Texas Independence Community Plan Member Documents

Important Member Documents

As a valued member of TIHP in Texas, you can access your important documents at any time by clicking on the links below.

Member MaterialS

• 2025 Summary of Benefits
  (contains multi-language insert)
• 2025 Summary of Benefits (Spanish)
• 2025 Evidence of Coverage
• 2025 Evidence of Coverage (Spanish)
• 2025 Star Ratings
• 2025 Star Ratings (Spanish)
• 2025 LIS Summary
• 2025 LIS Summary (Spanish)
• Appointment of Representative Form CMS-1696
• Appointment of Representative Form CMS-1696 (Spanish)
• 2025 Member Reimbursement Form
• 2025 Member Reimbursement Form (Spanish)
• Participating Providers
• Participating Pharmacies
• Appeals, Organizational Determinations, Coverage Determinations, Grievances
• Over The Counter (OTC) Catalog – coming soon
• Over The Counter (OTC) Catalog (Spanish) – coming soon
• 2025 Authorization Form
• 2025 Authorization Form (Spanish)

Enrollment

• Enrollment Process
• 2025 Enrollment Form
• 2025 Enrollment Form (Spanish)
• Disenrollment Process

Pharmacy Materials

Formulary 2025

• 2025 Formulary (List of Covered Drugs)
  (last updated 11/5/2024)
• 2025 Formulary (List of Covered Drugs) (Spanish)
  (last updated 11/5/2024)
• 2025 Prior Authorization Criteria
  (last updated 11/19/2024)
• 2025 Step Therapy Criteria
  (last updated 11/19/2024)
• 2025 Formulary (Prescription Drugs) Search Tool

Additional Pharmacy Information

• Coverage Determination, Appeals, and Grievances Information
• 2025 Request for Medicare Prescription Drug Coverage Determination Form
  (last updated 10/15/2024)
• 2025 Request for Medicare Prescription Drug Coverage Determination Form (Spanish)
• 2025 Request for Medicare Prescription Drug Coverage Appeal (Redetermination) Form
  (last updated 10/15/2024)
• 2025 Request for Medicare Prescription Drug Coverage Appeal (Redetermination) (Spanish)
• Online Medicare Prescription Drug Coverage Determination/Appeal (Redetermination)
• 2025 Medicare Prescription Drug Coverage Transition Policy
• 2025 Medicare Prescription Drug Coverage Transition Policy (Spanish)
• 2025 Medication Therapy Management Program Description
• 2025 Pharmacy Reimbursement Form
• 2025 Pharmacy Reimbursement Form (Spanish)