Plan Information


Annual Notice of Change

Product Brochure

Provider Directory

Prescription Drug and Pharmacy Information


Formulary Directory

Medication Therapy Management (MTM) Medication List

Medication Therapy Management (MTM) Program

Member Part D Claims Form

Pharmacy Directory

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)

Claims Information


Submit claims to:

Experience Health Claims
PO Box 17509
Winston-Salem, NC 27116-7509

Member Claim Form

Enrollment Forms


Authorization for Automatic Bank Draft

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