For Medica Medicare Members
Before you get started, grab your Medica ID card. You’ll need it to complete this form.
If you need multiple Evidence of Coverage (EOC) documents, you’ll need to submit a separate request for each one. IMPORTANT: If you ask for a provider directory, pharmacy directory, formulary, or other material as part of your first EOC request, you don’t need to ask for the same material again in future EOC requests.
Fields marked with an asterisk * are required
Where do I find my group number?
Where do I find my care type?
Where do I find my CMS code?
Select the material(s) below that you need to receive by mail using your CMS code found on the front your Medica ID card. Click here for help finding your CMS Code on your Medica ID card.
If you have a Medicare plan sponsored by an employer group, select the appropriate Group plan option for material(s) you are requesting when applicable.
Information in parenthesis below is for administrative purposes only.
EOC (average page count: 240 pages) Please select one if needed.
Provider directory (average page count: 436 pages) Please select one if needed.
Pharmacy Directory (average page count: 108 pages) Please select one if needed.
Formulary (average page count: 144 pages) Please select one if needed.
Catalogs (average page count: 28 pages) Please select one if needed.
Forms (average page count: 1 page) Please select one if needed.
Read instructions for each material section to select what you need to receive by mail.
EOC (average page count: 198 pages)
If needed, please select the EOC option that includes your Group number found on the front your Medica ID card. Click here for help finding your Group Number on your Medica ID card.
If you have a Medicare plan sponsored by an employer group, select "Medica Group Prime Solution (Cost) members only."
Provider Directory (average page count: 436 pages)
If needed, please select the option below that includes the state your plan is issued. Applies to all Medica Prime Solution (Cost) members, including employer group-sponsored plans.
Pharmacy directory (average page count: 108 pages) Please select one if needed.
Y0088_1000973_C Last Updated: November 2023
