Maryland Advantage Plan

Important Member Documents

As a valued member of Provider Partners Health Plans in Maryland, you can access your important documents at any time by clicking on the links below.

Member Materials

• 2025 Annual Notice of Change
• 2025 Advantage Plan Summary of Benefits
  (contains multi-language insert)
• 2025 Evidence of Coverage
• 2025 Star Ratings
• 2025 LIS Summary
• Appointment of Representative Form CMS-1696
• Member Reimbursement Form Part C
• Member Reimbursement Form Part D
• Participating Providers
• Participating Pharmacies
• Appeals, Organizational Determinations, Coverage Determinations, Grievances
• Over The Counter (OTC) Catalog

Enrollment

• Enrollment Process
• 2025 Enrollment Form
• Disenrollment Process

Pharmacy Materials

Formulary 2025

• 2025 Comprehensive Formulary (Prescription Drugs)
  (last updated 10/15/2024)
• 2025 Prior Authorization Criteria
  (last updated 10/15/2024)
• 2025 Step Therapy Criteria
  (last updated 10/15/2024)
• 2025 Formulary (Prescription Drugs) Search Tool

Additional Pharmacy Information

• Coverage Determination, Appeals, and Grievances Information
• 2025 Request for Medicare Prescription Drug Coverage Determination Form
  (last updated 10/15/2024)
• 2025 Request for Medicare Prescription Drug Coverage Appeal (Redetermination) Form
  (last updated 10/15/2024)
• Online Medicare Prescription Drug Coverage Determination/Appeal (Redetermination)
• 2025 Medicare Prescription Drug Coverage Transition Policy
• 2025 Medication Therapy Management Program Description