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Plan Documents for {{selectedPlanName}}

All documents are PDF (Portable Document Format) files. They can be viewed with Adobe® Reader®. If you don't already have this viewer on your computer, download it free from the Adobe website.

English

General Plan Information
    {{ passportLinkGenerate(pdfs.docListMap.1.en_us.link) }}
  • Enrollment Form (PDF) (Updated {{pdfs.docListMap.1.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Enrollment Form (PDF)Opens in new tab
    • {{ passportLinkGenerate(pdfs.docListMap.3.en_us.link) }}
  • Summary of Benefits (PDF) (Updated {{pdfs.docListMap.3.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Summary of Benefits (PDF)Opens in new tab
    • {{ passportLinkGenerate(pdfs.docListMap.2.en_us.link) }}
  • Evidence of Coverage (PDF)* (Updated {{pdfs.docListMap.2.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Evidence of Coverage (PDF)*Opens in new tab
    • {{ passportLinkGenerate(pdfs.docListMap.1043.en_us.link) }}
  • Star Ratings (PDF) (Updated {{pdfs.docListMap.1043.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Star Ratings (PDF)Opens in new tab
    • {{ passportLinkGenerate(pdfs.docListMap.6014.en_us.link) }}
  • Annual Notice of Changes (ANOC) (PDF)5 (Updated {{pdfs.docListMap.6014.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Annual Notice of Changes (ANOC) (PDF)5Opens in new tab
    • {{ passportLinkGenerate(pdfs.docListMap.7001.en_us.link) }}
  • UnitedHealth Passport Program (PDF) (Updated {{pdfs.docListMap.7001.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • UnitedHealth Passport Program (PDF)Opens in new tab
    • {{ passportLinkGenerate(pdfs.docListMap.6002.en_us.link) }}
  • Benefit Highlights (Updated {{pdfs.docListMap.6002.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Benefit HighlightsOpens in new tab
Medical Providers
  • Provider Directory (PDF) (Updated {{pdfs.docListMap.1027.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Provider Directory (PDF)Opens in new tab
  • Vendor Information Sheet (PDF) (Updated {{pdfs.docListMap.7025.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Vendor Information Sheet (PDF)Opens in new tab

Other Languages

General Plan Information
  • Formulario de Inscripción (PDF) (Actualizado {{pdfs.docListMap.1.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Formulario de Inscripción (PDF)Opens in new tab
  • Resumen de Beneficios (PDF) (Actualizado {{pdfs.docListMap.3.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Resumen de Beneficios (PDF)Opens in new tab
  • Comprobante de Cobertura (PDF)* (Actualizado {{pdfs.docListMap.2.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Comprobante de Cobertura (PDF)*Opens in new tab
  • Clasificación de la Calidad del Plan (PDF) (Actualizado {{pdfs.docListMap.1043.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Clasificación de la Calidad del Plan (PDF)Opens in new tab
  • Aviso Annual de Cambios (PDF)5 (Actualizado {{pdfs.docListMap.6014.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Aviso Annual de Cambios (PDF)5Opens in new tab
  • Programa UnitedHealth Passport (en formato PDF) (Actualizado {{pdfs.docListMap.7001.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Programa UnitedHealth Passport (en formato PDF)Opens in new tab
  • Beneficios Importantes (Actualizado {{pdfs.docListMap.6002.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Beneficios ImportantesOpens in new tab
  • 註冊表格 (PDF) (更新日期: {{pdfs.docListMap.1.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • 註冊表格 (PDF)Opens in new tab
  • 福利概覽 (PDF) (更新日期: {{pdfs.docListMap.3.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • 福利概覽 (PDF)Opens in new tab
  • 承保證書 (PDF)* (更新日期: {{pdfs.docListMap.2.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • 承保證書 (PDF)*Opens in new tab
  • 星級評定 (PDF) (更新日期: {{pdfs.docListMap.1043.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • 星級評定 (PDF)Opens in new tab
  • 年度變更通知 (PDF)5 (更新日期: {{pdfs.docListMap.6014.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • 年度變更通知 (PDF)5 Opens in new tab
  • 聯合健康護照(UnitedHealth Passport) 計劃(PDF檔) (更新日期: {{pdfs.docListMap.7001.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • 聯合健康護照(UnitedHealth Passport) 計劃(PDF檔)Opens in new tab
  • 福利摘要 (PDF) (更新日期: {{pdfs.docListMap.6002.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • 福利摘要 (PDF)Opens in new tab
Medical Providers
  • Directorio de Proveedores (PDF) (Actualizado {{pdfs.docListMap.1027.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Directorio de Proveedores (PDF)Opens in new tab
  • Información sobre proveedores - Spanish (PDF) (Actualizado {{pdfs.docListMap.7025.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Información sobre proveedores - Spanish (PDF)Opens in new tab
  • 醫生名冊 (PDF) (更新日期: {{pdfs.docListMap.1027.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • 醫生名冊 (PDF)Opens in new tab
  • 供應商資訊表 - Chinese (PDF) (更新日期: {{pdfs.docListMap.7025.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • 供應商資訊表 - Chinese (PDF) Opens in new tab

Plan Documents for {{selectedPlanName}}

All documents are PDF (Portable Document Format) files. They can be viewed with Adobe® Reader®. If you don't already have this viewer on your computer, download it free from the Adobe website.

English

General Plan Information
    {{ passportLinkGenerate(pdfs.docListMap.1.en_us.link) }}
  • Enrollment Form (PDF) (Updated {{pdfs.docListMap.1.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Enrollment Form (PDF)Opens in new tab
    • {{ passportLinkGenerate(pdfs.docListMap.3.en_us.link) }}
  • Summary of Benefits (PDF) (Updated {{pdfs.docListMap.3.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Summary of Benefits (PDF)Opens in new tab
    • {{ passportLinkGenerate(pdfs.docListMap.2.en_us.link) }}
  • Evidence of Coverage (PDF)* (Updated {{pdfs.docListMap.2.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Evidence of Coverage (PDF)*Opens in new tab
    • {{ passportLinkGenerate(pdfs.docListMap.1043.en_us.link) }}
  • Star Ratings (PDF) (Updated {{pdfs.docListMap.1043.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Star Ratings (PDF)Opens in new tab
    • {{ passportLinkGenerate(pdfs.docListMap.6014.en_us.link) }}
  • Annual Notice of Changes (ANOC) (PDF)5 (Updated {{pdfs.docListMap.6014.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Annual Notice of Changes (ANOC) (PDF)5 Opens in new tab
    • {{ passportLinkGenerate(pdfs.docListMap.7001.en_us.link) }}
  • UnitedHealth Passport Program (PDF) (Updated {{pdfs.docListMap.7001.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • UnitedHealth Passport Program (PDF)Opens in new tab
    • {{ passportLinkGenerate(pdfs.docListMap.6002.en_us.link) }}
  • Benefit Highlights (Updated {{pdfs.docListMap.6002.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Benefit HighlightsOpens in new tab
Medical Providers
  • Provider Directory (PDF) (Updated {{pdfs.docListMap.1027.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Provider Directory (PDF)Opens in new tab
  • Vendor Information Sheet (PDF) (Updated {{pdfs.docListMap.7025.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Vendor Information Sheet (PDF)Opens in new tab
Prescription Drug Coverage
  • Comprehensive Formulary (PDF) (Updated {{pdfs.docListMap.1022.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Comprehensive Formulary (PDF)Opens in new tab
  • Prior Authorization Criteria (PDF) (Updated {{pdfs.docListMap.2019.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Prior Authorization Criteria (PDF) Opens in new tab
  • Step Therapy Criteria (PDF) (Updated {{pdfs.docListMap.2020.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Step Therapy Criteria (PDF)Opens in new tab
  • Formulary Additions (PDF) (Updated {{pdfs.docListMap.2021.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Formulary Additions (PDF)Opens in new tab
  • Formulary Deletions (PDF) (Updated {{pdfs.docListMap.2022.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Formulary Deletions (PDF)Opens in new tab
  • Alternative Drugs List (PDF) (Updated {{pdfs.docListMap.7022.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Alternative Drugs List (PDF)Opens in new tab

    •       Formulary Search

Pharmacy Directory
  • Pharmacy Directory Information (PDF) (Updated {{pdfs.docListMap.1028.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Pharmacy Directory Information (PDF)Opens in new tab

    •       Online pharmacy directory

          Pharmacy Search

Other Languages

General Plan Information
  • Formulario de Inscripción (PDF) (Actualizado {{pdfs.docListMap.1.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Formulario de Inscripción (PDF)Opens in new tab
  • Resumen de Beneficios (PDF) (Actualizado {{pdfs.docListMap.3.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Resumen de Beneficios (PDF)Opens in new tab
  • Comprobante de Cobertura (PDF)* (Actualizado {{pdfs.docListMap.2.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Comprobante de Cobertura (PDF)*Opens in new tab
  • Clasificación de la Calidad del Plan (PDF) (Actualizado {{pdfs.docListMap.1043.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Clasificación de la Calidad del Plan (PDF)Opens in new tab
  • Aviso Annual de Cambios (PDF)5 (Actualizado {{pdfs.docListMap.6014.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Aviso Annual de Cambios (PDF)5 Opens in new tab
  • Programa UnitedHealth Passport (en formato PDF) (Actualizado {{pdfs.docListMap.7001.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Programa UnitedHealth Passport (en formato PDF)Opens in new tab
  • Beneficios Importantes (Actualizado {{pdfs.docListMap.6002.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Beneficios ImportantesOpens in new tab
  • 註冊表格 (PDF) (更新日期: {{pdfs.docListMap.1.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • 註冊表格 (PDF)Opens in new tab
  • 福利概覽 (PDF) (更新日期: {{pdfs.docListMap.3.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • 福利概覽 (PDF)Opens in new tab
  • 承保證書 (PDF)* (更新日期: {{pdfs.docListMap.2.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • 承保證書 (PDF)*Opens in new tab
  • 星級評定 (PDF) (更新日期: {{pdfs.docListMap.1043.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • 星級評定 (PDF)Opens in new tab
  • 年度變更通知 (PDF)5 (更新日期: {{pdfs.docListMap.6014.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • 年度變更通知 (PDF)5 Opens in new tab
  • 聯合健康護照(UnitedHealth Passport) 計劃(PDF檔) (更新日期: {{pdfs.docListMap.7001.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • 聯合健康護照(UnitedHealth Passport) 計劃(PDF檔) Opens in new tab
  • 福利摘要 (PDF) (更新日期: {{pdfs.docListMap.6002.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • 福利摘要 (PDF)Opens in new tab
Medical Providers
  • Directorio de Proveedores (PDF) (Actualizado {{pdfs.docListMap.1027.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Directorio de Proveedores (PDF)Opens in new tab
  • Información sobre proveedores - Spanish (PDF) (Actualizado {{pdfs.docListMap.7025.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Información sobre proveedores - Spanish (PDF)Opens in new tab
  • 醫生名冊 (PDF) (更新日期: {{pdfs.docListMap.1027.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • 醫生名冊 (PDF)Opens in new tab
  • 供應商資訊表 - Chinese (PDF) (更新日期: {{pdfs.docListMap.7025.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • 供應商資訊表 - Chinese (PDF)Opens in new tab

Prescription Drug Coverage

  • Formulario Completo (PDF) (Actualizado {{pdfs.docListMap.1022.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Formulario Completo (PDF)Opens in new tab
  • Prior Authorization Criteria (PDF) (Actualizado {{pdfs.docListMap.2019.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Prior Authorization Criteria (PDF) Opens in new tab
  • Step Therapy Criteria (PDF) (Actualizado {{pdfs.docListMap.2020.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Step Therapy Criteria (PDF)Opens in new tab
  • Formulary Additions (PDF) (Actualizado {{pdfs.docListMap.2021.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Formulary Additions (PDF)Opens in new tab
  • Formulary Deletions (PDF) (Actualizado {{pdfs.docListMap.2022.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Formulary Deletions (PDF)Opens in new tab
  • Lista de Medicamentos Alternativos - Spanish (PDF) (Actualizado {{pdfs.docListMap.7022.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Lista de Medicamentos Alternativos - Spanish (PDF)Opens in new tab

    •       Directorio de Farmacias en Internet

  • 綜合處方藥一覽表(PDF) (更新日期: {{pdfs.docListMap.1022.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • 綜合處方藥一覽表(PDF)Opens in new tab
  • Prior Authorization Criteria (PDF) (更新日期: {{pdfs.docListMap.2019.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Prior Authorization Criteria (PDF) Opens in new tab
  • Step Therapy Criteria (PDF) (更新日期: {{pdfs.docListMap.2020.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Step Therapy Criteria (PDF)Opens in new tab
  • Formulary Additions (PDF) (更新日期: {{pdfs.docListMap.2021.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Formulary Additions (PDF)Opens in new tab
  • Formulary Deletions (PDF) (更新日期: {{pdfs.docListMap.2022.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Formulary Deletions (PDF)Opens in new tab
  • 替代藥物清單 (PDF) (更新日期: {{pdfs.docListMap.7022.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • 替代藥物清單 (PDF)Opens in new tab

    • Formulary search for Piedmont Plans

Pharmacy Directory

  • Información del Directorio de Farmacias (PDF) (Actualizado {{pdfs.docListMap.1028.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Información del Directorio de Farmacias (PDF)Opens in new tab
  • 網站查詢網上藥房名冊 (PDF) (更新日期: {{pdfs.docListMap.1028.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • 網站查詢網上藥房名冊 (PDF)Opens in new tab

    •       Directorio de Farmacias en Internet

          網站查詢網上藥房名冊

          Buscar Farmacia

    Find a pharmacy near you for Piedmont Plans

Plan Documents for {{selectedPlanName}}

All documents are PDF (Portable Document Format) files. They can be viewed with Adobe® Reader®. If you don't already have this viewer on your computer, download it free from the Adobe website.

English

General Plan Information
  • Enrollment Form (PDF) (Updated {{pdfs.docListMap.1.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Enrollment Form (PDF)Opens in new tab
  • Summary of Benefits (PDF) (Updated {{pdfs.docListMap.3.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Summary of Benefits (PDF) Opens in new tab
  • Evidence of Coverage (PDF)* (Updated {{pdfs.docListMap.2.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Evidence of Coverage (PDF)*Opens in new tab
  • Star Ratings (PDF) (Updated {{pdfs.docListMap.1043.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Star Ratings (PDF)Opens in new tab
  • Annual Notice of Changes (ANOC) (PDF)2 (Updated {{pdfs.docListMap.6014.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Annual Notice of Changes (ANOC) (PDF)2 Opens in new tab
Prescription Drug Coverage
  • Comprehensive Formulary (PDF) (Updated {{pdfs.docListMap.4.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Comprehensive Formulary (PDF)Opens in new tab
  • Prior Authorization Criteria (PDF) (Updated {{pdfs.docListMap.2019.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Prior Authorization Criteria (PDF) Opens in new tab
  • Step Therapy Criteria (PDF) (Updated {{pdfs.docListMap.2020.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Step Therapy Criteria (PDF)Opens in new tab
  • Formulary Additions (PDF) (Updated {{pdfs.docListMap.2021.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Formulary Additions (PDF)Opens in new tab
  • Formulary Deletions (PDF) (Updated {{pdfs.docListMap.2022.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Formulary Deletions (PDF)Opens in new tab
  • Alternative Drugs List (PDF) (Updated {{pdfs.docListMap.7022.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Alternative Drugs List (PDF)Opens in new tab
Pharmacy Directory
  • Pharmacy Directory Information (PDF) (Updated {{pdfs.docListMap.1026.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Pharmacy Directory Information (PDF) Opens in new tab

    •       Online pharmacy directory

Other Languages

General Plan Information
  • Formulario de Inscripción (PDF) (Actualizado {{pdfs.docListMap.1.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Formulario de Inscripción (PDF)Opens in new tab
  • Resumen de Beneficios (PDF) (Actualizado {{pdfs.docListMap.3.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Resumen de Beneficios (PDF)Opens in new tab
  • Comprobante de Cobertura (PDF)* (Actualizado {{pdfs.docListMap.2.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Comprobante de Cobertura (PDF)*Opens in new tab
  • Clasificación de la Calidad del Plan (PDF) (Actualizado {{pdfs.docListMap.1043.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Clasificación de la Calidad del Plan (PDF)Opens in new tab
  • Aviso Annual de Cambios (PDF)2 (Actualizado {{pdfs.docListMap.6014.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Aviso Annual de Cambios (PDF)2 Opens in new tab
  • 註冊表格 (PDF) (更新日期: {{pdfs.docListMap.1.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • 註冊表格 (PDF)Opens in new tab
  • 福利概覽 (PDF) (更新日期: {{pdfs.docListMap.3.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • 福利概覽 (PDF)Opens in new tab
  • 承保證書 (PDF)* (更新日期: {{pdfs.docListMap.2.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • 承保證書 (PDF)*Opens in new tab
  • 星級評定 (PDF) (更新日期: {{pdfs.docListMap.1043.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • 星級評定 (PDF)Opens in new tab
  • 年度變更通知 (PDF)2 (更新日期: {{pdfs.docListMap.6014.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • 年度變更通知 (PDF)2 Opens in new tab
Prescription Drug Coverage
  • Formulario Completo (PDF) (Actualizado {{pdfs.docListMap.4.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Formulario Completo (PDF)Opens in new tab
  • Prior Authorization Criteria (PDF) (Actualizado {{pdfs.docListMap.2019.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Prior Authorization Criteria (PDF) Opens in new tab
  • Step Therapy Criteria (PDF) (Actualizado {{pdfs.docListMap.2020.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Step Therapy Criteria (PDF)Opens in new tab
  • Formulary Additions (PDF) (Actualizado {{pdfs.docListMap.2021.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Formulary Additions (PDF)Opens in new tab
  • Formulary Deletions (PDF) (Actualizado {{pdfs.docListMap.2022.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Formulary Deletions (PDF)Opens in new tab
  • Lista de Medicamentos Alternativos (PDF) (Actualizado {{pdfs.docListMap.7022.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Lista de Medicamentos Alternativos (PDF)Opens in new tab
  • 綜合處方藥一覽表(PDF) (更新日期: {{pdfs.docListMap.4.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • 綜合處方藥一覽表(PDF)Opens in new tab
  • Prior Authorization Criteria (PDF) (更新日期: {{pdfs.docListMap.2019.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Prior Authorization Criteria (PDF) Opens in new tab
  • Step Therapy Criteria (PDF) (更新日期: {{pdfs.docListMap.2020.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Step Therapy Criteria (PDF)Opens in new tab
  • Formulary Additions (PDF) (更新日期: {{pdfs.docListMap.2021.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Formulary Additions (PDF)Opens in new tab
  • Formulary Deletions (PDF) (更新日期: {{pdfs.docListMap.2022.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Formulary Deletions (PDF)Opens in new tab
  • 替代藥物清單 (PDF) (更新日期: {{pdfs.docListMap.7022.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • 替代藥物清單 (PDF)Opens in new tab
Pharmacy Directory
  • Información del Directorio de Farmacias (PDF) (Actualizado {{pdfs.docListMap.1026.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Información del Directorio de Farmacias (PDF)Opens in new tab
  • 網站查詢網上藥房名冊 (PDF) (更新日期: {{pdfs.docListMap.1026.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • 網站查詢網上藥房名冊 (PDF)Opens in new tab

    •       Directorio de Farmacias en Internet

          網站查詢網上藥房名冊

Plan Documents for {{selectedPlanName}}

All documents are PDF (Portable Document Format) files. They can be viewed with Adobe® Reader®. If you don't already have this viewer on your computer, download it free from the Adobe website.

English

General Plan Information
  • Enrollment Form (PDF) (Updated {{pdfs.docListMap.1.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Enrollment Form (PDF)Opens in new tab
  • Summary of Benefits (PDF) (Updated {{pdfs.docListMap.3.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Summary of Benefits (PDF)Opens in new tab
  • Evidence of Coverage (PDF)* (Updated {{pdfs.docListMap.2.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Evidence of Coverage (PDF)*Opens in new tab
  • Star Ratings (PDF) (Updated {{pdfs.docListMap.1043.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Star Ratings (PDF)Opens in new tab
  • Annual Notice of Changes (ANOC) (PDF)6 (Updated {{pdfs.docListMap.6014.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Annual Notice of Changes (ANOC) (PDF)6Opens in new tab
  • UnitedHealth Passport Program (PDF) (Updated {{pdfs.docListMap.7001.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • UnitedHealth Passport Program (PDF)Opens in new tab
  • Benefit Highlights (Updated {{pdfs.docListMap.6002.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Benefit HighlightsOpens in new tab
Medical Providers
  • Provider Directory (PDF) (Updated {{pdfs.docListMap.1027.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Provider Directory (PDF)Opens in new tab
  • Vendor Information Sheet (PDF) (Updated {{pdfs.docListMap.7025.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Vendor Information Sheet (PDF)Opens in new tab
Prescription Drug Coverage
  • Comprehensive Formulary (PDF) (Updated {{pdfs.docListMap.1022.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Comprehensive Formulary (PDF)Opens in new tab
  • Prior Authorization Criteria (PDF) (Updated {{pdfs.docListMap.2019.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Prior Authorization Criteria (PDF)Opens in new tab
  • Step Therapy Criteria (PDF) (Updated {{pdfs.docListMap.2020.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Step Therapy Criteria (PDF)Opens in new tab
  • Formulary Additions (PDF) (Updated {{pdfs.docListMap.2021.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Formulary Additions (PDF)Opens in new tab
  • Formulary Deletions (PDF) (Updated {{pdfs.docListMap.2022.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Formulary Deletions (PDF)Opens in new tab
  • Alternative Drugs List (PDF) (Updated {{pdfs.docListMap.7022.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Alternative Drugs List (PDF)Opens in new tab
Pharmacy Directory
  • Pharmacy Directory Information (PDF) (Updated {{pdfs.docListMap.1028.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Pharmacy Directory Information (PDF) Opens in new tab

    •       Online pharmacy directory

Other Languages

General Plan Information
  • Formulario de Inscripción (PDF) (Actualizado {{pdfs.docListMap.1.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Formulario de Inscripción (PDF)Opens in new tab
  • Resumen de Beneficios (PDF) (Actualizado {{pdfs.docListMap.3.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Resumen de Beneficios (PDF)Opens in new tab
  • Comprobante de Cobertura (PDF)* (Actualizado {{pdfs.docListMap.2.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Comprobante de Cobertura (PDF)*Opens in new tab
  • Clasificación de la Calidad del Plan (PDF) (Actualizado {{pdfs.docListMap.1043.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Clasificación de la Calidad del Plan (PDF)Opens in new tab
  • Aviso Annual de Cambios (PDF)6 (Actualizado {{pdfs.docListMap.6014.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Aviso Annual de Cambios (PDF)6Opens in new tab
  • Programa UnitedHealth Passport (en formato PDF) (Actualizado {{pdfs.docListMap.7001.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Programa UnitedHealth Passport (en formato PDF)Opens in new tab
  • Beneficios Importantes (Actualizado {{pdfs.docListMap.6002.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Beneficios ImportantesOpens in new tab
  • 註冊表格 (PDF) (更新日期: {{pdfs.docListMap.1.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • 註冊表格 (PDF)Opens in new tab
  • 福利概覽 (PDF) (更新日期: {{pdfs.docListMap.3.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • 福利概覽 (PDF)Opens in new tab
  • 承保證書 (PDF)* (更新日期: {{pdfs.docListMap.2.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • 承保證書 (PDF)*Opens in new tab
  • 星級評定 (PDF) (更新日期: {{pdfs.docListMap.1043.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • 星級評定 (PDF)Opens in new tab
  • 年度變更通知 (PDF)6 (更新日期: {{pdfs.docListMap.6014.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • 年度變更通知 (PDF)6Opens in new tab
  • 聯合健康護照(UnitedHealth Passport) 計劃(PDF檔) (更新日期: {{pdfs.docListMap.7001.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • 聯合健康護照(UnitedHealth Passport) 計劃(PDF檔)Opens in new tab
  • 福利摘要 (PDF) (更新日期: {{pdfs.docListMap.6002.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • 福利摘要 (PDF)Opens in new tab
Medical Providers
  • Directorio de Proveedores (PDF) (Actualizado {{pdfs.docListMap.1027.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Directorio de Proveedores (PDF)Opens in new tab
  • Información sobre proveedores (PDF) (Actualizado {{pdfs.docListMap.7025.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Información sobre proveedores (PDF)Opens in new tab
  • 醫生名冊 (PDF) (更新日期: {{pdfs.docListMap.1027.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • 醫生名冊 (PDF)Opens in new tab
  • 供應商資訊表 (PDF) (更新日期: {{pdfs.docListMap.7025.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • 供應商資訊表 (PDF)Opens in new tab
Prescription Drug Coverage
  • Formulario Completo (PDF)(Actualizado {{pdfs.docListMap.1022.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Formulario Completo (PDF)Opens in new tab
  • Prior Authorization Criteria (PDF)(Actualizado {{pdfs.docListMap.2019.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Prior Authorization Criteria (PDF)Opens in new tab
  • Step Therapy Criteria (PDF)(Actualizado {{pdfs.docListMap.2020.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Step Therapy Criteria (PDF)Opens in new tab
  • Formulary Additions (PDF)(Actualizado {{pdfs.docListMap.2021.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Formulary Additions (PDF)Opens in new tab
  • Formulary Deletions (PDF)(Actualizado {{pdfs.docListMap.2022.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Formulary Deletions (PDF)Opens in new tab
  • Lista de Medicamentos Alternativos (PDF) (Actualizado {{pdfs.docListMap.7022.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Lista de Medicamentos Alternativos (PDF) Opens in new tab
  • 綜合處方藥一覽表(PDF)(更新日期: {{pdfs.docListMap.1022.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • 綜合處方藥一覽表(PDF)Opens in new tab
  • Prior Authorization Criteria (PDF)(更新日期: {{pdfs.docListMap.2019.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Prior Authorization Criteria (PDF)Opens in new tab
  • Step Therapy Criteria (PDF)(更新日期: {{pdfs.docListMap.2020.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Step Therapy Criteria (PDF)Opens in new tab
  • Formulary Additions (PDF)(更新日期: {{pdfs.docListMap.2021.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Formulary Additions (PDF)Opens in new tab
  • Formulary Deletions (PDF)(更新日期: {{pdfs.docListMap.2022.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Formulary Deletions (PDF)Opens in new tab
  • 替代藥物清單 (PDF)(更新日期: {{pdfs.docListMap.7022.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • 替代藥物清單 (PDF)Opens in new tab
Pharmacy Directory
  • Información del Directorio de Farmacias (PDF) (Actualizado {{pdfs.docListMap.1028.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • Información del Directorio de Farmacias (PDF) Opens in new tab
  • 網站查詢網上藥房名冊 (PDF) (更新日期: {{pdfs.docListMap.1028.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab
  • 網站查詢網上藥房名冊 (PDF) Opens in new tab

    •       Directorio de Farmacias en Internet

          網站查詢網上藥房名冊

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