Important Member Documents
As a valued member of Provider Partners Health Plans in North Carolina, you can access your important documents at any time by clicking on the links below.
![Sunrise Bodie Island Lighthouse OBX Outer Banks NC Part of the beautiful Cape Hatteras National Seashore, the Bodie Island Lighthouse is an Iconic Lighthouse of Nags Head Outer Banks North Carolina. This incredible stretch of coastal barrier islands along the east coast of NC is known for its amazing beaches and abundant wildlife.](https://www.pphealthplan.com/wp-content/uploads/2023/10/GettyImages-1411830219-scaled-600x400.jpg)
Member Materials
- 2024 Summary of Benefits
(contains multi-language insert) - 2024 Evidence of Coverage
- 2024 Star Ratings
- 2024 LIS Summary
- Appointment of Representative Form CMS-1696
- Member Reimbursement Form
- Participating Providers
- Participating Pharmacies
- Appeals, Organizational Determinations, Coverage Determinations, Grievances
- Over The Counter (OTC) Catalog
Enrollment
Pharmacy Materials
Formulary 2024
- 2024 Comprehensive Formulary (Prescription Drugs)
(last updated 7/1/2024) - 2024 Prior Authorization Criteria
(last updated 7/1/2024) - 2024 Step Therapy Criteria
(last updated 7/1/2024) - 2024 Formulary (Prescription Drugs) Search Tool
Additional Pharmacy Information
- Coverage Determination, Appeals, and Grievances Information
- 2024 Request for Medicare Prescription Drug Coverage Determination Form
(last updated 10/15/2023) - 2024 Request for Medicare Prescription Drug Coverage Appeal (Redetermination) Form
(last updated 10/15/2023) - Online Medicare Prescription Drug Coverage Determination/Appeal (Redetermination)
- 2024 Medicare Prescription Drug Coverage Transition Policy
- 2024 Medication Therapy Management Program Description
Pharmacy Materials
Formulary 2024
- 2024 Comprehensive Formulary (Prescription Drugs)
(last updated 6/1/2024) - 2024 Prior Authorization Criteria
(last updated 6/1/2024) - 2024 Step Therapy Criteria
(last updated 6/1/2024) - 2024 Formulary (Prescription Drugs) Search Tool
Additional Pharmacy Information
- Coverage Determination, Appeals, and Grievances Information
- 2024 Request for Medicare Prescription Drug Coverage Determination Form
(last updated 10/15/2023) - 2024 Request for Medicare Prescription Drug Coverage Appeal (Redetermination) Form
(last updated 10/15/2023) - Online Medicare Prescription Drug Coverage Determination/Appeal (Redetermination)
- 2024 Medicare Prescription Drug Coverage Transition Policy
- 2024 Medication Therapy Management Program Description
Page Last Updated: 7/1/2024