Member Resources
Browse all plan materials, forms, documents, and resources you’ll need to stay healthy.
2026 Plan Benefit Details
Summary of Benefits
If you want to compare our individual Medicare Advantage plans and see their key features, you’ll want to look at a summary of benefits.
Essential and Enhanced PPO Evidence of Coverage
This book explains how your Essential or Enhanced plan works.
Entrust PPO MA Only Evidence of Coverage
This book explains how your Entrust PPO plan works.
LIS Premium Summary Chart
If you qualify for extra help paying for prescription drug coverage, you can use these charts to find out what you’ll pay each month for our plans.
Pre-enrollment Checklist
Use this checklist to make sure you understand your benefits and important rules before enrolling in a plan.
Enrollment Form
The easiest way to enroll in this plan is online, or call us at 1-888-468-0179. TTY users call 711. You can also print, fill out and mail this paper application.
List of Part B Drugs Requiring Prior Authorization
This list shows all of the part B drugs that require prior authorization.
Medical Policies and List of Part B Drugs Requiring Prior Authorization
Member Rights
If you have questions about your rights as a Medicare customer, this information explains how you’re protected.
When you want to ask your plan to cover or share the cost of a medical service or drug, this explains how to ask for a coverage decision.
If you experience a problem related to quality of care, service or long wait times or if you have other concerns, this information will tell you how to let us know.
If you don’t agree with a decision we made about what your plan covers or how something is covered, including what you have to pay, this explains how to file an appeal.
Appointment of a representative
If you want to appoint someone as your legal representative for Medicare coverage requests and appeals, you can download the required form and get instructions here.
If you’re a Medicare Advantage member and want to cancel your plan, this information will tell you when and how to do it.
Pharmacy Resources
Prescription Drug Prior Authorization
If your pharmacist said your prescription drug needs our approval, this explains why and what your options are.
Prescription Drug Transition Policy
If you’re a new or current member of our Medicare Advantage plans, this explains how our transition policy helps you get the medication you need.
Payment Resources
If you want to have your Medicare plan payment automatically deducted from your bank account or social security each month, use the below form to tell us. Please allow up to 60 days to process your request.
Claim Resources
Use these forms to ask us to pay you back for medical expenses, like prescriptions or out-of-network doctor costs.
- Member Reimbursement Form – Coming soon!
- Pharmacy Reimbursement Form
Privacy Resources
These privacy forms are for managing protected health information, or PHI, which is what we call your private medical information we have on file. For example, you can tell us who s allowed to see your information, or you can ask to see your information. If you have any questions, please call the number on the back of your ID Card.
What you’ll need:
- Your enrollee ID card
- A printer to print the form
- An envelope and postage to mail the form, or a fax machine. Each form includes instructions, a mailing address and a fax number
Privacy Notice under the HIPAA Privacy Rule
We know how important your privacy is to you. It’s important to us too. This is how we protect the information you give us.
Member Consent for Release of Protected Health Information
You may choose someone such as a family member or friend to share your Protected Health Information (PHI) with. Request for Release of Member s Protected
Health Information
Authorization to Revoke a Previous Authorization
I want to stop sharing PHI with a person or place I previously authorized.
Request for Access to Designated Protected Health Information Records
I want to see my PHI records that are maintained by WyoBlue Advantage.
Request to Amend Protected Health Information
I want to update or make changes to my health records.
Request for Restriction of Use and Disclosure of Protected Health Information
I want to restrict use of my protected health information.
Request for Confidential Communication
I want to change where I receive information for safety reasons.
Update Method of Confidential Communications
I would like to update my current method of confidential communications.
Cancel Confidential Communications
I would like to update my current method of confidential communications.
Request for List of Disclosures of Protected Health Information
I want to know if my PHI has been subject of certain disclosures.
If next of kin for someone who died and need to manage their PHI.
Health Care Privacy Practices Complaint Form
I have a complaint about your privacy practices.
Authorization for Use and Disclosure of Psychotherapy Notes
I want to share my Psychotherapy Notes with a designated family member or friend.