Medicare Forms and Documents

General Medicare Forms

Center for Medicare and Medicaid Services Disaster Tip Sheet
Getting medical care and prescription drugs in a disaster or emergency area.

Multi-Language Non-Discrimination Interpreter Services Insert
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

Medicare PPO Plan Change Election Form

Western NY Medicare PPO Plan Change Election Form

2024 Medicare Advantage Formularies and Part D Coverage Documents

2024 Medicare Advantage Formulary
The list of covered drugs for all individual members of CDPHP Medicare Advantage plans with Part D prescription drug coverage and all members of the CDPHP Care Advantage (HMO C-SNP) plan.

Medicare Advantage: Notice of Formulary Updates
List of updates and changes to the CDPHP Medicare Advantage 2024 Formulary.

Medicare Vaccine Coverage Guide: Part B Versus Part D
This tip sheet explains how certain vaccinations are covered.

Medicare Part B Drug List
The list of Part B drugs for all individual and group CDPHP Medicare Advantage and CDPHP Care Advantage (HMO-CSNP) 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 Guidelines Grid
This grid outlines which drugs require prior authorization through the CDPHP pharmacy department.

Medicare Part D Prior Authorization Criteria
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

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 Advantage Part D High-Risk Medications List
A list of medications that require prior authorization due to increased risks.

Medicare Part D Hospice Information Form

$0 Medicare Rx

Summary of Benefits - $0 Medicare Rx

Annual Notice of Changes - $0 Medicare Rx