Drug claims & reimbursements, special medicine requests, exceptions or appeals.
Use to appoint a person to file a grievance, request a coverage determination, or request an appeal on your behalf.
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.
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,
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
Use this form to request reimbursement for prescription drugs purchased without using your Member ID card.
May be called: General Prescription, Vaccine Administration
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
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