Menu
| Documents & Forms | Download Link |
|---|---|
|
Pharmacy – 2024 Step Therapy (ST) Criteria – Complete Health Medicare Advantage (HMO), Tiers Medicare Advantage (HMO), and Dual Complete (HMO D-SNP) |
|
|
Pharmacy – 2024 Step Therapy (ST) Criteria – Diabetes Wellness (HMO C-SNP) and Heart Healthy (HMO C-SNP) |
|
|
Pharmacy – 2024 Prior Authorization (PA) Criteria – Complete Health Medicare Advantage (HMO), Tiers Medicare Advantage (HMO), and Dual Complete (HMO D-SNP) 2024 Prior Authorization (PA) Criteria |
|
|
Pharmacy – 2024 Prior Authorization (PA) Criteria – Diabetes Wellness (HMO C-SNP) and Heart Healthy (HMO C-SNP) |
|
|
Pharmacy – 2024 Formulary List of Covered Drugs – Diabetes Wellness and Heart Healthy (HMO C-SNP) 2024 Formulary List of Covered Drugs |
|
|
Pharmacy – 2024 Formulary List of Covered Drugs – Dual Complete (HMO D-SNP) |
|
|
Pharmacy – 2024 Formulary List of Covered Drugs – Complete Health Medicare Advantage (HMO) and Tiers Medicare Advantage (HMO) |
|
|
2024 Summary of Benefits – Sonder Complete Health Medicare Advantage (HMO) |
|
|
2024 Summary of Benefits – Sonder Diabetes Wellness (HMO C-SNP) |
|
|
2024 Summary of Benefits – Sonder Heart Healthy (HMO C-SNP) |
|
|
2024 Summary of Benefits – Sonder Dual Complete (HMO D-SNP) |
|
|
2024 Summary of Benefits – Sonder Tiers Medicare Advantage (HMO) |
|
|
2024 Grocery Catalog (English) |
|
|
2024 Over-The-Counter Catalog (Spanish) |
|
|
2024 Over-The-Counter Catalog (Chinese) |
|
|
2024 Over-The-Counter Catalog (Korean) |
|
|
2024 Grocery Catalog |
|
|
2024 Grocery Catalog (Spanish) |
|
|
2024 Grocery Catalog (Korean) |
|
|
Appointment of Representative CMS – 1696 |
|
|
Appointment of Representative CMS – 1696 (Large Print) |
|
|
Nombramiento de la Representante CMS – 1696 |
|
|
Nombramiento del representante CMS – 1696 (letra grande) |
|
|
Authorization to Use or Disclose PHI Form |
|
|
CSNP Prequalification Form & Verification Form |
|
|
Grievance Submission Form |
|
|
Low Income Subsidy (LIS) Information |
|
|
Member Appeal Request |
|
|
Mid-Year Change Notification |
|
|
Revocation of Authorization to Use or Disclose PHI Form |
|
|
Sonder Health Plans Advance Directive |
|
|
2023 Summary of Benefits – Sonder Complete Health Medicare Advantage (HMO) |
|
|
2023 Summary of Benefits – Sonder Diabetes Wellness (HMO C-SNP) |
|
|
2023 Summary of Benefits – Sonder Heart Healthy (HMO C-SNP) |
|
|
2023 Summary of Benefits – Sonder Dual Complete (HMO D-SNP) |
|
|
Pharmacy – 2023 Complete Health Medicare Advantage (HMO – H1748 – 001) Comprehensive Formulary |
|
|
Pharmacy – 2023 Diabetes Wellness / Heart Healthy (HMO C-SNP) Comprehensive Formulary |
|
|
Pharmacy – 2023 Dual Complete (HMO D-SNP) Comprehensive Formulary |
|
|
Pharmacy – 2023 Prior Authorization (PA) Criteria for Complete Health Medicare Advantage (HMO – 001) & Dual Complete (HMO D-SNP – 005) |
|
|
Pharmacy – 2023 Prior Authorization (PA) Criteria for Sonder Diabetes Wellness / Heart Healthy (HMO C-SNP) |
|
|
Pharmacy – 2023 Step Therapy (ST) Criteria for Complete Health Medicare Advantage (HMO – 001) & Dual Complete (HMO D-SNP – 005) |
|
|
Pharmacy – 2023 Step Therapy (ST) Criteria for Sonder Diabetes Wellness / Heart Healthy (HMO C-SNP) |
|
|
Pharmacy – 2023 Formulary Addendum for Complete Health Medicare Advantage (HMO – 001) & Dual Complete (HMO D-SNP – 005) |
|
|
Pharmacy – 2023 Formulary Addendum for Sonder Diabetes Wellness / Heart Healthy (HMO C-SNP) |
|
|
Pharmacy – Part D Drug Coverage Determination / Exception / Prior Authorization Form |
|
|
Pharmacy – Part D Drug Appeal / Redetermination Form |
|
|
Pharmacy – Part D Drug Direct Member Reimbursement (DMR) Form |
|
|
Pharmacy – Medicare Prescription Drug Coverage and Your Rights – Notice CMS-10147 |
|
|
Pharmacy – Medicare Prescription Drug Coverage and Your Rights – Notice CMS-10147 Spanish |