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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.

H5580_25_003_C
 

Notificación anual de cambios (PDF) Coming Soon

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.

H5580_25_003_C
 

Comprehensive Formulary|Formulario (PDF) Updated 10/2024

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.

H5580_25_006_C

 

Step Therapy Criteria (PDF) Updated 10/2024

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

H5580_25_031_C

Prior Authorization Criteria (PDF) Updated 10/2024

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

H5580_25_032_C

 

Evidence of Coverage - ACC/DD (PDF) 

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

H5580_25_007_C

 

Evidence of Coverage - ALTCS (PDF)

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

H5580_25_067_C

 

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 con Mercy Care Advantage.

H5580_25_007_C

 

Evidencia de Cobertura - ALTCS (PDF) Coming Soon

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

H5580_25_007_C

 

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.

H5580_25_004_M

 

Resumen de beneficios (PDF) Coming Soon

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.

H5580_25_004_M

 

2025 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 2025 (PDF) Coming Soon

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

H5580_25_043_C 

 

Mercy Care Advantage Star Ratings (PDF) Coming Soon

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_25_044_M
 

Mercy Care Advantage Calificaciones de estrellas (PDF) Coming Soon

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_25_044_M
 

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.

H5580_25_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_25_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_25_001_C
 

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_25_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_25_002_C
 

Multi-language Interpreter Services (PDF)

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

H5580_25_035_C

 

Part B Step Therapy drug list (PDF) Coming Soon

H5580_25_045_C

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.

H5580_24_003_M
 

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.

H5580_24_003_M
 

Comprehensive Formulary|Formulario (PDF) Updated 9/2024

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.

H5580_24_006_C

 

Formulary Changes (PDF) Updated 9/2024

This document outlines changes to the formulary.

H5580_24_125_C

 

Step Therapy Criteria (PDF) Updated 10/2023

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

H5580_24_012_C

Prior Authorization Criteria (PDF) Updated 9/2024

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

H5580_24_011_C

 

Evidence of Coverage (PDF)

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

H5580_24_007_C

 

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.

H5580_24_007_C

 

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. 

H5580_24_043_C 

 

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.

H5580_24_004_M

 

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. 

H5580_24_041_C 

 

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.

H5580_24_004_M

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_24_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_24_013_M
 

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.

H5580_24_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_24_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_24_001_C
 

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_24_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_24_002_C
 

Multi-language Interpreter Services (PDF)

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

H5580_24_035_C

 

2024 Part B Step Therapy drug list (PDF)

H5580_24_009_C

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.

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 - English (PDF)

Enrollment form - Español (PDF)

Enrollment form instructions - English (PDF)

Enrollment form instructions - Español (PDF)

Medicare Part D Prescription Claim form - English (PDF)

Medicare Part D Prescription Claim form - Español (PDF)

Personal Medication List (PDF)

Prescription Drug Mail-order form - English (PDF)

Prescription Drug Mail-order form - Español (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}.