• Summary of Benefits (Updated 6/13/23)
• Evidence of Coverage - Central Tennessee (Updated 4/27/23)
• Evidence of Coverage - Knoxville Tennessee (Updated 4/27/23)
• Evidence of Coverage - Tri-Cities Tennessee (Updated 4/27/23)
• Evidence of Coverage Errata (Updated 3-13-23)
• Provider Directory - Central Tennessee (Updated 9/13/23)
• Provider Directory - Knoxville Tennessee (Updated 9/13/23)
• Provider Directory - Tri-Cities Tennessee (Updated 9/13/23)
• Dental Provider Directory (Updated 9/7/23)
• VSP Provider Directory - Central Tennessee (Updated 11/14/23)
• VSP Provider Directory - Knoxville Tennessee (Updated 11/14/23)
• VSP Provider Directory - Tri-Cities Tennessee (Updated 11/14/23)
• TruHearing Provider Directory (8-7-23)
• Pharmacy Directory (Updated 11/6/23)
• Comprehensive Formulary (Updated 11/1/23)
• Comprehensive Formulary - Large Print (Updated 11/1/23)
• Medical - Prior Authorization Procedure Codes (Updated 11/2/23)
• Prescription Drug – Prior Authorization Criteria (Updated 11/1/23)
• Step Therapy Criteria (Updated 11/1/23)
• Quantity Limits Criteria (Updated 11/1/23)
• CMS Star Ratings (Updated 3/7/23)
• Pre-enrollment checklist (Updated 9/27/22)
• Enrollment Form (Updated 1/26/23)

• Summary of Benefits
• Annual Notice of Change - Central Tennessee
• Annual Notice of Change - Knoxville Tennessee
• Annual Notice of Change - Tri-Cities Tennessee
• Evidence of Coverage - Central Tennessee
• Evidence of Coverage - Knoxville Tennessee
• Evidence of Coverage - Tri-Cities Tennessee
• Provider Directory - Central Tennessee
• Provider Directory - Knoxville Tennessee
• Provider Directory - Tri-Cities Tennessee
• Pharmacy Directory
• Comprehensive Formulary (Updated 12/1/23)
• Comprehensive Formulary - Large Print (Updated 12/1/23)
• Medical - Prior Authorization Procedure Codes
• Prescription Drug - Prior Authorization Criteria (Updated 12/1/23)
• Step Therapy Criteria (Updated 12/1/23)
• Quantity Limits Criteria (Updated 11/1/23)
• CMS Star Ratings
• Pre-enrollment checklist
• Enrollment Form
• Sales Kit

• Member Reimbursement Drug Claim Form (Updated 9/27/22)
• Appointment of Representative Form  (Updated 9/27/22)
• Coverage Determination Request Form (Updated 1/11/23)
• Request for Redetermination (Updated 10/6/22)
• SSA Extra Help Information(Updated 9/27/22)
• Scope of Appointment (Updated 9/27/22)
• Authorization for Release of Protected Health Information (Updated 12/2/22)
• Prior Authorization Form (Updated 12/6/22)
• Medicare Advantage Subscriber Health Care Claim Form (Updated 1/17/23)
• Disenrollment Form (Updated 8/25/23

• Member Reimbursement Drug Claim Form
• Appointment of Representative Form
• Coverage Determination/Prior Authorization Request Form – Drugs
• Request for Redetermination
• Request for Redetermination - Drugs
• SSA Extra Help Information 
• Scope of Appointment
• Authorization for Release of Protected Health Information
• Coverage Determination/Prior Authorization Request Form – Medical 
• Medicare Advantage Member Health Care Claim Form
• Disenrollment Form
• Supplemental Benefits Contacts
• Personal Medication List
• Appeals Form
• MTMP Enrollment Mailer
• Recommended To-Do-List
• Prescription Drug Home Delivery Form and FAQ’s

• Late Enrollment Penalty (LEP) Premium - Billing FAQ (Updated 6/1/23)
• Bank Withdrawal Form (Updated 6/7/23)

Late Enrollment Penalty (LEP) Premium - Billing FAQ

Bank Withdrawal Form

RRB Withhold Form