Medicare Forms

General Medicare Forms

• Center for Medicare and Medicaid Services Disaster Tip Sheet
  Getting medical care and prescription drugs in a disaster or emergency area.
• Appointment of Representative Form - Instructions
  Instruction on how to complete the form to Appointment of Representative.
• Appointment of Representative Form
  CDPHP Medicare plan members may appoint any individual (e.g., a friend, relative, lawyer) as your representative to assist with you with understanding and following coverage determinations, exceptions, appeals or grievances.
• Medicare Coordination of Benefits Questionnaire
  Keeping CDPHP up-to-date about other insurance coverage can help avoid claim payment delays.
• Medicare Health Survey
  Filling out this brief survey can help CDPHP better understand your individual health care needs.

Medicare Advantage HMO Plans

Medicare Advantage PPO Plans

2013 Medicare Choices Formularies and Part D Coverage

• Medicare Choices Drug Plans - 2013 Formulary - Y0019_13_5041A CMS Accepted
  The list of covered drugs for all individual members of CDPHP Medicare Choices plans with Part D prescription drug coverage.
• Medicare Choices Group Drug Plans - 2013 Group Formulary
  The list of covered drugs for employer group members of CDPHP Medicare Choices Group plans with Part D prescription drug coverage.
• Medicare Choices Group Drug Plans - 2013 Enhanced Formulary
  The list of additional covered non-Part D prescription drugs for some employer group members of CDPHP Medicare Choices Group Drug Plans.
• Medicare: Notice of Formulary Updates
  List of updates and changes to the CDPHP Medicare Choices Drug Plans 2013 Formulary.
• Medicare Vaccine Coverage Guide: Part B Versus Part D
  This tip sheet explains how certain vaccinations are covered under CDPHP Medicare Choices plans.

Medicare Choices - Prior Authorization Forms

• Medicare Prior Authorization Guidelines Grid 2013
  This grid outlines those services that require prior authorization through the CDPHP pharmacy department for 2013.
• Medicare Part D Prior Authorization Criteria 2013 
  This document outlines the criteria for the services that require prior authorization through the CDPHP pharmacy department for 2013.
• Medicare Prior Authorization Drugs (Part B versus Part D) 2013 
  Drugs on this list may be covered under Medicare Part B or Part D depending on the circumstances

Medicare Choices - Mail Order & Claim Forms

• Medicare Part D Mail Order Pharmacy Overview 2013 - Y0019_12-002 File & Use 07272011
• Medicare Part D Mail Order Pharmacy Order Form 
  By ordering your maintenance drugs through the mail, you can obtain up to a three (3)-month supply of drugs at a discounted rate, depending on your drug coverage.
• Medicare Prescription Claim Form 
  Medicare Choices Drug Plan members should use this form to request direct reimbursement for covered prescription drugs you’ve purchased.

Y0019_13_10035REV CMS Approved 1/8/13