Important Member Documents
As a valued member of Provider Partners Health Plans in Texas, you can access your important documents at any time by clicking on the links below.
Member Materials
- 2023 Annual Notice of Change
- 2023 Annual Notice of Change (Spanish)
- 2023 Summary of Benefits
(contains multi-language insert) - 2023 Summary of Benefits (Spanish)
- 2023 Evidence of Coverage
- 2023 Evidence of Coverage (Spanish)
- 2023 Star Ratings
- 2023 Star Ratings (Spanish)
- 2023 LIS Summary
- 2023 LIS Summary (Spanish)
- Appointment of Representative Form CMS-1696
- Appointment of Representative Form CMS-1696 (Spanish)
- Member Reimbursement Form
- Member Reimbursement Form (Spanish)
- Participating Providers
- Participating Pharmacies
- Appeals, Organizational Determinations, Coverage Determinations, Grievances
- Over The Counter (OTC) Catalog
- Over The Counter (OTC) Catalog (Spanish)
Enrollment
Pharmacy Materials
Formulary 2023
- 2023 Comprehensive Formulary (Prescription Drugs)
(last updated 10/1/2023) - 2023 Comprehensive Formulary (Prescription Drugs) (Spanish)
(last updated 10/1/2023) - 2023 Formulary (Prescription Drugs) Changes
(last updated 10/1/2023) - 2023 Formulary (Prescription Drugs) Changes (Spanish)
(last updated 10/1/2023) - 2023 Prior Authorization Criteria
(last updated 10/1/2023) - 2023 Step Therapy Criteria
(last updated 10/1/2023) - 2023 Formulary (Prescription Drugs) Search Tool
Additional Pharmacy Information
- Coverage Determination, Appeals, and Grievances Information
- 2023 Request for Medicare Prescription Drug Coverage Determination Form
(last updated 10/15/2022) - 2023 Request for Medicare Prescription Drug Coverage Determination Form (Spanish)
(last updated 10/15/2022) - 2023 Request for Medicare Prescription Drug Coverage Appeal (Redetermination) Form
(last updated 10/15/2022) - 2023 Request for Medicare Prescription Drug Coverage Appeal (Redetermination) Form (Spanish)
(last updated 10/15/2022) - Online Medicare Prescription Drug Coverage Determination/Appeal (Redetermination)
- 2023 Medicare Prescription Drug Coverage Transition Policy
- 2023 Medicare Prescription Drug Coverage Transition Policy (Spanish)
- 2023 Medication Therapy Management Program Description
Page Last Updated: 9/30/2023