Member Materials & Forms

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

Annual Materials 2020

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.

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

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

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

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

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

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 2020 plan.

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.

Member Forms

Appointment of Representative Form

Medicare Part D Coverage Determination Request Form

Medicare Part D Request for Reconsideration

Member Disenrollment Form

Member Opt-out Form