Important Member Document
As a valued member of PPHP in Pennsylvania, you can access your important documents at any time by clicking on the links below.
Member Materials
- 2021 Annual Notice of Change
- 2021 Summary of Benefits
(contains multi-language insert) - 2021 Evidence of Coverage
- 2021 Star Ratings
- 2021 LIS Summary
- Appointment of Representative Form CMS-1696
- Appointment of Representative Form CMS-1696 (Spanish)
- Member Reimbursement Form
- Participating Providers
- Participating Pharmacies
- Appeals, Organizational Determinations, Coverage Determinations, Grievances
- Over The Counter (OTC) Catalog
Enrollment
Pharmacy Materials
Formulary 2021
- 2021 Comprehensive Formulary (Prescription Drugs)
(last updated 11/22/2020) - 2021 Formulary (Prescription Drugs) Changes
(last updated 11/22/2020) - 2021 Prior Authorization Criteria
(last updated 11/22/2020) - 2021 Step Therapy Criteria
(last updated 11/22/2020) - 2021 Quantity Limits
(last updated 11/22/2020) - 2021 Formulary (Prescription Drugs) Search Tool
Additional Pharmacy Information
- Coverage Determination, Appeals, and Grievances Information
- 2021 Request for Medicare Prescription Drug Coverage Determination Form
(last updated 10/15/2020) - 2021 Request for Medicare Prescription Drug Coverage Appeal (Redetermination) Form
(last updated 10/15/2020) - Online Medicare Prescription Drug Coverage Determination/Appeal (Redetermination)
- 2021 Medicare Prescription Drug Coverage Transition Policy
- 2021 Medication Therapy Management Program Description