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Important Forms
Drug claims & reimbursements, special medicine requests, exceptions or appeals.
Appointment of Representative
Use to appoint a person to file a grievance, request a coverage determination, or request an appeal on your behalf.
Medicare Advantage Member Submitted Health Insurance Claim Form
Use this form to submit requests for reimbursement for health care provided by out-of-network providers. For Medicare Advantage Medical Claims Only.
May be called: Health Insurance Claim, Medical Claim Form.
Medicare Part D Coverage Determination Request Form
Use this form to request a coverage determination, including an exception, from a plan sponsor, for your Medicare Part D Coverage. Can be used by you, your appointed representative, or your doctor.
May be called: CMS Coverage Determination Provider Form, Medicare Coverage Determination,
Medicare Part D Hospice Prior Authorization Information
Use this form to request coverage/prior authorization of medications for individuals in hospice care.
May be called: Request for Prescription Medication for Hospice, Hospice Prior Authorization Request Form
Medicare Part D Prescription Drug Claim Form
Use this form to request reimbursement for prescription drugs purchased without using your Member ID card.
May be called: General Prescription, Vaccine Administration
Medicare Part D Specialty Drug Request Form
Use this form to request a coverage determination, including an exception, from a plan sponsor. Can be used by you, your appointed representative, or your doctor.
May be called: Medicare Prescription Coverage Request, CMS Coverage Determination Form
Request for Redetermination of Medicare Prescription Drug Denial
Use this form to request a redetermination/appeal from a plan sponsor on a denied medication request or direct claim denial. Can be used by you, your appointed representative, or your doctor.
May be called: CMS Redetermination Request Form