Member Materials

Annual Notice of Changes

Click below to download the full list of benefit changes for 2023.

• 2023 Annual Notice of Changes – English
• 2023 Annual Notice of Changes – Portuguese
• 2023 Annual Notice of Changes – Spanish
• 2023 Annual Notice of Changes – Khmer

Provider/Pharmacy Directory

Click below to find a provider, specialist, hospital or pharmacy near you.  All directories were last updated on February 18, 2023:

• 2023 Provider/Pharmacy Directory – English
• 2023 Provider/Pharmacy Directory – Portuguese
• 2023 Provider/Pharmacy Directory – Spanish
• 2023 Provider/Pharmacy Directory – Khmer

To see a list of our pharmacies, you can search our Pharmacy Locator

To request a hard copy of the Provider Pharmacy Directory, call Neighborhood Member Services at 1-844-812-6896 (TTY 711).

Member Handbook (Evidence of Coverage)

Click below to get detailed information about your coverage with Neighborhood INTEGRITY.

• Member Handbook – English
• Member Handbook – Portuguese
• Member Handbook – Spanish
• Member Handbook – Khmer

List of Covered Drugs (Formulary)

Click below to download the full list of covered drugs under this plan.

• 2023 Formulary – English
  • Updated 2/28/2023
• 2023 Formulary – Khmer
  • Updated 2/28/2023
• 2023 Formulary – Portuguese
  • Updated 2/28/2023
• 2023 Formulary – Spanish
  • Updated 2/28/2023

Click below for a list of Durable Medical Equipment Supplies limited at pharmacies. 

• Durable Medical Equipment List – English
• Durable Medical Equipment List – Portuguese
• Durable Medical Equipment List – Spanish
• Durable Medical Equipment List – Khmer

Summary of Benefits

Click below for a summary of benefits available under the Neighborhood INTEGRITY plan.

• Summary of Benefits – English 
• Summary of Benefits – Portuguese
• Summary of Benefits – Spanish
• Summary of Benefits – Khmer

Interpreter and Language Services

Click below for interpreter and language services available to you.

• Interpreter and Language Services

Sample ID Card

Click below to see a sample Neighborhood INTEGRITY member ID card.

• ID Card Sample

Appointment of Representative (AOR) Form

This form is used to appoint an individual to act as your representative. You can name another person to ask for a coverage decision or make an appeal. If you want a friend, relative, lawyer or another person to be your representative, this form will give the person permission to act for you. You must give us a copy of the signed form.

Request for Drug Determination Form

Request for Drug Determination Form – Portuguese

Request for Drug Determination Form – Spanish

Request for Drug Determination Form – Khmer

Use this form to request a decision on a request for a Part D drug with Neighborhood INTEGRITY.

Enrollee Grievance Request Form

Use this form if you would like to notify Neighborhood of a complaint or grievance.

Enrollee Appeal Request Form

Use this form to file an appeal of an adverse decision.

Request for Redetermination of Part D Denial Form

Request for Redetermination of Part D Denial Form – Portuguese

Request for Redetermination of Part D Denial Form – Spanish

Request for Redetermination of Part D Denial Form – Khmer

Use this form if a Part D drug has been denied and you believe it should be covered.

Member Reimbursement Form for Part D Drugs

Member Reimbursement Form for Part D Drugs – Spanish

Member Reimbursement Form for Part D Drugs – Portuguese

Member Reimbursement Form for Part D Drugs – Khmer

Use this form to request reimbursement if you paid the full cost of a prescription from one of our Network pharmacies.

Member Consent for Release of Protected Health Information Form

Member Consent for Release of Protected Health Information Form – Spanish

Member Consent for Release of Protected Health Information Form – Portuguese

Member Consent for Release of Protected Health Information Form – Khmer

Use this form to let another person see, receive or talk about your Protected Health Information.

Request for Alternate Means of Confidential Communications Form

Use this form to receive mail or phone calls at a different phone number.

Request for Access to Designated Protected Health Information Records Form

Use this form to get a copy of your Neighborhood records, such as pharmacy or claims information.

Annual Notice of Changes

Click below to download the full list of benefit changes for 2022.

• 2022 Annual Notice of Changes – English
• 2022 Annual Notice of Changes – Portuguese
• 2022 Annual Notice of Changes – Spanish
• 2022 Annual Notice of Changes – Khmer

Member Handbook (Evidence of Coverage)

Click below to get detailed information about your coverage with Neighborhood INTEGRITY.

• Member Handbook – English
  • Updated 10/19/2022
• Member Handbook – Portuguese 
  • Updated 10/19/2022
• Member Handbook – Spanish
  • Updated 10/19/2022
• Member Handbook – Khmer
  • Updated 10/19/2022

List of Covered Drugs (Formulary)

Click below to download the full list of covered drugs under this plan.

• 2022 Formulary – English
  • Updated 11/28/2022
• 2022 Formulary – Khmer
  • Updated 11/28/2022
• 2022 Formulary – Portuguese
  • Updated 11/28/2022
• 2022 Formulary – Spanish
  • Updated 11/28/2022

Click below for a list of Durable Medical Equipment Supplies limited at pharmacies. 

• Durable Medical Equipment List – English
• Durable Medical Equipment List – Portuguese
• Durable Medical Equipment List – Spanish
• Durable Medical Equipment List – Khmer

Summary of Benefits

Click below for a summary of benefits available under the Neighborhood INTEGRITY plan.

• Summary of Benefits – English 
• Summary of Benefits – Portuguese
• Summary of Benefits – Spanish
• Summary of Benefits – Khmer

Interpreter and Language Services

Click below for interpreter and language services available to you.

• Interpreter and Language Services

Sample ID Card

Click below to see a sample Neighborhood INTEGRITY member ID card.

• ID Card Sample

Appointment of Representative (AOR) Form

This form is used to appoint an individual to act as your representative. You can name another person to ask for a coverage decision or make an appeal. If you want a friend, relative, lawyer or another person to be your representative, this form will give the person permission to act for you. You must give us a copy of the signed form.

Request for Drug Determination Form

Request for Drug Determination Form – Portuguese

Request for Drug Determination Form – Spanish

Request for Drug Determination Form – Khmer

Use this form to request a decision on a request for a Part D drug with Neighborhood INTEGRITY.

Enrollee Grievance Request Form

Use this form if you would like to notify Neighborhood of a complaint or grievance.

Enrollee Appeal Request Form

Use this form to file an appeal of an adverse decision.

Request for Redetermination of Part D Denial Form

Request for Redetermination of Part D Denial Form – Portuguese

Request for Redetermination of Part D Denial Form – Spanish

Request for Redetermination of Part D Denial Form – Khmer

Use this form if a Part D drug has been denied and you believe it should be covered.

Member Reimbursement Form for Part D Drugs

Member Reimbursement Form for Part D Drugs – Spanish

Member Reimbursement Form for Part D Drugs – Portuguese

Member Reimbursement Form for Part D Drugs – Khmer

Use this form to request reimbursement if you paid the full cost of a prescription from one of our Network pharmacies.

Member Consent for Release of Protected Health Information Form

Member Consent for Release of Protected Health Information Form – Spanish

Member Consent for Release of Protected Health Information Form – Portuguese

Member Consent for Release of Protected Health Information Form – Khmer

Use this form to let another person see, receive or talk about your Protected Health Information.

Request for Alternate Means of Confidential Communications Form

Use this form to receive mail or phone calls at a different phone number.

Request for Access to Designated Protected Health Information Records Form

Use this form to get a copy of your Neighborhood records, such as pharmacy or claims information.