CenCal CareConnect Materials

Your Plan Documents, All in One Place
Here, you’ll find important information about your coverage, rights, and responsibilities as a CenCal CareConnect member. You can view, download, or request a printed copy of any of the documents listed below.

If you have questions, we can help. You can also ask for materials in another format, like large print, Braille, or a different language. Contact Member Services at 1-877-814-1861 (TTY: CA Relay at 711).

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 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
Formulary – 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 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).

Member Handbook – English
Member Handbook – Spanish