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Forms & Documents
Viewing documents for:
Medicare & Managed Long Term Care Plans
* = managed long-term care plan
Plan Documents
Member Resources
65 Plus Plan (HMO)
Comprehensive Formulary
2023 Star Ratings
Every year, Medicare evaluates plans based on a 5-star rating system.
CompleteCare (HMO D-SNP)*
Comprehensive Formulary
2023 Star Ratings
Every year, Medicare evaluates plans based on a 5-star rating system.
Coordinated Benefits Plan (HMO)
Increased Benefits Plan (HMO)
Comprehensive Formulary
2023 Star Ratings
Every year, Medicare evaluates plans based on a 5-star rating system.
Life Improvement Plan (HMO D-SNP)
Comprehensive Formulary
2023 Star Ratings
Every year, Medicare evaluates plans based on a 5-star rating system.
Senior Health Partners*
Signature (HMO)
Comprehensive Formulary
2023 Star Ratings: New York City & Nassau
Every year, Medicare evaluates plans based on a 5-star rating system.
2023 Star Ratings: Orange, Rockland, Sullivan & Westchester
Every year, Medicare evaluates plans based on a 5-star rating system.
Signature (PPO)
Comprehensive Formulary
2023 Star Ratings
Every year, Medicare evaluates plans based on a 5-star rating system.
Medicare Part D Resources
Medicare Advantage Plan Enrollment Resources
Privacy, Protected Health Information (PHI), and Non-Discrimination
General Forms, Documents, and Resources
Member Resources
Appointment of Representative Form
Appoint a representative to make requests for you—give a caregiver or another person permission to file a complaint (grievance), ask for coverage, or make an appeal for you. Have the person you appoint sign the completed Appointment of Representative form and send it to us. This person is then your appointed representative for one year from the date that you both sign an Appointment of Representative form.
65 Plus Plan (HMO)
CompleteCare (HMO D-SNP)*
Coordinated Benefits Plan (HMO)
Increased Benefits Plan (HMO)
Life Improvement Plan (HMO D-SNP)
Senior Health Partners*
Signature (HMO)
Signature (PPO)