2021 Member Materials and Forms

On this page, you’ll find important documents related to your MCC of AZ (HMO SNP) health plan. Click the links below to download each document.

Annual Materials 2021

Annual Notice of Change (ANOC): describes changes to your MCC of AZ (HMO SNP) plan coverage, costs or service area.
English          Spanish

Summary of Benefits: a summary of what we cover and what you pay. For a complete list of covered services and exclusions, refer to your Evidence of Coverage.
English          Spanish

Evidence of Coverage (EOC): your Medicare health benefits and services and prescription drug coverage as a member of MCC of AZ (HMO SNP).
English           Spanish

Formulary: a list of the drugs covered in this plan.
English            Spanish

LIS Premium Summary: explains your monthly plan premium if you get Extra Help paying for your prescription drugs.
English            Spanish

LIS Rider:  describes the Extra Help you get paying for your prescription drugs.
English            Spanish

Provider and Pharmacy Directory: a list of MCC of AZ (HMO SNP)’s current network providers and pharmacies.
English            Spanish

General Information

Advance Directive Information: the Arizona Advance Directive Registry tells you how to fill out, store and access your medical directive.

Enrollment Information: everything you need to know about joining our 2021 plan.

Member Forms

Appointment of Representative Form
English          Spanish

Member Disenrollment Form
English          Spanish

Member Opt-out Form
English          Spanish

Prescription Drugs Materials & Forms

Medicare Part D Coverage Determination Request Form (download and mail or fax form)
English          Spanish
OR
Medicare Part D Coverage Determination Request Form (submit form online)
English          Spanish


Medicare Part D Request for Redetermination Form (download and mail or fax form)
English          Spanish
OR
Medicare Part D Request for Redetermination Form  (submit form online)
English          Spanish


Medicare Part D Request for Reconsideration of Drug Denial Form (download and mail or fax form)
English               Spanish


Medicare Part B Prior Authorization Drug List: (effective 5/01/2021) medicines on this list need to be approved by the plan before you can take them.


Medication Therapy Management Program: explains our plan’s drug program for members who take multiple medicines.


Pharmacy Transition Management Policy: describes how our plan works with members on needed drugs not on our Formulary.


RX Member Reimbursement Form:  use this form to ask us to pay you back for a covered drug you bought.