Plan Documents
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2009 Summary of Benefits
Quick reference guide to your Medicare benefits under the Physicians Choice Advantage + Rx plan.
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2009 PCA + Rx enrollment form
Form potential members complete and send to Physicians Choice Advantage + Rx to be enrolled into the plan.
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Document providing detailed information will be available in January 2009.
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2009 PCA + Rx formulary
Comprehensive list of prescription drugs covered by Physicians Choice Advantage + Rx and other useful information about your prescription drug benefit.
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Member Appeal Form
Download and fill out this form to appeal a Plan denial (organizational determination) regarding your care.
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Authorized Representative Form
Download and fill out this form to appoint another individual to file an appeal on your behalf.
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Exceptions and Prior Authorization Form
To request a non-formulary drug, an exception to our coverage rules, or to obtain a medication prior authorization please download and fill out this form.
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Mail Order Form
Form beneficiaries fill out and submit to fill mail order prescriptions.
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Privacy and Practice Notice
Physicians Choice Advantage + Rx policies on protected health information.
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Disclosure Authorization Form
Form members fill out and send to Physicians Choice Advantage + Rx granting Physicians Choice Advantage + Rx permission to release certain protected patient information to listed individuals.
E-Pay Form
Form members complete to pay their monthly premium each month through electronic funds transferred from their bank account.-
2009 Provider Directory
Listing of Physicians Choice Advantage + Rx network providers.
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2009 Pharmacy Directory
List of participating pharmacies in the Physicians Choice Advantage + Rx network and other useful information about your prescription drug benefit.