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 - Instructions
Instructions on how to complete the Appointment of Representative form.
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.
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 Disenrollment Form
Complete and mail in this form to disenroll from an individual CDPHP Medicare plan.
Medicare HMO Plan Change Election Form
2026 Medicare Advantage Formularies and Part D Coverage Documents
2026 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 (coming soon)
List of updates and changes to the CDPHP Medicare Advantage 2026 Formulary.
Medicare Vaccine Coverage Guide: Part B Versus Part D
This tip sheet explains how certain vaccinations are covered.
Medicare Part B Drug List (coming soon)
The list of Part B drugs for all individual and group CDPHP Medicare Advantage plans.
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 Criteria (coming soon)
This document outlines the criteria for the drugs that require prior authorization through the CDPHP pharmacy department.
Coverage Determination Request Form
Medical Exception Request and Prior Authorization Form
Pharmacy Directory, Medicare (coming soon)
Appeals and Grievances Overview for CDPHP Medicare Advantage Plan Members
Request for Redetermination of Medicare Prescription Drug Denial
Medicare Advantage Part B Step Therapy Drug List
Medicare Advantage Part D 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
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