General Information and Forms

Extra Help (Low Income Subsidy) / Best Available Evidence

For information about Best Available Evidence (BAE) of Low Income Subsidy for Prescription Drugs, click here.

For information about Extra Help for Prescription Drug Costs, click here.

Centers for Medicare & Medicaid Services (CMS) Best Available Evidence (BAE) policy can be accessed on CMS website here.

How to Appoint a Representative

You can ask someone to act on your behalf. If you want to, you can name another person to act for you as your “representative” to file a grievance, request a coverage decision, or make an appeal at any level of the process.

  • There may be someone who is already legally authorized to act as your representative under State law.
  • If you want a friend, relative, your doctor or other provider, or other person to be your representative, call Member Services and ask for the “Appointment of Representative” form.

The form is also available on Medicare’s website here.
The form is also available in Spanish.

The form gives that person permission to act on your behalf. It must be signed by you and by the person who you would like to act on your behalf. You must give us a copy of the signed form.

Mail or fax your completed form to the address or number below.

Address

Vitality Health Plan of California
Member Services Department
18000 Studebaker Road, Suite 960
Cerritos, CA 90703

Fax

1-866-207-6539

Member Rights & Responsibilities

For information about your rights and responsibilities, click here.


To view documents in Spanish, please click here.

To view documents in Chinese, please click here.

To view documents in Korean, please click here.

To view documents in Vietnamese, please click here.