Plan Information
Annual Notice of Change
Evidence of Coverage
Product Brochure
Provider Directory
Summary of Benefits
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) 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
PO Box 17509
Winston-Salem, NC 27116-7509
Member Claim Form
Enrollment Forms
Authorization for Automatic Bank Draft
Enrollment Form
Pre-Enrollment Checklist
