2020 Plan Materials - Administered by UnitedHealthcare

Nondiscrimination Notice

Piedmont Select Medicare Option One Annual Notice of Changes

Piedmont Select Medicare Option One Evidence of Coverage

Piedmont Select Medicare Option Two Annual Notice of Changes

Piedmont Select Medicare Option Two Evidence of Coverage

Piedmont Select Medicare Option Three Annual Notice of Changes

Piedmont Select Medicare Option Three Evidence of Coverage

Individual Enrollment form Option 1

Individual Enrollment form Option 2

Individual Enrollment form Option 3

Star Ratings

LIS Premium Summary Chart

Enrollment Guide - Option 1

Enrollment Guide - Option 2

Enrollment Guide - Option 3

2020 Member Experience Materials - Administered by UnitedHealthcare

Provider Directory

Pharmacy Directory For a web search click Here

Formulary "Drug List"  For a web search click Here

Transition Fill Policy 

Step Therapy Criteria

Prior Authorization Part D

Part D Coverage Determination Request Form (includes Exception Request form for physicians and enrollees)

Form to appoint a representative for your account

Summary of Benefits and Pre-Enrollment Checklist Option 1

Summary of Benefits and Pre-Enrollment Checklist Option 2

Summary of Benefits and Pre-Enrollment Checklist Option 3

Piedmont Medicare Advantage is a PPO plan with a Medicare contract.  Enrollment in Piedmont Medicare Advantage depends on contract renewal. Out-of-network/non-contracted providers are under no obligation to treat Piedmont Medicare Advantage members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.

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Last Updated 10/01/2019