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    Materials and forms 

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

    Materials and forms

    Tips to find the materials you need:

    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.

    • Annual Notice of Changes ACC/DD (PDF) 

      This booklet explains changes to the plan benefits for the upcoming year.

      H5580_27_010_C
       

      Annual Notice of Changes ALTCS (PDF) 

      This booklet explains changes to the plan benefits for the upcoming year.

      H5580_27_003_C

       

      Notificación anual de cambios ACC/DD (PDF)

      Este folleto explica los cambios en los beneficios del plan para el próximo año.

      H5580_27_010_C_SP

       

      Notificación anual de cambios ALTCS (PDF)
      Este folleto explica los cambios en los beneficios del plan para el próximo año.

      H5580_27_003_C_SP

       

      Comprehensive Formulary|Formulario (PDF) Updated 9/2026

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

      H5580_27_006_C

       

      Formulary Changes (PDF) Coming soon

      This document outlines changes to the formulary.

       

      Step Therapy Criteria (PDF) Coming soon

      This is a list of prescription drugs that require step therapy.

       

      Prior Authorization Criteria (PDF)  Coming soon

      This is a list of prescription drugs that require prior authorization.

       

      Evidence of Coverage - ACC/DD (PDF) Coming soon

      This booklet explains the details about health care coverage and prescription drug coverage.

       

      Evidence of Coverage - ALTCS (PDF) Coming soon

      This booklet explains the details about health care coverage and prescription drug coverage.

       

      Evidencia de Cobertura - ACC/DD (PDF) Coming soon

      Este folleto explica los detalles sobre la cobertura de atención médica y la cobertura de medicamentos recetados.

      H5580_26_007_C_SP

       

      Evidencia de Cobertura - ALTCS (PDF) Coming soon

      Este folleto explica los detalles sobre la cobertura de atención médica y la cobertura de medicamentos recetados.

      H5580_26_055_C_SP

       

      2027 Summary of Benefits (PDF)

      This booklet highlights features of our 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.

      H5580_27_004_M

       

      2027 Resumen de beneficios (PDF)

      Este folleto destaca las características de nuestro plan. No incluye todos los servicios que cubrimos ni todas las limitaciones o exclusiones. Para obtener información completa sobre nuestro plan, consulte la Evidencia de Cobertura.

      H5580_27_004_M_SP

       

      2026 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 2026 (PDF) Coming soon

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

      H5580_26_061_C

       

      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.

      H5580_27_013_M

       

      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.

      H5580_27_013_M_SP

       

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

      This notice tells you how to access certain Mercy Care Advantage materials online and how to request a copy by mail. Este aviso le informa cómo acceder a ciertos materiales de Mercy Care Advantage en línea y cómo solicitar una copia por correo. 

      H5580_27_008_C
       

      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.

      H5580_27_001_C
       

      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.

      H5580_27_001_C_SP
       

      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.

      H5580_27_002_C
       

      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.

      H5580_27_002_C_SP
       

      Notice of Availability (NOA) (PDF)

      To learn more, view the Mercy Care Advantage Multi-Language document.

      H5580_26_020_C

       

      Part B Step Therapy drug list (PDF) Coming soon

       

    Forms

    Get the forms you need in the list that follows.

    Appointment of Representative (AOR) form - English (PDF)

    Appointment of Representative (AOR) form - Español (PDF)

    Online Coverage Determination form - English

    Online Coverage Determination form - Español

    Print Coverage Determination form (PDF)

    Online Coverage Redetermination form - English

    Online Coverage Redetermination form  - Español

    Print Coverage Redetermination form (PDF)

    Enrollment form and instructions - English (PDF)

    Enrollment form and insructions - Español (PDF)

    Medicare Part D Prescription Claim form - English (PDF)

    Medicare Part D Prescription Claim form - Español (PDF)

    Personal Medication List (PDF)

    Patient Checklist - English and Español (PDF)

    Removal of Authorization Previously Given to Mercy Care - English (PDF)

    Removal of Authorization Previously Given to Mercy Care - Español (PDF)

    Request for an Accounting of Disclosures of Protected Health Information (PHI) - English (PDF)

    Request for an Accounting of Disclosures of Protected Health Information (PHI) - Español (PDF)

    Protected Health Information (PHI) Access Request - English (PDF)

    Protected Health Information (PHI) Access Request - Español (PDF)

    Authorization to Release Psychotherapy Notes - English (PDF)

    Authorization to Release Psychotherapy Notes - Español (PDF)

    Authorization to Release Protected Health Information (PHI) - English (PDF)

    Authorization to Release Protected Health Information (PHI) - Español (PDF)

    Questions? 

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

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