pdf)
Annual Notice of Change – Vietnamese (pdf)
Annual Notice of Change – Farsi (pdf)
Annual Notice of Change – Khmer/Cambodian (pdf)
Annual Notice of Change – Arabic (pdf)
List of Covered Drugs (Formulary)

Below are our Formulary documents in eleven languages.
(Updated 02/05/2021)

List of Covered Drugs - English (pdf)
List of Covered Drugs - Spanish (pdf)
List of Covered Drugs - Chinese (pdf)
List of Covered Drugs - Korean (pdf)
List of Covered Drugs - Armenian (pdf)
List of Covered Drugs - Russian (pdf)
List of Covered Drugs - Tagalog (pdf)
List of Covered Drugs - Vietnamese (pdf)
List of Covered Drugs - Farsi (pdf)
List of Covered Drugs - Khmer/Cambodian (pdf)
List of Covered Drugs - Arabic (pdf)
Member Handbook

Below are our Member Handbook documents in eleven languages.
(Updated 10/14/2020)

Member Handbook – English (pdf)
Member Handbook – Spanish (pdf)
Member Handbook – Chinese (pdf)
Member Handbook – Korean (pdf)
Member Handbook – Armenian (pdf)
Member Handbook – Russian (pdf)
Member Handbook – Tagalog (pdf)
Member Handbook – Vietnamese (pdf)
Member Handbook – Farsi (pdf)
Member Handbook – Khmer/Cambodian (pdf)
Member Handbook – Arabic (pdf)
Notice of Privacy Practices

Below are our Notice of Privacy Practices documents in eleven languages.
(Updated 10/13/20)

Notice of Privacy Practices - English (pdf)
Notice of Privacy Practices - Spanish (pdf)
Notice of Privacy Practices - Chinese (pdf)
Notice of Privacy Practices - Korean (pdf)
Notice of Privacy Practices - Armenian (pdf)
Notice of Privacy Practices - Russian (pdf)
Notice of Privacy Practices - Tagalog (pdf)
Notice of Privacy Practices - Vietnamese (pdf)
Notice of Privacy Practices - Farsi (pdf)
Notice of Privacy Practices - Khmer/Cambodian (pdf)
Notice of Privacy Practices - Arabic (pdf)
Provider/Pharmacy Directory

Below are our Provider/Pharmacy Directory documents in eleven languages.

Provider, Facility and Pharmacy Directory Vol. 1

The Provider, Facility and Pharmacy Directory Vol. 1 has the location and contact information you need to select an in-network Primary Care Provider, Vision Provider, Dental Provider, Hospital, Pharmacy and more.
(Updated 02/22/2021)

Provider, Facility and Pharmacy Directory Vol. 1 – English (pdf)
Provider, Facility and Pharmacy Directory Vol. 1 – Spanish (pdf)
Provider, Facility and Pharmacy Directory Vol. 1 – Chinese (pdf)
Provider, Facility and Pharmacy Directory Vol. 1 – Korean (pdf)
Provider, Facility and Pharmacy Directory Vol. 1 – Armenian (pdf)
Provider, Facility and Pharmacy Directory Vol. 1 – Russian (pdf)
Provider, Facility and Pharmacy Directory Vol. 1 – Tagalog (pdf)
Provider, Facility and Pharmacy Directory Vol. 1 – Vietnamese (pdf)
Provider, Facility and Pharmacy Directory Vol. 1 – Farsi (pdf)
Provider, Facility and Pharmacy Directory Vol. 1 – Khmer/Cambodian (pdf)
Provider, Facility and Pharmacy Directory Vol. 1 – Arabic (pdf)

Specialist Directory Vol. 2

The Specialist Directory Vol. 2 has the location and contact information you need to select an in-network specialty care provider such as: Allergists, Cardiologists, Podiatrists, Proctologists, and more.
(Updated 02/22/2021)

Specialist Directory Vol. 2 – English (pdf)
Specialist Directory Vol. 2 – Spanish (pdf)
Specialist Directory Vol. 2 – Chinese (pdf)
Specialist Directory Vol. 2 – Korean (pdf)
Specialist Directory Vol. 2 – Armenian (pdf)
Specialist Directory Vol. 2 – Russian (pdf)
Specialist Directory Vol. 2 – Tagalog (pdf)
Specialist Directory Vol. 2 – Vietnamese (pdf)
Specialist Directory Vol. 2 – Farsi (pdf)
Specialist Directory Vol. 2 – Khmer/Cambodian (pdf)
Specialist Directory Vol. 2 – Arabic (pdf)

Mental Health Provider Directory Vol. 3

Mental Health Provider Directory Vol. 3 has the location and contact information you need to select an in-network Mental Health Provider.
(Updated 02/22/2021)

Mental Health Provider Directory Vol. 3 – English (pdf)
Mental Health Provider Directory Vol. 3 – Spanish (pdf)
Mental Health Provider Directory Vol. 3 – Chinese (pdf)
Mental Health Provider Directory Vol. 3 – Korean (pdf)
Mental Health Provider Directory Vol. 3 – Armenian (pdf)
Mental Health Provider Directory Vol. 3 – Russian (pdf)
Mental Health Provider Directory Vol. 3 – Tagalog (pdf)
Mental Health Provider Directory Vol. 3 – Vietnamese (pdf)
Mental Health Provider Directory Vol. 3 – Farsi (pdf)
Mental Health Provider Directory Vol. 3 – Khmer/Cambodian (pdf)
Mental Health Provider Directory Vol. 3 – Arabic (pdf)
Summary of Benefits

Below are our Summary of Benefits documents in eleven languages.
(Updated 10/07/2020)

Summary of Benefits – English (pdf)
Summary of Benefits – Spanish (pdf)
Summary of Benefits – Chinese (pdf)
Summary of Benefits – Korean (pdf)
Summary of Benefits – Armenian (pdf)
Summary of Benefits – Russian (pdf)
Summary of Benefits – Tagalog (pdf)
Summary of Benefits – Vietnamese (pdf)
Summary of Benefits – Farsi (pdf)
Summary of Benefits – Khmer/Cambodian (pdf)
Summary of Benefits – Arabic (pdf)
Notice of Nondiscrimination

Below is our Notice of Nondiscrimination in eleven languages.

Notice of Nondiscrimination – English (pdf)
Notice of Nondiscrimination – Spanish (pdf)
Notice of Nondiscrimination – Chinese (pdf)
Notice of Nondiscrimination – Korean (pdf)
Notice of Nondiscrimination – Armenian (pdf)
Notice of Nondiscrimination – Russian (pdf)
Notice of Nondiscrimination – Tagalog (pdf)
Notice of Nondiscrimination – Vietnamese (pdf)
Notice of Nondiscrimination – Farsi (pdf)
Notice of Nondiscrimination – Khmer/Cambodian (pdf)
Notice of Nondiscrimination – Arabic (pdf)
Additional Links
Request to Inspect, Copy, and Release Protected Health Information Forms
Authorized Representative Form