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Plan Documents for {{selectedPlanName}}

All documents are PDF (Portable Document Format) files. They can be viewed with Adobe^® Reader^®. If you don't already have this viewer on your computer, download it free from the Adobe website.

English

General Plan Information

Enrollment Form (PDF) (Updated {{pdfs.docListMap.1.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Enrollment Form (PDF)Opens in new tab

Summary of Benefits (PDF) (Updated {{pdfs.docListMap.3.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Summary of Benefits (PDF)Opens in new tab

Evidence of Coverage (PDF)* (Updated {{pdfs.docListMap.2.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Evidence of Coverage (PDF)*Opens in new tab

Star Ratings (PDF) (Updated {{pdfs.docListMap.1043.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Star Ratings (PDF)Opens in new tab

Annual Notice of Changes (ANOC) (PDF)⁵ (Updated {{pdfs.docListMap.6014.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Annual Notice of Changes (ANOC) (PDF)⁵Opens in new tab

UnitedHealth Passport Program (PDF) (Updated {{pdfs.docListMap.7001.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

UnitedHealth Passport Program (PDF)Opens in new tab

Benefit Highlights (Updated {{pdfs.docListMap.6002.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Benefit HighlightsOpens in new tab

Medical Providers

Provider Directory (PDF) (Updated {{pdfs.docListMap.1027.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Provider Directory (PDF)Opens in new tab

Vendor Information Sheet (PDF) (Updated {{pdfs.docListMap.7025.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Vendor Information Sheet (PDF)Opens in new tab

Other Languages

General Plan Information

Formulario de Inscripción (PDF) (Actualizado {{pdfs.docListMap.1.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Formulario de Inscripción (PDF)Opens in new tab

Resumen de Beneficios (PDF) (Actualizado {{pdfs.docListMap.3.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Resumen de Beneficios (PDF)Opens in new tab

Comprobante de Cobertura (PDF)* (Actualizado {{pdfs.docListMap.2.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Comprobante de Cobertura (PDF)*Opens in new tab

Clasificación de la Calidad del Plan (PDF) (Actualizado {{pdfs.docListMap.1043.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Clasificación de la Calidad del Plan (PDF)Opens in new tab

Aviso Annual de Cambios (PDF)⁵ (Actualizado {{pdfs.docListMap.6014.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Aviso Annual de Cambios (PDF)⁵Opens in new tab

Programa UnitedHealth Passport (en formato PDF) (Actualizado {{pdfs.docListMap.7001.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Programa UnitedHealth Passport (en formato PDF)Opens in new tab

Beneficios Importantes (Actualizado {{pdfs.docListMap.6002.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Beneficios ImportantesOpens in new tab

註冊表格 (PDF) (更新日期: {{pdfs.docListMap.1.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

註冊表格 (PDF)Opens in new tab

福利概覽 (PDF) (更新日期: {{pdfs.docListMap.3.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

福利概覽 (PDF)Opens in new tab

承保證書 (PDF)* (更新日期: {{pdfs.docListMap.2.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

承保證書 (PDF)*Opens in new tab

星級評定 (PDF) (更新日期: {{pdfs.docListMap.1043.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

星級評定 (PDF)Opens in new tab

年度變更通知 (PDF)⁵ (更新日期: {{pdfs.docListMap.6014.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

年度變更通知 (PDF)⁵ Opens in new tab

聯合健康護照(UnitedHealth Passport) 計劃(PDF檔) (更新日期: {{pdfs.docListMap.7001.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

聯合健康護照(UnitedHealth Passport) 計劃(PDF檔)Opens in new tab

福利摘要 (PDF) (更新日期: {{pdfs.docListMap.6002.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

福利摘要 (PDF)Opens in new tab

Medical Providers

Directorio de Proveedores (PDF) (Actualizado {{pdfs.docListMap.1027.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Directorio de Proveedores (PDF)Opens in new tab

Información sobre proveedores - Spanish (PDF) (Actualizado {{pdfs.docListMap.7025.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Información sobre proveedores - Spanish (PDF)Opens in new tab

醫生名冊 (PDF) (更新日期: {{pdfs.docListMap.1027.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

醫生名冊 (PDF)Opens in new tab

供應商資訊表 - Chinese (PDF) (更新日期: {{pdfs.docListMap.7025.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

供應商資訊表 - Chinese (PDF) Opens in new tab

Plan Documents for {{selectedPlanName}}

All documents are PDF (Portable Document Format) files. They can be viewed with Adobe^® Reader^®. If you don't already have this viewer on your computer, download it free from the Adobe website.

English

Other Languages

General Plan Information

Formulario de Inscripción (PDF) (Actualizado {{pdfs.docListMap.1.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Formulario de Inscripción (PDF)Opens in new tab

Resumen de Beneficios (PDF) (Actualizado {{pdfs.docListMap.3.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Resumen de Beneficios (PDF)Opens in new tab

Comprobante de Cobertura (PDF)* (Actualizado {{pdfs.docListMap.2.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Comprobante de Cobertura (PDF)*Opens in new tab

Clasificación de la Calidad del Plan (PDF) (Actualizado {{pdfs.docListMap.1043.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Clasificación de la Calidad del Plan (PDF)Opens in new tab

Aviso Annual de Cambios (PDF)⁵ (Actualizado {{pdfs.docListMap.6014.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Aviso Annual de Cambios (PDF)⁵ Opens in new tab

Programa UnitedHealth Passport (en formato PDF) (Actualizado {{pdfs.docListMap.7001.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Programa UnitedHealth Passport (en formato PDF)Opens in new tab

Beneficios Importantes (Actualizado {{pdfs.docListMap.6002.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Beneficios ImportantesOpens in new tab

註冊表格 (PDF) (更新日期: {{pdfs.docListMap.1.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

註冊表格 (PDF)Opens in new tab

福利概覽 (PDF) (更新日期: {{pdfs.docListMap.3.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

福利概覽 (PDF)Opens in new tab

承保證書 (PDF)* (更新日期: {{pdfs.docListMap.2.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

承保證書 (PDF)*Opens in new tab

星級評定 (PDF) (更新日期: {{pdfs.docListMap.1043.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

星級評定 (PDF)Opens in new tab

年度變更通知 (PDF)⁵ (更新日期: {{pdfs.docListMap.6014.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

年度變更通知 (PDF)⁵ Opens in new tab

聯合健康護照(UnitedHealth Passport) 計劃(PDF檔) (更新日期: {{pdfs.docListMap.7001.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

聯合健康護照(UnitedHealth Passport) 計劃(PDF檔) Opens in new tab

福利摘要 (PDF) (更新日期: {{pdfs.docListMap.6002.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

福利摘要 (PDF)Opens in new tab

Medical Providers

Directorio de Proveedores (PDF) (Actualizado {{pdfs.docListMap.1027.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Directorio de Proveedores (PDF)Opens in new tab

Información sobre proveedores - Spanish (PDF) (Actualizado {{pdfs.docListMap.7025.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Información sobre proveedores - Spanish (PDF)Opens in new tab

醫生名冊 (PDF) (更新日期: {{pdfs.docListMap.1027.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

醫生名冊 (PDF)Opens in new tab

供應商資訊表 - Chinese (PDF) (更新日期: {{pdfs.docListMap.7025.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

供應商資訊表 - Chinese (PDF)Opens in new tab

Prescription Drug Coverage

Formulario Completo (PDF) (Actualizado {{pdfs.docListMap.1022.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Formulario Completo (PDF)Opens in new tab

Prior Authorization Criteria (PDF) (Actualizado {{pdfs.docListMap.2019.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Prior Authorization Criteria (PDF) Opens in new tab

Step Therapy Criteria (PDF) (Actualizado {{pdfs.docListMap.2020.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Step Therapy Criteria (PDF)Opens in new tab

Formulary Additions (PDF) (Actualizado {{pdfs.docListMap.2021.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Formulary Additions (PDF)Opens in new tab

Formulary Deletions (PDF) (Actualizado {{pdfs.docListMap.2022.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Formulary Deletions (PDF)Opens in new tab

Lista de Medicamentos Alternativos - Spanish (PDF) (Actualizado {{pdfs.docListMap.7022.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Lista de Medicamentos Alternativos - Spanish (PDF)Opens in new tab

Directorio de Farmacias en Internet

綜合處方藥一覽表(PDF) (更新日期: {{pdfs.docListMap.1022.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

綜合處方藥一覽表(PDF)Opens in new tab

Prior Authorization Criteria (PDF) (更新日期: {{pdfs.docListMap.2019.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Prior Authorization Criteria (PDF) Opens in new tab

Step Therapy Criteria (PDF) (更新日期: {{pdfs.docListMap.2020.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Step Therapy Criteria (PDF)Opens in new tab

Formulary Additions (PDF) (更新日期: {{pdfs.docListMap.2021.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Formulary Additions (PDF)Opens in new tab

Formulary Deletions (PDF) (更新日期: {{pdfs.docListMap.2022.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Formulary Deletions (PDF)Opens in new tab

替代藥物清單 (PDF) (更新日期: {{pdfs.docListMap.7022.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

替代藥物清單 (PDF)Opens in new tab

Formulary search for Piedmont Plans

Pharmacy Directory

Información del Directorio de Farmacias (PDF) (Actualizado {{pdfs.docListMap.1028.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Información del Directorio de Farmacias (PDF)Opens in new tab

網站查詢網上藥房名冊 (PDF) (更新日期: {{pdfs.docListMap.1028.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

網站查詢網上藥房名冊 (PDF)Opens in new tab

Directorio de Farmacias en Internet

網站查詢網上藥房名冊

Buscar Farmacia

Find a pharmacy near you for Piedmont Plans

Plan Documents for {{selectedPlanName}}

All documents are PDF (Portable Document Format) files. They can be viewed with Adobe^® Reader^®. If you don't already have this viewer on your computer, download it free from the Adobe website.

English

General Plan Information

Enrollment Form (PDF) (Updated {{pdfs.docListMap.1.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Enrollment Form (PDF)Opens in new tab

Summary of Benefits (PDF) (Updated {{pdfs.docListMap.3.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Summary of Benefits (PDF) Opens in new tab

Evidence of Coverage (PDF)* (Updated {{pdfs.docListMap.2.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Evidence of Coverage (PDF)*Opens in new tab

Star Ratings (PDF) (Updated {{pdfs.docListMap.1043.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Star Ratings (PDF)Opens in new tab

Annual Notice of Changes (ANOC) (PDF)² (Updated {{pdfs.docListMap.6014.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Annual Notice of Changes (ANOC) (PDF)² Opens in new tab

Prescription Drug Coverage

Comprehensive Formulary (PDF) (Updated {{pdfs.docListMap.4.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Comprehensive Formulary (PDF)Opens in new tab

Prior Authorization Criteria (PDF) (Updated {{pdfs.docListMap.2019.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Prior Authorization Criteria (PDF) Opens in new tab

Step Therapy Criteria (PDF) (Updated {{pdfs.docListMap.2020.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Step Therapy Criteria (PDF)Opens in new tab

Formulary Additions (PDF) (Updated {{pdfs.docListMap.2021.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Formulary Additions (PDF)Opens in new tab

Formulary Deletions (PDF) (Updated {{pdfs.docListMap.2022.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Formulary Deletions (PDF)Opens in new tab

Alternative Drugs List (PDF) (Updated {{pdfs.docListMap.7022.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Alternative Drugs List (PDF)Opens in new tab

Pharmacy Directory

Pharmacy Directory Information (PDF) (Updated {{pdfs.docListMap.1026.en_us.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Pharmacy Directory Information (PDF) Opens in new tab

Online pharmacy directory

Other Languages

General Plan Information

Formulario de Inscripción (PDF) (Actualizado {{pdfs.docListMap.1.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Formulario de Inscripción (PDF)Opens in new tab

Resumen de Beneficios (PDF) (Actualizado {{pdfs.docListMap.3.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Resumen de Beneficios (PDF)Opens in new tab

Comprobante de Cobertura (PDF)* (Actualizado {{pdfs.docListMap.2.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Comprobante de Cobertura (PDF)*Opens in new tab

Clasificación de la Calidad del Plan (PDF) (Actualizado {{pdfs.docListMap.1043.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Clasificación de la Calidad del Plan (PDF)Opens in new tab

Aviso Annual de Cambios (PDF)² (Actualizado {{pdfs.docListMap.6014.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Aviso Annual de Cambios (PDF)² Opens in new tab

註冊表格 (PDF) (更新日期: {{pdfs.docListMap.1.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

註冊表格 (PDF)Opens in new tab

福利概覽 (PDF) (更新日期: {{pdfs.docListMap.3.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

福利概覽 (PDF)Opens in new tab

承保證書 (PDF)* (更新日期: {{pdfs.docListMap.2.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

承保證書 (PDF)*Opens in new tab

星級評定 (PDF) (更新日期: {{pdfs.docListMap.1043.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

星級評定 (PDF)Opens in new tab

年度變更通知 (PDF)² (更新日期: {{pdfs.docListMap.6014.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

年度變更通知 (PDF)² Opens in new tab

Prescription Drug Coverage

Formulario Completo (PDF) (Actualizado {{pdfs.docListMap.4.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Formulario Completo (PDF)Opens in new tab

Prior Authorization Criteria (PDF) (Actualizado {{pdfs.docListMap.2019.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Prior Authorization Criteria (PDF) Opens in new tab

Step Therapy Criteria (PDF) (Actualizado {{pdfs.docListMap.2020.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Step Therapy Criteria (PDF)Opens in new tab

Formulary Additions (PDF) (Actualizado {{pdfs.docListMap.2021.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Formulary Additions (PDF)Opens in new tab

Formulary Deletions (PDF) (Actualizado {{pdfs.docListMap.2022.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Formulary Deletions (PDF)Opens in new tab

Lista de Medicamentos Alternativos (PDF) (Actualizado {{pdfs.docListMap.7022.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Lista de Medicamentos Alternativos (PDF)Opens in new tab

綜合處方藥一覽表(PDF) (更新日期: {{pdfs.docListMap.4.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

綜合處方藥一覽表(PDF)Opens in new tab

Prior Authorization Criteria (PDF) (更新日期: {{pdfs.docListMap.2019.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Prior Authorization Criteria (PDF) Opens in new tab

Step Therapy Criteria (PDF) (更新日期: {{pdfs.docListMap.2020.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Step Therapy Criteria (PDF)Opens in new tab

Formulary Additions (PDF) (更新日期: {{pdfs.docListMap.2021.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Formulary Additions (PDF)Opens in new tab

Formulary Deletions (PDF) (更新日期: {{pdfs.docListMap.2022.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Formulary Deletions (PDF)Opens in new tab

替代藥物清單 (PDF) (更新日期: {{pdfs.docListMap.7022.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

替代藥物清單 (PDF)Opens in new tab

Pharmacy Directory

Información del Directorio de Farmacias (PDF) (Actualizado {{pdfs.docListMap.1026.es.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

Información del Directorio de Farmacias (PDF)Opens in new tab

網站查詢網上藥房名冊 (PDF) (更新日期: {{pdfs.docListMap.1026.zh.lastModifiedDate | date : "MM/dd/yyyy" }})Opens in new tab

網站查詢網上藥房名冊 (PDF)Opens in new tab

Directorio de Farmacias en Internet

網站查詢網上藥房名冊

Plan Documents for {{selectedPlanName}}

All documents are PDF (Portable Document Format) files. They can be viewed with Adobe^® Reader^®. If you don't already have this viewer on your computer, download it free from the Adobe website.