Documents and Forms
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The following documents provide detailed information on Choices 65 (HMO) benefits and plan design. Use the links below to view Choices 65 (HMO) documents directly from your computer.
If you would like any of these documents mailed to you, please complete the form below. Be sure to select the documents you would like us to send to you. You should receive the documents within two weeks of your request.
2010 Documents
2010 Abridged Formulary (PDF file - 664 KB) - a partial list of the open formulary for prescription drugs.
2010 Provider Directory (PDF file - 5 MB)
2010 Evidence of Coverage (PDF file - 6.1 MB) - provides information about your benefits, membership, covered and non-covered services, member rights and responsibilities and other important plan details.
2010 Summary of Benefits (PDF file - 664 KB) - provides a general summary of benefits and services for each of our health plans.
Notice of Privacy Practices (PDF file - 588 KB) - describes how your medical information may be used and disclosed and how you can get access to this information.
Medicare Part D Tiering or Formulary Exception Request
(PDF file - 28KB)
2009 Documents
2009 Abridged Formulary (PDF file - 3 MB) - a partial list of the open formulary for prescription drugs covered by Choices 65.
2009 Provider Directory (PDF file - 4.4 MB)
2009 Evidence of Coverage (PDF file - 1.4 MB) - provides information about your benefits, membership, covered and non-covered services, member rights and responsibilities and other important plan details.
2009 Summary of Benefits (PDF file - 404 KB) - provides a general summary of benefits and services for each of our health plans.
Amendment to 2009 Evidence of Coverage and Summary of Benefits
(PDF file - 9KB)
Viewing these documents requires the Adobe Acrobat Reader, which can be downloaded for free.
If you would like any of these documents mailed to you, please complete the form below.