Documents & Resources
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?
Peak Plus: Health Risk Assessment Questionnaire
Peak Advantage: Health Risk Assessment Questionnaire
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
Peak Advantage Plan-Related Documents:
*For prior year plan information, please contact Peak Advantage Member Service at 1-855-962-7325.
Prescription Drug and Pharmacy Information
Peak Advantage & Peak Plus Formulary
Peak Advantage Prior Authorization Criteria
Peak Plus Prior Authorization Criteria
Peak Advantage Step Therapy Criteria
Peak Plus Step Therapy Criteria
Covered Diabetes Testing Supplies
Prescription Drug Transition Policy
Peak Advantage Pharmacy Directory
Peak Plus Pharmacy Directory
Beneficiary Opioid Education Flyer
Peak Advantage Preferred Pharmacy Network
Coverage Request Forms
- Coverage Determination Request Form
- Online Form: Coverage Determination Request
- Request for Redetermination of Prescription Drug Denial Form
- Online Form: Redetermination Request
Member Part D Claim Form
Navitus Member Portal
*For prior year plan information, please contact Peak Advantage Member Service at 1-855-962-7325.