Pacificare

Authorized Agent

Brochure
Personal Select Plan & SDHP (SDA Self Directed)  $3,000 Deductible

Application

Attestation Form

Rx Formulary

Provider Finder

EOC Evidence of Coverage

HMO EOC - could be different for HIPAA

EOC Supplement

Plan Benefit Schedules

FROM DMHC Website

Individual Conversion Benefit Matrix

Individual Conversion Rate Matrix

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Broker ONLY

Provider Tools for Claims & Eligibility

866.405.7174
800.474.4467

evidence of coverage

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