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

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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