Request a Member ID Card

Order Over-the-Counter Supplies

Appoint Representation

File a Grievance

File an Appeal

Get a Temporary Supply of Prescription Drugs

Submit a Healthcare Claim or Bill

Disenroll from Brand New Day

Find Community Based Resources

Participate in the Rewards Plus Program

Mail Order Rx and Extra Help

Medication Therapy Management Program

Extra Help to Pay for Prescription Drugs

Prior-Authorization, Coverage Determination, and Exceptions

Prescription Drug Transition Policy

Step Therapy

File an Appeal for Part D Prescription Drugs

Plan Documents (ANOC, EOC and Summary of Benefits)

Health Education

Medicare Resources

Member Resource Guide 2021 (English | Spanish | Chinese | Korean | Vietnamese)

Member Resource Guide 2022 (English | Spanish | Chinese | Korean | Vietnamese)

Multi-Language Interpreter Services

Non-Discrimination Notice

Out-of-Network Coverage Rules

Part C Pre-Authorizations, Organizational Determination, Appeals, and Grievances

Privacy Practices for Protected Health Information (PHI)

Provider/Pharmacy Search

Utilization Management

Medicare Plan Ratings / Medicare STAR Ratings ( English | Spanish | Chinese | Korean | Vietnamese )

Winter Newsletters (English | Spanish | Chinese | Korean | Vietnamese)

Spring Newsletters (English | Spanish | Chinese | Korean | Vietnamese)

Summer Newsletters (English | Spanish | Chinese | Korean | Vietnamese)

Fall Newsletter (English | Spanish | Chinese | Korean | Vietnamese)

2021 Over-the-Counter (OTC) Order Form
(English | Spanish | Chinese | Korean | Vietnamese)

2022 Over-the-Counter (OTC) Order Form
(English | Spanish | Chinese | Korean | Vietnamese)

2021 Appeal Form
(English | Spanish | Chinese | Korean | Vietnamese)

Appointment of Representative Form (English | Spanish)

Authorization for Disclosure of Protected Health Information

Enrollment Forms (2021)

Enrollment Forms (2022)

2021 Grievance Form
(English | Spanish | Chinese | Korean | Vietnamese)

Authorization Service Request Form (English | Spanish)

Benefit Highlights

2021 Health Risk Assessment (HRA)
(English | Spanish | Chinese | Korean | Vietnamese)

2022 Health Risk Assessment (HRA)
(English | Spanish | Chinese | Korean | Vietnamese)

To complete an Electronic HRA click here

DeltaCare USA Dental
Medicare Fee Schedule | Fee Schedule for Dual Eligibles

Western Dental
Medicare Fee Schedule | Fee Schedule for Dual Eligibles