Plan Information
Annual Notice of Change
2024 English:
- Durham and Person counties
- Granville, Lee, Orange and Vance counties
- Franklin and Wake counties
- 2023 English
2024 Spanish:
Evidence of Coverage
2024 English:
- Durham and Person counties
- Granville, Lee, Orange and Vance counties
- Franklin and Wake counties
- 2023 English
2024 Spanish:
Product Brochure
Provider Directory
Summary of Benefits
Explanation of Benefits (EOB)
Prescription Drug and Pharmacy Information
Drug Information
Formulary Directory
Formulary Guide
Medication Therapy Management (MTM) Medication List
Medication Therapy Management (MTM) Program
Member Part D Claims Form
Pharmacy Directory
Top 100 Drugs
Over-the-Counter (OTC) and Bathroom Safety Devices Catalog
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
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
Pre-Enrollment Checklist
- 2024 English
- 2024 Spanish Coming Soon
- 2023 English
- 2023 Spanish