General Medicare Forms
Center for Medicare and Medicaid Services Disaster Tip Sheet
Getting medical care and prescription drugs in a disaster or emergency area.
Notice of Availability of Language Assistance Services and Auxiliary Aids and Services
Access to interpreter services for non-English language speakers.
Appointment of Representative Form
CDPHP Medicare Advantage members may appoint any individual (friend, relative, lawyer) as a representative to assist them with understanding and following coverage determinations, exceptions, appeals, or grievances.
2027 Medicare Advantage Formularies and Part D Coverage Documents
2027 Medicare Advantage Formulary
The list of covered drugs for all individual members of CDPHP Medicare Advantage plans with Part D prescription drug coverage.
Medicare Advantage: Notice of Formulary Updates
List of updates and changes to the CDPHP Medicare Advantage 2027 Formulary.
Understanding Your Vaccine Coverage
This tip sheet explains how certain vaccinations are covered.
Medicare Part D Mail Order Pharmacy Overview
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 Advantage Drug Plan members should use this form to request direct reimbursement for covered prescription drugs you’ve purchased.
Medicare Part D Prior Authorization Policy
This document outlines the criteria for the drugs that require prior authorization through the CDPHP pharmacy department.
Coverage Determination Request Form
Medicare Pharmacy Directory
Request for Redetermination of Medicare Prescription Drug Denial
Medicare Advantage Part B Step Therapy Drug List
Medicare Part D Hospice Information Form
$0 Medicare Rx (HMO) Documents
Summary of Benefits - $0 Medicare Rx
Annual Notice of Changes - $0 Medicare Rx
Evidence of Coverage - $0 Medicare Rx
Clear Rx (HMO) Documents
Summary of Benefits - Clear Rx
Annual Notice of Changes - Clear Rx
Evidence of Coverage - Clear Rx
Choice Rx (HMO) Documents
Summary of Benefits - Choice Rx
Annual Notice of Changes - Choice Rx
Evidence of Coverage - Choice Rx
Core (HMO) Documents
Summary of Benefits - Core
Annual Notice of Changes - Core
Evidence of Coverage - Core