Pennsylvania Provider Documents

Provider Information

• 2024 Provider Manual
• Participating Providers
• Participating Pharmacies
• Model of Care Training and Attestation
• 2025 Provider Quick Reference Guide (Pennsylvania Advantage Plan)
• 2025 Provider Quick Reference Guide (Pennsylvania Community Plan)
• 2025 Provider Quick Reference Guide (Pennsylvania Essential Plan)
• Provider Information Update
• 2025 Provider Coverage Determination Form

Medical Information and Authorization

• 2025 Authorization Form

Pharmacy Information and Authorization

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

• Online Part D Coverage Determination/Redetermination

Member Benefit Information

• 2025 Advantage Plan Summary of Benefits
  (contains multi-language insert)
• 2025 Community Plan Summary of Benefits
  (contains multi-language insert)
• 2025 Essential Plan Summary of Benefits
  (contains multi-language insert)