Member Documents

  • Member Booklet: Overview of Pharmacy Benefits
  • Patient Order Form: Form used to register and complete with needed information on an initial order/prescription being submitted for home delivery.
  • Acute Medications Formulary: List of top 125 dispensed immediate need medications that can be purchased up to a 21-Day supply for FREE at a Retail pharmacy
  • Chronic Medications Formulary: List of covered ongoing/maintenance medications that can be filled by Bonanza Rx Home delivery for specified quantities and prices.
  • OTC Medications Formulary: List of all OTC Medications
  • Notice of Privacy Practices: The Notice of Privacy Practices (NPP) is a document that tells your patients, employees, or clients how their health information may be used and shared and lists their health privacy rights related to Protected Health Information (PHI).
  • HIPAA Authorized Representative Form: Must be completed and signed by both the patient and the designated HIPAA representative. This will allow a person to act as an individual's personal representative. If under applicable state law, he or she can act on the individual's behalf in making decisions related to health care.
  • Authorization to Release Records Form: This form is used to release your protected health information as required by federal and state privacy laws. Your authorization allows the Health Plan entity to release your protected health information to a person or organization that you choose.
  • Revocation of Authorization to Release Records Form: You have the right to revoke any Authorization for Release of Records Health Information. To do so, you must fill out this form.