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Materials
Here are some tips to find the materials you need:
- Look at your Summary of Benefits or Evidence of Coverage to learn more about your plan benefits and cost sharing.
- Check your comprehensive 2024 Formulary - drug list (PDF) or 2025 Formulary - drug list (PDF). Or learn more about Part D prescription drug benefits.
- Get materials in other languages or formats. Visit our language help page to learn more about translation and interpretation. You can also learn about multi-language interpreter services (PDF).
- Check your provider directory for health care providers, pharmacies and more. No matter what page you’re on, you can always choose find a provider at the top of the page.
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) 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.
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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.
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Step Therapy Criteria (PDF) Updated 10/2024
This is a list of prescription drugs that require step therapy with Mercy Care Advantage.
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Prior Authorization Criteria (PDF) Updated 10/2024
This is a list of prescription drugs that require prior authorization with Mercy Care Advantage.
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Evidence of Coverage - ACC/DD (PDF)
This booklet explains the details about health care coverage and prescription drug coverage with Mercy Care Advantage.
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Evidence of Coverage - ALTCS (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 - 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.
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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
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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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.
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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.
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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.
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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.
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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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Part B Step Therapy drug list (PDF) Coming Soon
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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.
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Formulary Changes (PDF) Updated 9/2024
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.
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
This booklet explains the details about health care coverage and prescription drug coverage with Mercy Care Advantage.
H5580_24_007_C
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.
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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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Medicare deductible and coinsurance amounts. Montos deducibles y coseguros de Medicare.
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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
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.
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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.
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)
Spotlight newsletters
Check our newsletters for topics that affect your benefits:
2024 Spring and Summer English (PDF)
2024 Spring and Summer Español (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}.