2021 Member Materials & Forms

On this page, you’ll find important documents related to your MCC of VA (HMO SNP) health plan. Click the links below to download each document.

Annual Materials 2021

Annual Notice of Change (ANOC): describes changes to your MCC of VA (HMO SNP) plan coverage, costs or service area.
English          Spanish

Summary of Benefits: a summary of what we cover and what you pay. For a complete list of covered services and exclusions, refer to your Evidence of Coverage.
English         Spanish

Evidence of Coverage (EOC): your Medicare health benefits and services and prescription drug coverage as a member of MCC of VA (HMO SNP).
English          Spanish

Formulary: a list of the drugs covered in this plan. 
English          Spanish

LIS Premium Summary: explains your monthly plan premium if you get Extra Help paying for your prescription drugs.
English          Spanish

LIS Rider: describes the Extra Help you get paying for your prescription drugs.
English          Spanish

Provider and Pharmacy Directory: a list of MCC of VA (HMO SNP)’s current network providers and pharmacies.
English          Spanish

General Information

Advance Directive Information: the Virginia State Bar Association tells you how to fill out, store and access your medical directive.

Enrollment Information: everything you need to know about joining our 2021 plan.

Member Forms

Appointment of Representative Form
English         Spanish

Member Disenrollment Form
English          Spanish

Member Opt-out Form
English          Spanish

Prescription Drugs Materials & Forms

Medicare Part D Coverage Determination Request Form  (download and mail or fax)
English          Spanish
                 OR
Medicare Part D Coverage Determination Request Form (submit online)
English          Spanish


Medicare Part D Request for Redetermination after Denial (download and mail or fax)
English         Spanish
OR
Medicare Part D Request for Redetermination after Denial (submit online)
English          Spanish


Medicare Part D Request for Reconsideration of Drug Denial Form (download and mail or fax form)
English           Spanish


Medicare Part B Prior Authorization Drug List: medicines on this list need to be approved by the plan before you can take them.

Medication Therapy Management Program: explains our plan’s drug program for members who take multiple medicines.

Pharmacy Transition Management Policy: describes how our plan works with members on needed drugs not on our Formulary.


RX Member Reimbursement Form: use this form to ask us to pay you back for a covered drug you bought.