Forms

Forms for authorizations, appeals, enrollment and member requests.

Plan Year

State

Language

Plan Name

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2026 Covered Medication List (Formulary) – Nevada (English)

*Note: Covered Medication List (Formulary) is updated on a monthly basis.

Last Modified Date:

2026 Covered Medication List (Formulary) – California (English)

*Note: Covered Medication List (Formulary) is updated on a monthly basis.

Last Modified Date:

2026 Covered Medication List (Formulary) – California (Spanish)

*Note: Covered Medication List (Formulary) is updated on a monthly basis.

Last Modified Date:

2026 Covered Medication List (Formulary) – Nevada (Spanish)

*Note: Covered Medication List (Formulary) is updated on a monthly basis.

Last Modified Date:

Verification of Chronic Condition and SSBCI Clinical Assessment Form (English)

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2027 NV Scope of Appointment Form (English)

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Health Risk Assessment (HRA) Form (English)

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Health Risk Assessment (HRA) Form (Spanish)

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Health Risk Assessment (HRA) Form (Vietnamese)

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Complaint & Appeal Form (English)

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Complaint & Appeal Form (Spanish)

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2027 CA Enrollment Form (Spanish)

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2027 CA Enrollment Form (English)

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2027 CA Enrollment Form (Vietnamese)

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2027 CA Enrollment Form (Chinese, Traditional)

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2027 NV Enrollment Form (English)

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2027 NV Enrollment Form (Spanish)

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2027 NV Enrollment Form (Vietnamese)

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2026 CA Enrollment Form (English)

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2026 CA Enrollment Form (Spanish)

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