Documents and Forms
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
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
Terms and Conditions
Plan Related Documents
Provider Directory
Explanation of Benefits (EOB)
WVU Medicine Summary of Benefits
WVU Medicine Evidence of Coverage (EOC)
WVU Medicine Annual Notice of Change (ANOC)
Marshall Health Summary of Benefits
Marshall Health 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
Prior Authorization Criteria
Step Therapy Criteria
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
*For prior year plan information, please contact Peak Advantage Member Service at 1-855-962-7325.