Hi, thanks for visiting. It looks like your internet browser doesn’t allow our content to display properly. Please use Chrome or Edge or contact our Licensed Medicare Advisors @ 844-593-0265

 

Important Forms

Drug claims & reimbursements, special medicine requests, exceptions or appeals.

Appointment of Representative

1. You and the person accepting the appointment must fill out this form and submit it with the request. 2. Your doctor may request: a coverage determination, re-determination, or Independent Review Entity (IRE) reconsideration, on your behalf, without having to be an appointed representative. 3. Send this form to the same address where you are sending your: appeal, grievance, initial determination, or decision. If additional help is needed, call:1-800-633-4227

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

More Info

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

Request for Medicare Prescription Drug Coverage Determination

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