Medicare Advantage Forms & Information

Navigating Medicare can feel overwhelming, but UCLA Health Medicare Advantage Plan is here to simplify the process. Whether you're looking for essential health plan forms, detailed information, or trusted resources, we have you covered. Our comprehensive provider directory ensures that you can easily find the right healthcare providers to meet your needs. Explore our resources to stay informed and empowered on your healthcare journey.

Download Our Medicare Advantage Plan Documents

To request a hard copy of the forms and resources on this page, please contact Member Services at 1-833-627-8252 (833-MAP-UCLA). TTY users should call 711. The Member Services team will mail a hard copy to you within 3 days of the request.

Older male swimming with grandchildren.

Summary of Benefits

: Summary of Benefits Principal Plan
Summary of Benefits Principal Plan (Spanish)
Summary of Benefits Prestige Plan
Summary of Benefits Prestige Plan (Spanish)
: Summary of Benefits Principal Plan
Summary of Benefits Principal Plan (Spanish)
Summary of Benefits Principal Plan (Korean)
Summary of Benefits Principal Plan (Chinese)
Summary of Benefits Prestige Plan
Summary of Benefits Prestige Plan (Spanish)
Summary of Benefits Prestige Plan (Korean)
Summary of Benefits Prestige Plan (Chinese)

Older couple sitting on couch

Evidence of Coverage

: Evidence of Coverage- Principal Plan (English)
Evidence of Coverage- Principal Plan (Spanish)
Evidence of Coverage- Prestige Plan (English)
Evidence of Coverage- Prestige Plan (Spanish)
: Evidence of Coverage- Principal Plan (English)
Evidence of Coverage- Prestige Plan (English)

Woman on phone

Directories

: Provider Directory
Pharmacy Directory (English)
Pharmacy Directory (Spanish)
: Provider Directory (English)
Pharmacy Directory (English)

Information Kit - Medicare Advantage

Enrollment Documents

: Information Kit
Pre-Enrollment Checklist
Enrollment Form (English)
Enrollment Form (Spanish)
: Information Kit
Pre-Enrollment Checklist
Enrollment Form (English)
Enrollment Form (Spanish)
Plan Comparison (Spanish)
Plan Comparison (Korean)
Plan Comparison (Chinese)

woman and child

Additional Resources

: Advance Healthcare Directive Form
Appeals and Grievances Form
Appointment of Representative
CMS Redetermination Form
Complex Care Management (CCM) Referral Form
Continuity of Care Form
If you prefer to fill out the Continuity of Care Form electronically or to view the form in an alternative language click here.
Exceptions Request Form
LEP Reconsideration
Medical Claim Form
Prior Authorization Request Form
Prescription Drug Coverage Determination Request
Reconsideration Form
: Real-time benefit tool – Principal plan
Real-time benefit tool – Prestige plan
Prescription Drug Prior Authorization Criteria
Prescription Drug Step Therapy Criteria
2025 Comprehensive Prescription Drug Formulary - English
2025 Comprehensive Prescription Drug Formulary – Spanish
2026 Comprehensive Prescription Drug Formulary - English
: Organization Determination
Rights & Responsibilities Upon Disenrollment For more information please refer to Chapter 10 Section 1 to Section 5 in the Evidence Of Coverage document at EOCPrincipal (for Principal Plan members) or EOCPrestige (for Prestige Plan members)
DME Supplier
2025 LIS Premium Summary Chart – Prestige Plan
2026 LIS Premium Summary Chart – Principle Plan
2026 LIS Premium Summary Chart – Prestige Plan
Transparency in Healthcare
Notices and Policies
Nondiscrimination Notice –Spanish
Notice of Privacy Practices –Spanish
Prescription Drug Transition Policy
Disaster & Emergency Policy