Plan Information
Annual Notice of Change
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Evidence of Coverage
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Product Brochure
Provider Directory
Summary of Benefits
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Star Rating
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Explanation of Benefits (EOB)
Prescription Drug and Pharmacy Information
Drug Information
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Formulary Directory
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Formulary Guide
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Medication Therapy Management (MTM) Medication List
Medication Therapy Management (MTM) Program
Member Part D Claims Form
Pharmacy Directory
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Top 100 Drugs
Over-the-Counter (OTC) and Bathroom Safety Devices Catalog
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Request for Medicare Prescription Drug Determination
Other Important Programs, Forms and Policies
Appointment of Representative (AOR) Form
Diabetes Prevention Program (MDPP)
Important Legal Information
LIS Premium Summary Chart
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Non-Discrimination Policy
PHI Authorization Request Form
Privacy Notice (NOPP)
Policies & Procedures
Claims Information
Submit claims to:
Experience Health Claims
P.O. Box 30010
Durham, NC 27702
Member Claim Form
Enrollment Forms
Authorization for Automatic Bank Draft
Enrollment Form
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Pre-Enrollment Checklist
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