Important TotalCare (HMO D-SNP) Member Materials

All TotalCare plan materials are available in English, Spanish and Hmong. If you need materials in any other language, you can call Member Services at 833-530-9015 (TTY: 800-735-2929 (Dial 711)), 8 a.m. to 8 p.m., seven days a week (except Thanksgiving and Christmas) from Oct. 1 through March 31, and Monday to Friday (except holidays) from April 1 through Sept. 30.

The TotalCare documents listed below can be viewed or downloaded as a PDF. To view and print them, you must have Adobe Acrobat Reader.

If you need a printed version of a document, or a printed document in another language or formats such as large print, braille, and/or audio please call Member Services.

• Summary of Benefits
• Evidence of Coverage (Member Handbook)
• List of Covered Drugs (Formulary)
• Provider and Pharmacy Directory
• Flex Card OTC Catalog
• Quick-start Plan Guide

Forms

• Appointment of Representative Form
• Authorization for Release of Protected Health Information (PHI) Form
• Choose or Change Primary Care Provider
• Community Supports: Environmental Accessibility and Adaptability (EAA) Member Referral Form
• Community Supports: Medically Tailored Meals Form
• Community Supports: Member Housing Referral Form
• Community Supports: Member Personal Care and Homemaker Services and Respite Services Referral Form
• Compliance and Fraud, Waste and Abuse Reporting Form
• Confidential Communications Request Form
• Disenrollment Form
• Enrollment Form
• Grievances and Appeals Downloadable Form
• Health Programs Sign-up Form
• Health Risk Assessment Form
• Member Reimbursement Claim Form
• Online Grievance Form
• Order ID Card, Member Handbook and Provider/Pharmacy Directory
• Part D Coverage Determination Form
• Part D Model Redetermination Request Form
• Part D Prescription Drug Claim Form
• Privacy Request Form
• Record Access Request Form
• Update Contact Information

Notices and Documents

• Notice of Availability and Nondiscrimination, Grievance Filing, Civil Rights Notice (1557)
• Member Rights in the Complaint Process
• Notice of Privacy Practices
• List of Prior Authorization Requirements
• List of Step Therapy Requirements