Member Materials

Annual Notice of Changes

Click below to download the full list of benefit changes for 2020.

• 2020 Annual Notice of Changes – English
• 2020 Annual Notice of Changes – Portuguese
• 2020 Annual Notice of Changes – Spanish

Provider/Pharmacy Directory

Click below to find a provider, specialist, hospital or pharmacy near you.

• Provider/Pharmacy Directory [English]
  • Last Updated 5/12/2020
• Provider/Pharmacy Directory [Portuguese]
  • Last Updated 5/12/2020
• Provider/Pharmacy Directory [Spanish]
  • Last Updated 5/12/2020

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

List of Covered Drugs (Formulary)

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

• Formulary – English
  • Last Updated 4/29/2020
• Formulary – Portuguese
  • Last Updated 4/29/2020
• Formulary – Spanish
  • Last Updated 4/29/2020

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

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

Multi-Language Insert

Click below for interpreter services available to you.

• Multi-Language Insert

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

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

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

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

Annual Notice of Changes

Click below to download the full list of benefit changes for 2019.

• 2019 Annual Notice of Changes – English
• 2019 Annual Notice of Changes – Portuguese
• 2019 Annual Notice of Changes – Spanish

Provider/Pharmacy Directory

Click below to find a provider, specialist, hospital or pharmacy near you.

• Provider/Pharmacy Directory – English
  • Last Updated 10/3/19
• Provider/Pharmacy Directory [Portuguese] – Coming soon
• Provider/Pharmacy Directory [Spanish] – Coming soon

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

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

List of Covered Drugs (Formulary)

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

• Formulary – English
  • Last updated 11/26/19
• Formulary – Portuguese
  • Last updated 11/26/19
• Formulary – Spanish
  • Last updated 11/26/19

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

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

Multi-Language Insert

Click below for interpreter services available to you.

• Multi-Language Insert

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

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  – Coming Soon

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

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