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Materials and forms 

Here, you’ll find the info and forms you need to get the most from your Mercy Care Advantage plan. 

Materials

Here are some tips to find the materials you need:

Annual Notice of Changes (PDF)

This booklet is mailed to current Mercy Care Advantage members every year in September. It explains changes to the plan benefits for the upcoming year.

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Notificación anual de cambios (PDF)

Este folleto se envía por correo a los miembros actuales de Mercy Care Advantage cada año en septiembre. Explica los cambios en los beneficios del plan para el próximo año.

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Comprehensive Formulary|Formulario (PDF) Updated 4/2024

This booklet lists the prescription drugs covered by Mercy Care Advantage plan. Este folleto enumera los medicamentos recetados cubiertos por el plan Mercy Care Advantage.

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Formulary Changes (PDF) Updated 4/2024

This document outlines changes to the formulary.

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Step Therapy Criteria (PDF) Updated 10/2023

This is a list of prescription drugs that require step therapy with Mercy Care Advantage.

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Prior Authorization Criteria (PDF) Updated 4/2024

This is a list of prescription drugs that require prior authorization with Mercy Care Advantage.

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Evidence of Coverage (PDF)

This booklet explains the details about health care coverage and prescription drug coverage with Mercy Care Advantage.

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Evidencia de Cobertura (PDF)

Este folleto explica los detalles sobre la cobertura de atención médica y la cobertura de medicamentos recetados con Mercy Care Advantage.

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Evidence of Coverage - Errata (PDF)

This notice is to let you know there was an error in the EOC. Please keep this information for your reference. 

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Summary of Benefits (PDF)

This booklet lists certain features of the Mercy Care Advantage plan. It does not list every service we cover or list every limitation or exclusion. For complete details about our plan, please see the Evidence of Coverage.

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2024 Medicare Part A and B Deductible and Coinsurance Amounts / Montos de Cosgro y deducible de la Parte A y la Parte B de Medicare de 2024 (PDF)

Medicare deductible and coinsurance amounts. Montos deducibles y coseguros de Medicare. 

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Resumen de beneficios (PDF)

Este folleto enumera ciertas características del plan Mercy Care Advantage. No incluye todos los servicios que cubrimos o enumeramos todas las limitaciones o exclusiones. Para obtener detalles completos sobre nuestro plan, consulte la Evidencia de cobertura.

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Mercy Care Advantage Star Ratings (PDF)

The Centers for Medicare and Medicaid Services (CMS) rates all health and prescription drugs plans each year. The ratings are based on a plan’s quality and performance. This document shows the plan ratings for Mercy Care Advantage.

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Mercy Care Advantage Calificaciones de estrellas (PDF)

Los Centros de Servicios de Medicare y Medicaid (CMS) tasan todos los planes de salud y medicamentos recetados cada año. Las calificaciones se basan en la calidad y el desempeño de un plan. Este documento muestra las calificaciones de los planes de Mercy Care Advantage.

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Notice - How to access Mercy Care Advantage materials | Aviso: cómo acceder a los materiales de Mercy Care Advantage (PDF)

This notice describes how members can access certain Mercy Care Advantage materials online, or how to request a copy by mail. Este aviso describe cómo los miembros pueden acceder a ciertos materiales de Mercy Care Advantage en línea o cómo solicitar una copia por correo.

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Low Income Subsidy (LIS) Rider - Benefit Increased (PDF)

This is the Evidence of Coverage Rider for people who get extra help paying for prescription drugs – benefit increased.

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Subsidio de bajos ingresos (LIS) rider-Benefit Aumentado (PDF)

Esta es la Evidencia de Cobertura Rider para las personas que reciben ayuda adicional para pagar los medicamentos recetados - beneficio aumentado.

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Low Income Subsidy (LIS) Rider – Benefit Decreased (PDF)

This is the Evidence of Coverage Rider for people who get extra help paying for prescription drugs – benefit decreased.

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Subsidio de bajos ingresos (LIS) rider-Benefit Disminuido (PDF)

Esta es la Evidencia de Cobertura Rider para las personas que reciben ayuda adicional para pagar los medicamentos con receta - disminución del beneficio.

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Multi-language Interpreter Services (PDF)

We can communicate with you in other languages. To learn more, view the Mercy Care Advantage Multi-Language document.

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2024 Part B Step Therapy drug list (PDF)

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Not yet a member?

Call Member Services at 602-586-1730 or 1-877-436-5288 (TTY 711). We’re here for you 8 a.m. to 8 p.m., 7 days a week.

Forms

Sometimes you’ll need to fill out a form. The forms tell you what to do next. Get the forms you need in the list that follows.

Spotlight newsletters

Check our newsletters for topics that affect your benefits:

2022 Annual English (PDF) | Español (PDF)

2023 Spring (PDF)

2023 Fall/Winter (PDF)

 

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Questions? 

Call Member Services at ${MCA_MS_phone_1} or ${MCA_MS_phone_2} (TTY 711) We're here for you ${MCA_MS_hours}.