Forms and Policies
Accessing Care During a Disaster
Appointment of Representative (AOR) Form
Diabetes Prevention Program (MDPP)
Flex Card Refund Form
HIPAA Release Form
LIS Premium Summary Chart
Medical Management Policies & Transparency Tool
Definitions: What are Medicare Coverage Requests, Appeals, and Grievances?
Member Complaint and Appeal Form
Member Medical Claim Form
Non-Discrimination Policy
Notice of Privacy Practices
Report a Compliance Concern
Request for Pre-service Authorization Determination Form
Plan Related Documents
Provider Directory
WVU Medicine Summary of Benefits
Valley Health Summary of Benefits
WVU Medicine Evidence of Coverage (EOC)
Valley Health Evidence of Coverage (EOC)
WVU Medicine Annual Notice of Change (ANOC)
Explanation of Benefits (EOB)
Marshall Health Summary of Benefits
Pennsylvania Health Summary of Benefits
Marshall Health Evidence of Coverage (EOC)
Pennsylvania Evidence of Coverage (EOC)
Marshall Annual Notice of Change (ANOC)
*For prior year plan information, please contact Peak Advantage Member Service at 1-855-962-7325.
Prescription Drug and Pharmacy Information
Formulary
2026 Formulary Guide – Updated:
Prior Authorization Criteria
2026 Prior Authorization Criteria (Summit)
2026 Prior Authorization Criteria (Vista)
Step Therapy Criteria
2026 Step Therapy Criteria (Summit)
2026 Step Therapy Criteria (Vista)
2026 Step Therapy Criteria (Vista)
Covered Diabetes Testing Supplies
Prescription Drug Transition Policy
Medication Therapy Management (MTM)
Medication Action Plan
Personal Medication Worksheet
Pharmacy Directory
Beneficiary Opioid Education Flyer
Preferred Pharmacy Network
Medicare Prescription Payment Plan Information
Election Form
Fact Sheet
*For prior year plan information, please contact Peak Advantage Member Service at 1-855-962-7325.