Your Texas Health Plan
Whether you're looking to enroll in our plan or find information on your benefits and coverage, you can find it here.
Still have questions about our plan? Give us a call and we'll help.
Documents and Forms
Shared Health Dual Freedom (PPO D-SNP)SM
Enrollment
Use these resources to help you enroll in a plan.
Benefits and Coverage
These documents contain information about your benefits, network and coverage.
- 2025 Low Income Subsidy (LIS) Premium Summary Chart
- 2025 Low Income Subsidy (LIS) Premium Summary Chart (Spanish)
- 2025 Summary of Benefits (Updated: 10/01/2024)
- 2025 Summary of Benefits (Spanish) (Updated: 10/01/2024)
- 2025 Evidence of Coverage (EOC) (Updated: 10/01/2024)
- 2025 Evidence of Coverage (EOC) (Spanish) (Updated: 10/01/2024)
- 2025 Dental Benefits Guide
- 2025 Plan Rating (PPO D-SNP)
- 2025 Plan Rating (PPO D-SNP) (Spanish)
- Find a Doctor
- How It Works: Benefits Card Guide
- Member Claim Form
- How to File a Claim?
- OTC and Utility Reimbursement Form
Pharmacies and Prescriptions
These documents offer information about your covered drug benefits.
- 2025 Dual Freedom Covered Drug List (Formulary) (Updated: 4/1/2025)
- 2025 Dual Freedom Covered Drug List (Formulary) (Spanish) (Updated: 4/1/2025)
- Pharmacy Directory
- Medicare Prescription Payment Plan Terms and Conditions
- Medicare Prescription Payment Plan Terms and Conditions (Spanish)
- Medicare Prescription Payment Plan Fact Sheet
- Medicare Prescription Payment Plan Fact Sheet (Spanish)
- Medicare Prescription Payment Plan Election Request Form
- Medicare Prescription Payment Plan Election Request Form (Spanish)
- Part D Prescription Drug Claim Form
- Request for Medicare Prescription Drug Coverage Determination Form (Updated: 12/1/2023)
- Request for Redetermination of Medicare Prescription Drug Denial Form (Updated: 12/1/2023)
- Part D Prescription Home Delivery Form
- Part D Out of Network Coverage
- Medicare Part B Prior Authorization Criteria
- Medicare Part B Step Therapy Guide (Updated: 12/1/2024)
- 2025 Medicare Part D Prior Authorization Criteria (Updated: 4/1/2025)
- Provider-Administered Specialty Medication List (Updated: 4/1/2025)
- Provider-Administered Medication Authorization Form
- Part D Quality Assurance Policy
- Part D Quality Assurance Policy (Spanish)
- Part D Transition Supply Policy
- One Touch® Free Blood Glucose Monitor Voucher
- Free Contour Blood Glucose Monitor Coupon
- Blank Medication List
- Drug Disposal Information
Your Rights
You'll find notices and forms in this section that’ll help you understand your rights and responsibilities and make requests related to those rights.
- Appointment of Representative Form
- Appointment of Representative Form (Spanish)
- HIPAA Form
- Personal Representative Request Form
- Personal Representative Request Form (Spanish)
- Notice of Privacy Practices
- Confidential Communication Request Form
- Confidential Communication Request Form (Spanish)
- Disclosure Accounting Form
- Disclosure Accounting Form (Spanish)
- Access Request Form
- Access Request Form (Spanish)
- Restriction Request Form
- Restriction Request Form (Spanish)
- Request to Amend Records Form
- Request to Amend Records Form (Spanish)
- Privacy Complaint Form
- Privacy Complaint Form (Spanish)
Grievances and Appeals
Use these forms to file an appeal about coverage or payment decisions or to file a grievance if you have concerns about your plan, providers or quality of care.