CenCal CareConnect Member Materials

Annual Notice of Change for 2027

You’re currently enrolled as a member of our plan. Next year, there will be some changes to our benefits, coverage, rules, and costs. This Annual Notice of Change tells you about the changes and where to find more information about them.

Annual Notice of Change for 2027 – English
Annual Notice of Change for 2027 – Spanish

CMS Appointment of Representative Form

Use this form to appoint a representative to act on your behalf for your claim, appeal, grievance or request. By signing this form and appointing this representative, you agree that the representative will be the main contact and have the authority to make requests, present evidence, get information, and receive all communication about your action. This person may see your personal medical information.

CMS Appointment of Representative Form (CMS-1696) – English
CMS Appointment of Representative Form (CMS-1696) – Spanish

Formulary

The CenCal CareConnect plan formulary is a list of covered prescription drugs approved for members under the plan.

Online Formulary
Formulary – English & Spanish

Grievances & Appeals Forms

If you disagree with a decision we’ve made or want to file a complaint, you can use the links below:

Grievances & Appeals Form – English
Grievances & Appeals Form – Spanish
Part D Request for Supporting Statement Form

HIPAA Privacy Statement

Learn how CenCal CareConnect protects your personal health information and your rights under HIPAA.

Notice of Privacy Practices – English
Notice of Privacy Practices – Spanish

Member Reimbursement Claim Form

This form is for general member reimbursement requests. For over-the-counter (OTC) items, please contact NationsBenefits® directly.

Member Reimbursement Claim Form

Member Handbook

This document explains everything your plan covers, including rules and how to get services. It is your official CenCal CareConnect Member Handbook (Evidence of Coverage).

2026

2026 Member Handbook – English
Errata: Changes to the CenCal CareConnect 2026 Evidence of Coverage – English

2026 Member Handbook – Spanish
Errata: Changes to the CenCal CareConnect 2026 Evidence of Coverage – Spanish

2027

2027 CenCal CareConnect Member Handbook – English

2027 CenCal CareConnect Member Handbook – Spanish

Member Rights and Responsibilities

Learn about your rights as a CenCal CareConnect member and your responsibilities in using your benefits.


Member Rights & Responsibilities

Pharmacy Materials

Pharmacy materials for the CenCal CareConnect plan.

LIS Premium Summary – English
LIS Premium Summary – Spanish

Drug Coverage Determination (Exception) Form
Drug Redetermination (Appeal) Form

Prescription Drug Transition Policy
Prescription Drug Claim Form

Provider and Pharmacy Directory

Find doctors, specialists, hospitals, behavioral health providers, pharmacies, and more within the CenCal CareConnect network.

Online Provider Search
Print Provider and Pharmacy Directory (Santa Barbara & San Luis Obispo Counties)

Summary of Benefits

A simplified overview of your benefits, services, and what’s covered. Use it as a quick reference.

2026

2026 Summary of Benefits – English
2026 Summary of Benefits – Spanish

2027

2027 Summary of Benefits – English
2027 Summary of Benefits – Spanish

Utilization Management Prior Authorization Form

UM Prior Authorization Form

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